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INTERNATIONAL MULTI-INSTITUTIONAL PROPENSITY SCORE-MATCHED COMPARISON OF ROBOTIC VERSUS OPEN REPAIR FOR IATROGENIC BILE DUCT INJURY
Hasan Al Harakeh
*, Fabrizio Di Benedetto, Roberta Odorizzi, Christiano Guidetti, Sharona B. Ross, Garnet Vanterpool, Kristina Milivojev Covilo, Ismael Dominguez Rosado, Iswanto Sucandy
Digestive Health Institute, Advent Health Tampa, Tampa, FL
Background: Recent studies suggest robotic-assisted repair of iatrogenic bile duct injury (BDI) is a safe alternative to open repair. However, most studies are single-institutional with small sample size without matching. We present an international multi-institutional comparison of clinical outcomes after robotic vs open iatrogenic BDI repair.
Methods: We undertook a retrospective analysis of prospectively-maintained databases from hepatobiliary centers in Tampa, Mexico and Italy. 1:2 Propensity score matching (PSM) adjusting for age, sex, body mass index (BMI), American Society of Anesthesiology (ASA) Score, Strasberg-Bismuth grade (SBG) and concomitant vascular injury was conducted. BDIs were classified as low (SBG: A, B, C, D&E1), medium (E2&E3) or high (E4&E5) grade. Results were reported as Median (Mean ± STD).
Results: We included a total of 80 patients, 16 robotic and 64 open repairs of BDI. After PSM we retained 12 robotic and 24 open repairs. There were no statistically significant differences in sex, BMI, ASA score, or concomitant vascular injury between the two groups. More high-grade BDI repairs were performed robotically (7 (44%) vs 9 (14%) p=0.007). Intraoperatively, estimated blood loss (EBL) was significantly higher in the open cohort [robotic 50 (62
+ 47) ml vs open 200 (329
+ 436) ml, p=0.017] before PSM and [50 (54
+ 45) ml vs 225 (333
+ 345) ml p = 0.009] after PSM. Postoperatively, the need for intensive care (ICU) admission, complications (Clavien-Dindo < or
>3), bile leak, 30-day readmissions, and follow-up time were similar. Open repair was also associated with a longer hospital stay [8 (12
+12) vs 5 (4
+1.35) days, p = 0.028] and a higher 90-day readmission [7 (29%) vs 0 (0%), p = 0.0371]. Conversely, two postoperative cardiopulmonary arrests unrelated to the BDI repair leading to mortalities occurred on and the day after surgery in the robotic repair group, [2 (17%) vs 0 (0%), p = 0.039]. After adjusting for cause of mortality related to BDI repair, 90-day mortality is similar between robotic and open approaches. When further subdivided based on timing of repair, early repair (?7 days) using open approach were associated with higher overall postoperative complications (CD < or ?3) compared with those repaired using robotic approach. Patients undergoing Late repair, beyond 7 days, using robotic approach was associated with longer ICU stay. Primary patency rate was similar between both cohorts.
Conclusion: Open repair for iatrogenic bile duct injury is associated with a higher estimated blood loss, longer hospital stay, and higher 90-day readmission. When performed within 7 days, open repair is also associated with higher early postoperative complications. Robotic approach for BDI should be considered as an alternative technique to the conventional open operation.
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