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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 Surgery10.67
· DOI :10.1001/jamasurg.2016.4755
Matthew T. McMillan15
Estimated H-index: 15
(UPenn: University of Pennsylvania),
Amer H. Zureikat28
Estimated H-index: 28
(University of Pittsburgh)
+ 4 AuthorsCharles M. Vollmer38
Estimated H-index: 38
(UPenn: University of Pennsylvania)
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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 (15)
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References42
Newest
Published on Aug 1, 2016in Annals of Surgery9.48
Matthew T. McMillan15
Estimated H-index: 15
(Mayo Clinic),
Sameer Soi1
Estimated H-index: 1
+ 24 AuthorsMark P. Callery46
Estimated H-index: 46
Published on May 1, 2016in World Journal of Surgery2.77
Chien-Hung Liao5
Estimated H-index: 5
(CGU: Chang Gung University),
Yu-Tung Wu3
Estimated H-index: 3
(CGU: Chang Gung University)
+ 4 AuthorsTa-SenYeh27
Estimated H-index: 27
(CGU: Chang Gung University)
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.
Published on Apr 1, 2016in Surgery3.48
Matthew T. McMillan15
Estimated H-index: 15
(UPenn: University of Pennsylvania),
John D. Christein24
Estimated H-index: 24
(UA: University of Alabama)
+ 9 AuthorsAmmara Abbasi14
Estimated H-index: 14
(BIDMC: Beth Israel Deaconess Medical Center)
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...
Published on Feb 1, 2016in Journal of Gastrointestinal Surgery2.69
Matthew T. McMillan15
Estimated H-index: 15
(UPenn: University of Pennsylvania),
Charles M. Vollmer38
Estimated H-index: 38
(UPenn: University of Pennsylvania)
+ 26 AuthorsJohn D. Christein24
Estimated H-index: 24
(UA: University of Alabama)
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.
Chrysoula Doula2
Estimated H-index: 2
,
Ioannis D. Kostakis10
Estimated H-index: 10
+ 4 AuthorsEvangelos Felekouras20
Estimated H-index: 20
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...
Published on May 1, 2015in JAMA Surgery10.67
Brian A. Boone14
Estimated H-index: 14
(University of Pittsburgh),
Mazen S. Zenati27
Estimated H-index: 27
(University of Pittsburgh)
+ 5 AuthorsAmer H. Zureikat28
Estimated H-index: 28
(University of Pittsburgh)
Importance Quality assessment is an important instrument to ensure optimal surgical outcomes, particularly during the adoption of new surgical technology. The use of the robotic platform for complex pancreatic resections, such as the pancreaticoduodenectomy, requires close monitoring of outcomes during its implementation phase to ensure patient safety is maintained and the learning curve identified. Objective To report the results of a quality analysis and learning curve during the implementatio...
Published on Mar 1, 2015in Annals of Surgery9.48
Charles M. Vollmer38
Estimated H-index: 38
(UPenn: University of Pennsylvania),
Russell S. Lewis8
Estimated H-index: 8
(UPenn: University of Pennsylvania)
+ 12 AuthorsIrene Epelboym9
Estimated H-index: 9
(Columbia University)
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...
Published on Nov 1, 2014in Annals of Surgical Oncology3.68
Paul J. Speicher21
Estimated H-index: 21
(Duke University),
Daniel P. Nussbaum14
Estimated H-index: 14
(Duke University)
+ 7 AuthorsAlexander Perez19
Estimated H-index: 19
(Duke University)
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.
Published on Oct 1, 2014in Langenbeck's Archives of Surgery2.09
Matthew T. McMillan15
Estimated H-index: 15
(UPenn: University of Pennsylvania),
Charles M. Vollmer38
Estimated H-index: 38
(UPenn: University of Pennsylvania)
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.
Published on Aug 1, 2014in Surgery3.48
Russell C. Langan13
Estimated H-index: 13
(Georgetown University),
Jay A. Graham11
Estimated H-index: 11
(Georgetown University)
+ 13 AuthorsNadim Haddad12
Estimated H-index: 12
(Georgetown University)
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...
Cited By15
Newest
Published on Dec 1, 2019
Alan Kawarai Lefor12
Estimated H-index: 12
(Jichi Medical University)
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...
Published on Dec 1, 2019in Nutrition Journal3.59
Wan-Hsiang Hu3
Estimated H-index: 3
(UCSD: University of California, San Diego),
Samuel Eisenstein9
Estimated H-index: 9
(UCSD: University of California, San Diego)
+ 1 AuthorsSonia Ramamoorthy22
Estimated H-index: 22
(UCSD: University of California, San Diego)
Background Malnutrition with hypoalbuminemia (albumin < 35 g/L) is an important factor in predicting risks associated with colorectal cancer surgery. However, there is limited data about the effects of mild hypoalbuminemia with small decreases in albumin on postoperative complications.
Published on Jan 5, 2019in World Journal of Surgical Oncology1.97
Tianchong Wu (JNU: Jinan University), Yuehua Guo (JNU: Jinan University)+ 3 AuthorsShiyun Bao (JNU: Jinan University)
Background Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the most common neopathy after pancreatoduodenectomy (PD). An ideal pancreaticoenterostomy (PE) which can effectively reduce the incidence of CR-POPF and its potential neopathy is needed. We aimed to assess the efficacy of our modified duct-to-mucosa PE in the PD.
Published on May 31, 2019in Journal of Gastrointestinal Surgery2.69
Sushruta S. Nagarkatti (Carolinas Medical Center), A. Sastry1
Estimated H-index: 1
(Carolinas Medical Center)
+ 1 AuthorsJohn B. Martinie17
Estimated H-index: 17
(Carolinas Medical Center)
Published on May 30, 2019in Journal of Gastrointestinal Surgery2.69
Gregory C. Wilson1
Estimated H-index: 1
(University of Pittsburgh),
Herbert J. Zeh60
Estimated H-index: 60
(UTSW: University of Texas Southwestern Medical Center),
Amer H. Zureikat28
Estimated H-index: 28
(University of Pittsburgh)
Published on Jul 2, 2019in Journal of Gastrointestinal Surgery2.69
Jianpeng Cai (SYSU: Sun Yat-sen University), Rajesh Ramanathan1
Estimated H-index: 1
(University of Pittsburgh)
+ 4 AuthorsAmer H. Zureikat28
Estimated H-index: 28
(University of Pittsburgh)
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.
Published on Mar 1, 2019in Surgery3.48
Joal D. Beane2
Estimated H-index: 2
(University of Pittsburgh),
Mazen S. Zenati27
Estimated H-index: 27
(University of Pittsburgh)
+ 3 AuthorsAmer H. Zureikat28
Estimated H-index: 28
(University of Pittsburgh)
Abstract Introduction The safety, efficacy, and learning curve for robotic pancreatoduodenecomy has been reported; however, the outcomes and learning curve of robotic pancreatoduodenecomy with vascular resections remain unknown. Our aim was to evaluate the outcomes of robotic pancreatoduodenecomy with vascular resections compared with robotic pancreatoduodenecomy without vascular resection and to identify the learning curve and benchmarks for improved performance during robotic pancreatoduodenec...
Published on Jul 1, 2019in Fertility and Sterility5.41
Jean Marc Ayoubi3
Estimated H-index: 3
(UVSQ: Versailles Saint-Quentin-en-Yvelines University),
Marie Carbonnel (UVSQ: Versailles Saint-Quentin-en-Yvelines University)+ 3 AuthorsPernilla Dahm-Kähler19
Estimated H-index: 19
(University of Gothenburg)
Uterus transplantation (UTx) is the first available treatment for absolute uterine factor infertility, a condition due to absence of the uterus or presence of a non-functional uterus. The proof-of-concept of UTx as an infertility treatment for this group of patients occurred in 2014 in Sweden by the first birth after human UTx. That and subsequent cases of the Swedish trial were live-donor UTx procedures with laparotomy of both donor and recipient. Although results of the initial Swedish clinica...
Published on Dec 1, 2018in Surgical Oncology-oxford3.00
Jeroen Hagendoorn13
Estimated H-index: 13
,
Carolijn L.M.A. Nota4
Estimated H-index: 4
(City of Hope National Medical Center)
+ 1 AuthorsI. Quintus Molenaar1
Estimated H-index: 1
BACKGROUND: Pancreatoduodenectomy (Whipple resection) in children is feasible though rarely indicated. In several pediatric malignancies of the pancreas, however, it may be the only curative strategy [1]. With the emergence of robotic pancreatoduodenectomy as at least a clinically equivalent alternative to open surgery [2], it remains to be determined whether the pediatric population may potentially benefit from this minimally invasive procedure. Here we present, for the first time, a video of s...
View next paperA multi-institutional comparison of perioperative outcomes of robotic and open pancreaticoduodenectomy