Comparison of utilization trends, outcomes, and costs between open and minimally invasive esophagectomy

Many surgeons have adopted minimally invasive esophagectomy (MIE) as an alternative to open esophagectomy (OE). However, limited population-level data exist comparing clinical outcomes and costs by surgical approach. This study evaluated contemporary utilization trends, outcomes, and costs between MIE and OE using real-world data.

We conducted a retrospective cohort study of patients who underwent MIE or OE using data from the Healthcare Cost and Utilization Project Florida State Inpatient Database from 2016 to 2021. Utilization trends were analyzed using Cochran-Armitage tests. Multivariable regression models were utilized to evaluate the association of surgical approach with postoperative outcomes and hospitalization costs.

Of 2550 total patients, 1218 (47.8%) and 1332 (52.2%) underwent MIE and OE, respectively. Utilization of MIE increased significantly over time, as MIE grew from 43.4% of annual esophagectomy volume in 2016 to 57.7% by 2021 (trend P < 0.001). MIE patients had a higher prevalence of esophageal or esophagogastric junction cancer compared to OE patients (75.7% vs. 60.1%; P < 0.001), but exhibited a comparable overall comorbidity burden (e.g., 2-3 comorbidities: 44.1% vs. 43.5%; P = 0.061). MIE patients had significantly shorter hospital stays (median: 8 vs. 10 days, P < 0.001). MIE was associated with reduced risk-adjusted odds of postoperative complications (adjusted odds ratio 0.560, confidence interval 0.474-0.661, P < 0.001). Operating room costs were significantly higher with MIE compared to OE (median: $13,964 vs. $10,618, P < 0.001), whereas intensive care unit costs were lower (median: $2325 vs. $5706, P < 0.001). Index hospitalization (median: $41,795 vs. $40,289, P = 0.340) and 90-day costs (median: $46,509 vs. $45,408, P = 0.550) were comparable between groups. In subgroup analyses, in-hospital mortality was significantly lower with MIE at low-volume (< 20 esophagectomies annually) hospitals (2.5% vs. 5.3%, P = 0.010). However, this difference was not statistically significant at high-volume (≥ 20 esophagectomies annually) hospitals (2.9% vs. 5.0%, P = 0.072).

MIE has had rapid growth in utilization. MIE appears to provide a viable, cost-effective alternative to OE, with fewer postoperative complications, shorter hospital stays, and comparable overall costs.