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

Published on Apr 1, 2017in JAMA Surgery10.668
· DOI :10.1001/jamasurg.2016.4755
Matthew T. McMillan17
Estimated H-index: 17
(UPenn: University of Pennsylvania),
Amer H. Zureikat29
Estimated H-index: 29
(University of Pittsburgh)
+ 4 AuthorsCharles M. Vollmer40
Estimated H-index: 40
(UPenn: University of Pennsylvania)
Sources
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 P = .01), small pancreatic duct diameter (vs ≥5 mm: 2 mm, OR, 2.1 [95% CI, 1.4-3.1]; P 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 P = .005), and octreotide prophylaxis (OR, 3.1 [95% CI, 2.3-4.0]; P 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.
  • References (42)
  • Citations (24)
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References42
Newest
#1Matthew T. McMillan (Mayo Clinic)H-Index: 17
#2Sameer SoiH-Index: 6
Last. Charles M. VollmerH-Index: 40
view all 27 authors...
Objective:To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.Background:Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of
46 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2John D. Christein (UA: University of Alabama)H-Index: 29
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 12 authors...
Background Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after various pancreatic resections. Here, we compare POPFs after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) using the average complication burden (ACB), a quantitative measure of complication burden. Methods From 2001 to 2014, 837 DPs and 1,533 PDs were performed by 14 surgeons at 4 institutions. POPFs were categorized by International Study Group on Pancreatic Fistula standards...
32 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
Last. Stephen W. Behrman (UTHSC: University of Tennessee Health Science Center)H-Index: 28
view all 29 authors...
Introduction International Study Group of Pancreatic Fistula (ISGPF) grade C postoperative pancreatic fistulas (POPF) are the greatest contributor to major morbidity and mortality following pancreatoduodenectomy (PD); however, their infrequent occurrence has hindered deeper analysis. This study sought to develop a predictive algorithm, which could facilitate effective management of this challenging complication.
41 CitationsSource
Minimally invasive approaches (laparoscopic or robotic) are used in various operations. Our aim was to compare them with the open approach in pancreaticoduodenectomy.We conducted a search for articles published in MEDLINE database comparing minimally invasive (laparoscopic or robotic) with open pancreaticoduodenectomy on June 15, 2014.Our search yielded 136 articles. We excluded 122 articles and we took into consideration 14 (10 for laparoscopic and 4 for robotic pancreaticoduodenectomies). Most...
16 CitationsSource
#1Chien-Hung Liao (CGU: Chang Gung University)H-Index: 6
#2Yu-Tung Wu (CGU: Chang Gung University)H-Index: 3
Last. Ta-SenYeh (CGU: Chang Gung University)H-Index: 28
view all 7 authors...
Background Minimally invasive pancreaticoduodenectomy (MIPD), which includes laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is a complex procedure that needs to be performed by experienced surgeons. However, the safety and oncologic performance have not yet been conclusively determined.
26 CitationsSource
#1Brian A. Boone (University of Pittsburgh)H-Index: 15
#2Mazen S. Zenati (University of Pittsburgh)H-Index: 28
Last. Amer H. Zureikat (University of Pittsburgh)H-Index: 29
view all 8 authors...
107 CitationsSource
#1Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
#2Russell S. Lewis (UPenn: University of Pennsylvania)H-Index: 9
Last. Steven M. Strasberg (UPenn: University of Pennsylvania)H-Index: 32
view all 15 authors...
Objective: The study aim was to quantify the burden of complications of pancreatoduodenectomy (PD). Background: The Postoperative Morbidity Index (PMI) is a quantitative measure of the average burden of complications of a procedure. It is based on highly validated systems—ACS-NSQIP and the Modified Accordion Severity Grading System. Methods: Nine centers contributed ACS-NSQIP complication data for 1589 patients undergoing PD from 2005 to 2011. Each complication was assigned a severity weight ran...
34 CitationsSource
#1Russell C. Langan (Georgetown University)H-Index: 13
#2Jay A. Graham (Georgetown University)H-Index: 11
Last. Lynt B. Johnson (Georgetown University)H-Index: 41
view all 16 authors...
Background We compared outcomes and postpancreatectomy quality of life (QOL) in paired cohorts of patients undergoing conventional open pancreaticoduodenectomy (OPD) or laparoscopic-assisted pancreaticoduodenectomy (LAPD). Methods Comparative analysis of QOL was performed in a matched cohort of 53 patients after OPD or LAPD between 2010 and 2013. The Medical Outcomes Study Short Form-36 Health Survey and the Karnofsky score were used. Results Physical component score, mental component score, and...
37 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
Background Postoperative pancreatic fistula is a significant contributor to morbidity following proximal and distal pancreatic resections. In recent decades, the incidence of fistula has ranged from 2 to 33 %; however, the consistent identification of risk factors has been difficult due to significant variability in the definition of pancreatic fistula.
33 CitationsSource
#1Paul J. Speicher (Duke University)H-Index: 21
#2Daniel P. Nussbaum (Duke University)H-Index: 15
Last. Alexander Perez (Duke University)H-Index: 19
view all 10 authors...
Background The purpose of this study was to define the learning curves for laparoscopic pancreaticoduodenectomy (LPD) with and without laparoscopic reconstruction, using paired surgical teams consisting of advanced laparoscopic-trained surgeons and advanced oncologic-trained surgeons.
86 CitationsSource
Cited By24
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#1Ibrahim Nassour (University of Pittsburgh)H-Index: 9
#2Sharon Winters (University of Pittsburgh)H-Index: 8
Last. Amer H. Zureikat (University of Pittsburgh)H-Index: 29
view all 9 authors...
BACKGROUND: Robotic pancreatectomy is gaining momentum; however, limited data exist on the long-term survival of this approach for pancreatic ductal adenocarcinoma (PDAC). The objective of this study is to compare the long-term oncologic outcomes of robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP) to open surgery in patients with PDAC. STUDY DESIGN: Robotic and open pancreatectomy for stages I-III PDAC were obtained from the 2010 to 2016 National Cancer Database. RES...
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#1Bor-Uei Shyr (Taipei Veterans General Hospital)H-Index: 3
#2Bor-Shiuan Shyr (Taipei Veterans General Hospital)
Last. Shin-E Wang (Taipei Veterans General Hospital)H-Index: 12
view all 6 authors...
Summary Background/Objective There are no reports available on patient satisfaction and quality-of-life after robotic pancreaticoduodenectomy (RPD). This study aimed to evaluate not only surgical outcomes but also patient satisfaction after RPD. Methods Prospectively collected data for RPD were analyzed for surgical outcomes. Questionnaires were sent to patients to assess patient satisfaction regarding RPD. Results The study included 105 patients who underwent RPD, with 44 (41.9%) patients prese...
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#1Charles Christian Vining (U of C: University of Chicago)
#2Melissa E. Hogg (NorthShore University HealthSystem)H-Index: 17
Training for minimally invasive pancreas surgery is critical as an evolving body of literature supports its use with acceptable outcomes during training and improved short term outcomes following completion. Although case volume needed to achieve mastery remains unclear, improved outcomes for both laparoscopic and robotic pancreatectomy are demonstrated following a learning curve and inflection point. Therefore, dedicated training curricula for both laparoscopic and robotic pancreatectomy have b...
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#1Shengliang He (JHUSOM: Johns Hopkins University School of Medicine)
#2Ding Ding (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 8
Last. Jin He (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 24
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Abstract Background Patients with high body mass index are associated with a higher risk of complications after open pancreatectomy. We aimed to investigate the perioperative outcome for patients with high body mass index after robotic pancreatectomy. Methods This is a retrospective, propensity-score matched cohort analysis. From our prospectively maintained database, we identified consecutive patients with body mass index >25 who underwent robotic pancreatectomy between January 2016 and Decembe...
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#1Mauro Podda (University of Cagliari)H-Index: 9
#2Chiara GerardiH-Index: 5
Last. Adolfo Pisanu (University of Cagliari)H-Index: 16
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Although several non-randomized studies comparing robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) recently demonstrated that the two operative techniques could be equivalent in terms of safety outcomes and short-term oncologic efficacy, no definitive answer has arrived yet to the question as to whether robotic assistance can contribute to reducing the high rate of postoperative morbidity. Systematic literature search was performed using MEDLINE, the Cochrane Central ...
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#1Qing Yan (SYSU: Sun Yat-sen University)
#2Lei-bo Xu (SYSU: Sun Yat-sen University)
Last. Chao Liu (SYSU: Sun Yat-sen University)
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Background Although robotic surgery is popular around the world, its safety and efficacy over classical open surgery is still controversial. The purpose of this article is to compare the safety and efficacy of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD).
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#1Le Li (HMU: Harbin Medical University)H-Index: 6
#2Feng-Yu Tian (HMU: Harbin Medical University)H-Index: 2
Last. Bei Sun (HMU: Harbin Medical University)H-Index: 21
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The main mechanism of hyaluronidase 1(HYAL-1) in the development of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) was unknown. In this study, a comprehensive inventory of pre-, intra-, and postoperative clinical and biological data of two cohorts (62 pancreatic cancer [PCa] and 111 pancreatic ductal adenocarcinoma [PDAC]) which could induce POPF were retrospectively analyzed. Then, a total of 7644 genes correlated with HYAL-1 was predicted in PDAC tissues and the enric...
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#1Patrick R. Varley (University of Pittsburgh)H-Index: 6
#2Amr Al-abbas (University of Pittsburgh)H-Index: 2
Last. Melissa E. Hogg (University of Pittsburgh)H-Index: 17
view all 3 authors...
Though minimally invasive approaches have been readily incorporated into many areas of oncologic surgery, their use for pancreaticoduodenectomy (PD) has been less widespread. However, with the introduction of a robotic platform, surgeons have been able to overcome the technical challenges that limited the adoption of laparoscopic PD. Robotic PD (RPD) can now be performed with the same safety and oncologic outcome profile as open PD and is the preferred surgical approach in our institution. Here,...
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#1Alan Kawarai Lefor (Jichi Medical University)H-Index: 13
Surgery of the pancreas is a relatively new field, with operative series appearing only in the last 50 years. Surgery of the pancreas is technically challenging. The entire field of general surgery changed radically in 1987 with the introduction of the laparoscopic cholecystectomy. Minimally Invasive surgical techniques rapidly became utilized worldwide for gallbladder surgery and were then adapted to other abdominal operations. These techniques are used regularly for surgery of the pancreas inc...
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#1Jianpeng Cai (SYSU: Sun Yat-sen University)
#2Rajesh Ramanathan (University of Pittsburgh)H-Index: 9
Last. Amer H. Zureikat (University of Pittsburgh)H-Index: 29
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Background Clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) is a major complication that adversely affects recovery. The robotic approach may decrease the incidence of this complication. This propensity-matched analysis evaluates the impact of robotic PD (RPD) on CR-POPF.
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