Frailer Patients Undergoing Robotic Colectomies for Colon Cancer Experience Increased Complication Rates Compared With Open or Laparoscopic Approaches

Background: Minimally invasive surgical techniques are routinely promoted as alternatives to open surgery because of improved outcomes. However, the impact of robotic surgery on certain subsets of the population, such as frail patients, is poorly understood. Objective: The purpose of our study was to examine the association between frailty and minimally invasive surgical approaches with colon cancer surgery. Design: This is a retrospective study of prospectively collected outcomes data. Thirty-day surgical outcomes were compared by frailty and surgical approach using doubly robust multivariable logistic regression with propensity score weighting, and testing for interaction effects between frailty and surgical approach. Setting: Patients undergoing an open, laparoscopic, or robotic colectomy for primary colon cancer, 2012 to 2016, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients: Patients undergoing a colectomy with an operative indication for primary colon cancer were selected. Main Outcome Measures: The primary outcomes measured were 30-day postoperative complications. Results: After propensity score weighting of patients undergoing colectomy, 33.8% (n = 27,649) underwent an open approach versus 34.3% (n = 28,058) underwent laparoscopic surgery versus 31.9% (n = 26,096) underwent robotic surgery. Robotic (OR, 0.53; 95% CI, 0.42-0.69, p < 0.001) and laparoscopic (OR, 0.58; 95% CI, 0.52-0.66, p < 0.001) surgeries were independently associated with decreased rates of major complications. Frailer patients had increased complication rates (OR, 1.56; 95% CI, 1.07-2.25, p = 0.018). When considering the interaction effects between surgical approach and frailty, frailer patients undergoing robotic surgery were more likely to develop a major complication (combined adjusted OR, 3.15; 95% CI, 1.34-7.45, p = 0.009) compared with patients undergoing open surgery. Limitations: Use of the modified Frailty Index as an associative proxy for frailty was a limitation of this study. Conclusions: Although minimally invasive surgical approaches have decreased postoperative complications, this effect may be reversed in frail patients. These findings challenge the belief that robotic surgery provides a favorable alternative to open surgery in frail patients.