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Background Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS–HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS–HIPEC. Patients and Methods We performed a retrospective cohort study of patients undergoing CRS–HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity. Results Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% ( n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341–$7350) for the at-risk group and $3341 ($2500–$4022) for the not at-risk group ( p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile. Conclusions An estimated one-third of patients undergoing CRS–HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.

BackgroundResearch on the utilization of robotic surgical approaches in the management of inflammatory bowel disease (IBD) is limited. The aims of this study were to identify temporal trends in robotic utilization and compare the safety of a robotic to laparoscopic operative approach in patients with IBD.MethodsPatients who underwent minimally invasive surgery (MIS) for IBD were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2013–2021). Temporal trends of robotic utilization were assessed from 2013 to 2021. Primary (30-day overall and serious morbidity) and secondary (unplanned conversion to open) outcomes were assessed between 2019 and 2021, when robotic utilization was highest. Multivariable logistic regression was performed.ResultsThe use of a robotic approach for colectomies and proctectomies increased significantly between 2013 and 2021 (p < 0.001), regardless of disease type. A total of 6016 patients underwent MIS for IBD between 2019 and 2021. 2234 (37%) patients had surgery for UC [robotic 430 (19.3%), lap 1804 (80%)] and 3782 (63%) had surgery for CD [robotic 500 (13.2%), lap 3282 (86.8%)]. For patients with UC, there was no difference in rates of overall morbidity (22.6% vs. 20.7%, p = 0.39), serious morbidity (11.4% vs. 12.3%, p = 0.60) or conversion to open (1.5% vs. 2.1%, p = 0.38) between the laparoscopic and robotic approaches, respectively. There was no difference in overall morbidity between the two groups in patients with CD (lap 14.0% vs robotic 16.4%, p = 0.15), however the robotic group exhibited higher rates of serious morbidity (7.3% vs. 11.2%, p < 0.01), shorter LOS (3 vs. 4 days, p < 0.001) and lower rates of conversion to an open procedure (3.8% vs. 1.6%, p = 0.02). Adjusted analysis showed similar results.ConclusionThe use of the robotic platform in the surgical management of IBD is increasing and is not associated with an increase in 30-day overall morbidity compared to a laparoscopic approach.

Background Enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay (LOS) and complications. The impact of ERAS protocols on the cost of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has not been studied. Patients and Methods We performed a retrospective cohort analysis of patients undergoing CRS-HIPEC from 2016–2022 at a single quaternary center. Propensity score matching was used to create pre-and post-ERAS cohorts. Cost, overall and serious complications, and intensive care unit (ICU) length of stay (LOS) between the two cohorts were compared using the Mann–Whitney U -test for continuous variables and χ 2 test for categorical variables. Results Our final matched cohort consisted of 100 patients, with 50 patients in both the pre- and post-ERAS groups. After adjusting for patient complexity and inflation, the median total cost [$75,932 ($67,166–102,645) versus $92,992 ($80,720–116,710), p = 0.02] and operating room cost [$26,817 ($23,378–33,121) versus $34,434 ($28,085-$41,379), p < 0.001] were significantly higher in the post-ERAS cohort. Overall morbidity ( n = 22, 44% versus n = 17, 34%, p = 0.40) and ICU length of stay [2 days (IQR 1–3) versus 2 days (IQR 1–4), p = 0.70] were similar between the two cohorts. A total cost increase of $22,393 [SE $13,047, 95% CI (−$3178 to $47,965), p = 0.086] was estimated after implementation of ERAS, with operating room cost significantly contributing to this increase [$8419, SE $1628, 95% CI ($5228–11,609), p < 0.001]. Conclusions CRS-HIPEC ERAS protocols were associated with higher total costs due to increased operating room costs at a single institution. There was no significant difference in ICU LOS and complications after the implementation of the ERAS protocol.

Background Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS–HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown. Patients and Methods We performed a retrospective cohort study of patients undergoing CRS–HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal–Wallis test to compare continuous variables and a χ 2 test to compare categorical variables. Results Of 201 patients, the median age [interquartile range (IQR)] was 57 (47–65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477–54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period. Conclusions The CRS–HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.