Cost analysis of robot-assisted versus open transthoracic esophagectomy for resectable esophageal cancer. Results of the ROBOT randomized clinical trial

Lucas Goense; Pieter C van der Sluis; Sylvia van der Horst; Evangelos Tagkalos; Peter P Grimminger; Wouter van Dijk; Jelle P Ruurda; Richard van Hillegersberg

doi:10.1016/j.ejso.2023.06.020

Cost analysis of robot-assisted versus open transthoracic esophagectomy for resectable esophageal cancer. Results of the ROBOT randomized clinical trial

Eur J Surg Oncol. 2023 Oct;49(10):106968. doi: 10.1016/j.ejso.2023.06.020. Epub 2023 Jul 1.

Authors

Lucas Goense¹, Pieter C van der Sluis², Sylvia van der Horst³, Evangelos Tagkalos⁴, Peter P Grimminger⁴, Wouter van Dijk⁵, Jelle P Ruurda³, Richard van Hillegersberg⁶

Affiliations

¹ Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands. Electronic address: l.goense@umcutrecht.nl.
² Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
³ Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
⁴ Department of General-, Visceral- and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
⁵ MRDM, the Netherlands.
⁶ Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands. Electronic address: r.vanhillegersberg@umcutrecht.nl.

PMID: 37423873
DOI: 10.1016/j.ejso.2023.06.020

Abstract

Background: The previously published ROBOT trial demonstrated that robot assisted minimally invasive esophagectomy (RAMIE) is associated with a lower percentage of postoperative complications compared to open esophagectomy (OTE) for patients with esophageal cancer. The implications of these results on healthcare costs are important given the increased attention for cost-reduction in healthcare. Therefore the aim of this study was to report the hospital costs of RAMIE compared to OTE as treatment for esophageal cancer.

Methods: The ROBOT trial randomized 112 patients with esophageal cancer between RAMIE and OTE through January 2012 and August 2016 in a single tertiary care academic centre in the Netherlands. The primary outcome of the current study was hospital costs from the day of esophagectomy until 90 days after discharge based on Time-Driven Activity-Based Costing methodology. Secondary outcomes included the incremental cost-effectiveness ratio per complication prevented and risk factors for increased hospital costs.

Results: Of the 112 included patients, 109 patients underwent an esophagectomy, of whom 54 RAMIE and 55 OTE. The mean total hospital costs were comparable between RAMIE €40211 and OTE €39495 (mean difference €-715; bias-corrected and accelerated confidence interval € -14831 to 14783, p = 0.932). At a willingness-to-pay threshold of €20.000 to €25.000 (i.e. estimated additional costs to the hospital to treat patients with a complication) RAMIE had a probability 62%-70% of being cost effective to prevent postoperative complications. In multivariable regression analysis, major postoperative complications were the main driver of hospital costs after esophagectomy (€31839, p = 0.009).

Conclusion: In this randomized trial RAMIE resulted in fewer postoperative complications compared to OTE without increasing total hospital costs.

Keywords: Esophageal cancer; Esophagectomy; Healthcare costs; MIE; RAMIE.