Comparison of robotic versus open pancreaticoduodenectomy: achieving a textbook oncologic operation for pancreatic ductal adenocarcinoma

Abstract

Presenter: Charles C Vining MD | University of Chicago Background: For complex oncologic operations, individual quality metrics including morbidity, length of stay, readmission, and mortality are critical. However, composite outcomes that combine several individual metrics can more reliably be used to score hospital and surgical performance. Therefore, a composite outcome for cancer, or a “textbook oncologic operation” (TOO), can be used to determine the overall quality of care. The aim of this study was to determine the differences in robotic versus open pancreaticoduodenectomy (PD) TOO for patients with pancreatic ductal adenocarcinoma (PDAC) and determine if there is a survival benefit associated with a TOO. Methods: Patients undergoing PD for PDAC between 2010 and 2015 were identified in the National Cancer Database (NCDB). Patients with other tumor types, tumors involving the celiac or superior mesenteric artery, distant metastases, patients who underwent other procedures and patients missing data regarding the TOO outcome metrics were excluded. Patients were dichotomized to have undergone a TOO if they fulfilled all metrics including: 1) resection with negative margins; 2) resection of at least 12 lymph nodes; 3) Length of stay ≤50th percentile by year; 4) no 30-day unplanned readmission; 5) no 30-day mortality and; 6) initiation of adjuvant chemotherapy within 12 weeks of surgery. Baseline characteristics of patients undergoing PD were evaluated. Fisher’s exact test was used to compare robotic versus open PD TOO individual metrics and as a composite endpoint. Kaplan-Meier estimates with the log-rank test were used to evaluate survival. Results: A total of 6,571 patients met inclusion criteria of which 6,405 (97.5%) underwent open and 166 (2.5%) underwent robotic PD. There was no statistically significant difference in baseline characteristics including age, sex, tumor size, tumor grade, pathologic tumor or nodal stage (p>0.05). Comparing robotic and open PD, there was no statistically significant difference in the rate of R0 resection, prolonged LOS, 30-day mortality, readmission and receipt of adjuvant chemotherapy. Patients who underwent robotic PD were associated with increased adequate lymphadenectomy (77.1% vs 69.4%; p=0.034) compared to open PD. The total number of patients who achieved a TOO was 974 (14.8%), of which 24 (2.5%) were robotic and 950 (97.5%) were open. There was no statistically significant difference in the rate if TOO between robotic versus open PD (14.5% vs 14.8%; p=0.893). The median overall survival for the entire cohort was 23 months. Patients that underwent a TOO had an improved median OS (27 vs. 22 months, p<0.001) compared to those who did not. There was no difference in median OS in patients who achieved (21 vs. 27 months; p=0.571) and did not achieve (24 vs. 22, p=0.449) a TOO stratified by surgical approach. Conclusion: Robotic PD is associated with equivalent R0 resection, prolonged LOS, 30-day mortality, readmission, and receipt of adjuvant chemotherapy compared to open PD. Robotic PD is associated with a statistically significant improvement in adequate lymphadenectomy compared to open PD. As a composite outcome, robotic PD delivered similar TOO to open PD. Patients that undergo TOO have improved OS. Randomized controlled trials are required determine if the robotic approach is superior to open PD.