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Kenneth W. Bueltmann, Piotr J. Bachul, Lyonell B. Kone*, Marek Rudnicki
Surgery, Illinois Masonic Medical Center, Chicago, IL

Introduction: Pancreatodudenectomy (PDX) is a rare and complicated procedure as the majority of these cases are performed upon those suffering from pancreatic cancer. Improvements in surgical technology have benefited increased numbers of patients and often implement dramatic change with their arrival. It might be expected that lapaoscopic and/or robotic technnique could improve surgerry outcomes. This investigation uses a robust retrospective database to explore the impact of the advancement in techniques upon the prevalence of complications in those undergoing PDX.
Methods:The Nationwide Inpatient Sample (NIS) was referenced for inpatient visits for the years 2001 to 2014, and subsequently divided by the year 2008 to represent the advent of robotic surgery coding. PDX cases were then identified and flagged. The PDX subset was then subjected to the NIS, Elixhauser comorbidity software, and subsequently scored according to VanWaldren. The PDX subset was then scanned for the presence of discrete laparoscopic and robotic procedures, and combined together as minimally invasive (MIS). Perioperative complications were then identified and summarized within each individual record. The utilization rates of MIS and open cases were then calculated using SAS 9.2. The techniques were then analyzed between the time periods. The stratified data was then used to compute the significance of their association with the number of complications per patient using t-tests.
Results: From 2001 to 2014, 19,334 PDX cases were performed. In this time period, 1,579 MIS procedures were performed (8.17% +/- 0.20). The total number of complications found was 1,377, at a rate of 7.1+/- 0.2% overall. When compared, MIS resulted in 5.45+/- 0.59%, vs. 7.27+/-0.21% for open cases (p<.05). When compared between the time periods, pre-2008 MIS demonstrated a non-significant change in complication rates after 2007. Open cases before 2008 occurred at a rate of 8.0+/-0.34% and 6.8+/-0.27% after 2007 (p<.01). When controlling for comorbidity, MIS rates of complications had no significant difference after the introduction of the robot in 2008, and the addition to the MIS group. Open cases dropped from 5.5+/-0.5% pre-2008 to 3.9+/-0.4% post-2007 (p<.05). Complication rate for 166 isolated robotic PDX cases was 3.0+/-1.3% (post 2007).
Conclusion: Reductions in perioperative complications surrounding PDX have been reduced significantly in the last 20 years. Although advantages of MIS are demonstrated well in the literature and practical outcomes, the added value of MIS technique to PDX does not appear to be of considerable statistical significance. It is, however, possible that this paradigm may shift with an expected increase in utilization resulting from familiarity and proficiency with the technology.

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