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Original Investigation
December 28, 2016

A Propensity Score–Matched Analysis of Robotic vs Open Pancreatoduodenectomy on Incidence of Pancreatic Fistula

Author Affiliations
  • 1Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 2Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 3Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia
JAMA Surg. Published online December 28, 2016. doi:10.1001/jamasurg.2016.4755
Key Points

Question  Is the use of robotic pancreatoduodenectomy (RPD) noninferior to open pancreatoduodenectomy (OPD) in terms of clinically relevant pancreatic fistula occurrence?

Findings  In this propensity score–matched analysis of 304 patients, RPD demonstrated similar clinically relevant pancreatic fistula rates compared with OPD. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication, severe complications (Accordion severity grading system grade ≥3), hospital stay, 30-day readmission, and 90-day mortality.

Meaning  Robotic pancreatoduodenectomy is noninferior to OPD in terms of clinically relevant pancreatic fistula development and other major postoperative outcomes.

Abstract

Importance  The adoption of robotic pancreatoduodenectomy (RPD) is gaining momentum; however, its impact on major outcomes, including pancreatic fistula, has yet to be adequately compared with open pancreatoduodenectomy (OPD).

Objective  To demonstrate that use of RPD does not increase the incidence of clinically relevant pancreatic fistula (CR-POPF) compared with OPD.

Design, Setting, and Participants  Data were accrued from 2846 patients who underwent pancreatoduodenectomies (OPDs, n = 2661; RPDs, n = 185), performed by 51 surgeons at 17 institutions worldwide (2003-2015). All RPDs were conducted at a high-volume, academic, pancreatic surgery specialty center—in a standardized fashion—by surgeons who had surpassed the RPD learning curve. Propensity score matching was used to minimize bias from nonrandomized treatment assignment. The RPD and OPD cohorts were matched by propensity scores accounting for factors significantly associated with either undergoing robotic surgery or CR-POPF occurrence on logistic regression analysis. These variables included pancreatic gland texture, pancreatic duct diameter, intraoperative blood loss, pathologic findings of disease, and intraoperative drain placement.

Interventions  Use of RPD or OPD.

Main Outcomes and Measures  The major outcome of interest was CR-POPF occurrence, which is the most common and morbid complication following pancreatoduodenectomy.

Results  The overall cohort was 51.5% male, with a median age of 64 years (interquartile range, 56-72 years). The propensity score–matched cohort comprised 152 RPDs and 152 OPDs; all covariate imbalances were alleviated. After adjusting for potential confounders, undergoing RPD was associated with a reduced risk for CR-POPF incidence (OR, 0.4 [95% CI, 0.2-0.7]; P = .002) relative to OPD. Other predictors of risk-adjusted CR-POPF occurrence included soft pancreatic parenchyma (OR, 4.7 [95% CI, 3.4-6.6]; P < .001), pathologic findings of high-risk disease (OR, 1.4 [95% CI, 1.1-1.9]; P = .01), small pancreatic duct diameter (vs ≥5 mm: 2 mm, OR, 2.1 [95% CI, 1.4-3.1]; P < .001; ≤1 mm, OR, 1.8 [95% CI, 1.0-3.0]; P = .03), elevated intraoperative blood loss (vs ≤400 mL: 401-700 mL, OR, 1.5 [95% CI, 1.1-2.0]; P = .01; >1000 mL, OR, 2.1 [95% CI, 1.4-2.9]; P < .001), omission of intraoperative drain(s) (OR, 0.5 [95% CI, 0.3-0.8]; P = .005), and octreotide prophylaxis (OR, 3.1 [95% CI, 2.3-4.0]; P < .001). Patients undergoing RPD demonstrated similar CR-POPF rates compared with patients in the OPD cohort (6.6% vs 11.2%; P = .23). This relationship held for both grade B (6.6% vs 9.2%; P = .52) and grade C (0% vs 2.0%; P = .25) POPFs. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication (73.7% vs 66.4%; P = .21), severe complications (Accordion grade ≥3, 23.05% vs 23.7%; P > .99), hospital stay (median: 8 vs 8.5 days; P = .31), 30-day readmission (22.4% vs 21.7%; P > .99), and 90-day mortality (3.3% vs 1.3%; P = .38).

Conclusions and Relevance  To our knowledge, this is the first propensity score–matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.

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