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Maturation of Robot-Assisted Pancreaticoduodenectomy Program Within an Established Pancreatic Surgery Unit
Noaman Ali*, Mihir M. Shah, Kevin M. El-Hayek, Jane Wey, Sricharan Chalikonda, Matthew Walsh
Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
Background: There are potential advantages to the application of minimally invasive techniques to pancreaticoduodenectomy (PD). Technical feasibility and patient selection are important factors that will impact outcomes. We present a single center experience focusing on trends in patient selection and outcomes of robot-assisted pancreaticoduodenectomy (RAPD)
Methods: Retrospective review of a prospectively maintained database of all open and robotic pancreaticoduodenectomy from March 2009 to July 2013.
Results: 65 patients underwent attempted RAPD at a single institution during the study period. Concurrently, 211 open PD were performed. Operations were performed by three surgeons, who perform both open PD and RAPD. Conversion rate each year ranged from 15.4% to 38.9% (p = 0.81). Utilization of RAPD per year increased from 18% in 2009 to 26% for 2012-2013(p=0.45). There was no statistical difference between tumor size (2 to 2.45cm, p=0.24), percentage of malignant lesions (30.8% to 62.5%, p=0.36), and post-operative pancreatic fistula rate (grade A-C)(30% to 50%, p= 0.28) between the study years. Compared to the open PD cohort, mean estimated blood loss was significantly less (500cc vs. 200cc) (p<0.001). Length of stay (LOS) also had a trend towards significance with average LOS of 11.5 days for the open PD versus 9 days in the RAPD cohort (p=0.06). However, there was a significant decrease in mean LOS for the RAPD cohort, from 10 days in 2009 to 7 days in 2013 (p=0.03). The rate of BMI increase over time for RAPD was significantly higher compared to open PD cohort (p=0.04) (Figure 1). In comparison between groups in regard to overall surgical site infections, there was no difference between the open PD and RAPD groups (25% vs 28%, p=0.76). However, there was a trend towards a decrease rate of incisional infections in the RAPD group compared to open PD (8% vs 15%, p=0.32).
Conclusion: Increasing experience with RAPD has led to higher overall utilization regardless of underlying patient disease. To achieve the maximal benefits of a minimally invasive approach to PD, we have significantly and purposely increased the selection of obese patients. While a larger cohort of RAPD patients is needed, our initial experience suggests that the greatest benefit of RAPD is best utilized in patients with a higher BMI.
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