The article in this issue by McMillan et al1 represents a propensity score–matched analysis of robotic and open pancreatoduodenectomies (RPD and OPD, respectively), with results demonstrating noninferiority regarding major postoperative complications. This multi-institutional study represents a reasonable attempt to compare perioperative surgical outcomes for pancreatoduodenectomy (PD) by experienced surgeons who have surpassed the RPD learning curve, in carefully selected patients. The results demonstrate that clinically relevant fistula rates, overall complications, length of hospital stay (LOS), mortality, and readmission rates were similar, suggesting that RPD is not inferior to OPD for these metrics.
The authors, from the University of Pittsburgh (UPMC), should be commended for their dedication to the advancement and reporting of RPD, which remains a technically challenging endeavor,2 and for their work to define the learning curve and training curriculum.2 As the authors acknowledge, there are limitations to this retrospective analysis, including patient selection bias, and the challenge of controlling for all of the confounding variables in the propensity score-matching approach.
In this study, only cases from experienced surgeons that have surpassed the learning curve of 80 cases2 were included, but pancreatic fistula rates during the early phase of the learning curve were as high as 27.5%. Unlike the benefits demonstrated in left-sided pancreatectomies,3 minimally invasive PD has failed to consistently demonstrate significant improvements in outcomes, such as decreased LOS, quicker return to baseline activity, fewer complications, reduced mortality, and shorter time to adjuvant therapy.4 A recent multi-institutional comparison of perioperative outcomes for RPD and OPD5 demonstrated reduced operative blood loss without a decrease in transfusions, and perhaps a reduction in major complications for the RPD group, at the expense of substantially longer operative times with no LOS improvements. Although not measured, it is likely that RPD requires substantially increased costs to initiate the program and to establish the level of expertise attained at UPMC. These financial considerations warrant further investigation in this era of bundled payments, and increasing cost-value awareness.
Given the extensive learning curve, and the definition that high-volume centers perform 10 resections per year, it seems improbable that even high-volume surgeons could extrapolate the findings of this study to their own practice—and ultimately for what benefit and at what cost? Although the authors demonstrate the safety of this approach with highly trained physicians at one high-volume center, the wide adaptability and impact of RPD remains in question. Technological innovation should improve standards of care, rather than settling for noninferiority. As experience and technology improve, RPD and OPD will both evolve, but better studies are needed to clarify by whom and where these innovations will be advanced. This study represents an early effort to address these questions by an accomplished group of surgeons who are paving the way.
Corresponding Author: Hong Jin Kim, MD, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, 170 Manning Dr, P1150 Physicians Office Bldg, Ste CB 7213, Chapel Hill, NC 27599 (email@example.com).
Published Online: December 28, 2016. doi:10.1001/jamasurg.2016.4756
Conflict of Interest Disclosures: None reported.
Laks S, Kooby DA, Kim HJ. Comparing Outcomes for Robotic and Open PancreatoduodenectomyA Technological Advance?. JAMA Surg. Published online December 28, 2016. doi:10.1001/jamasurg.2016.4756