Pancreaticoduodenectomy for benign and pre-malignant pancreatic and ampullary disease: is robotic surgery the better approach?

Abstract

Presenter: Benedetto Mungo MD | University of Pittsburgh Medical Center Background: The robotic platform is increasingly being utilized in pancreatic surgery, yet its overall merits and putative advantages – compared to the classic laparotomy approach – remain to be adjudicated. The majority of available comparative analysis focuses primarily on pancreatic adenocarcinoma where surgical outcomes are influenced and conditioned by the complex underlying pathology and the need for peri-operative systemic therapy. We hypothesize that the benefits of minimally invasive pancreatic surgery are maximized in pancreatic benign and premalignant disease, in the setting of friable pancreatic tissue and small pancreatic duct. Methods: Retrospective analysis of a single institution prospectively maintained pancreatic database of all consecutive patients who underwent pancreaticoduodenectomy (PD) for benign or premalignant conditions between 2010 to 2020. Peri-operative outcomes and long-term complications (> 90 days post-PD) were compared between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD). Continuous variables were reported as means and standard deviation or medians and interquartile ranges and compared using two-sided t-test, while categorical variables were reported as frequencies and percentages and compared using Pearson chi-squared (p<0.05). Results: Two hundred and four (n=204) patients met our inclusion criteria, of which 68 were OPD and 136 RPD. Selected histologies included but were not limited to adenoma with dysplasia (any grade), intraepithelial neoplasia, intraductal oncocytic papillary neoplasm, intraductal papillary mucinous neoplasm, pseudopapillary neoplasm, serous cystadenoma and neuroendocrine tumor with no invasive or metastatic features. Findings are summarized in Table 1. There were no significant differences in baseline characteristics between the two groups, exception made for a higher rate of coronary artery disease (24.2% vs. 11%, p=0.015) in the OPD group. Patients in the RPD group were more likely to undergo a classic Whipple procedure (84.6% vs. 55.9%, p<0.001) had shorter operative time (387.80±114.11 vs. 453.79±159.18 minutes, p<0.001) and lesser lymph node yield (21 vs. 20, p=0.011) when compared to those in the open group. Notable post-operative merits of the RPD included a significantly shorter length of stay (LOS) (7 vs. 10 days, p=0.004), fewer grade B pancreatic fistulas (8.8% vs. 32.3%, p=0.001) and lower 90-day mortality (0.7% vs. 5.9%, p=0.025) as compared to OPD. Finally, rates of long-term complications were comparable between the two groups, exception made for a higher chance of needing surgery for small bowel obstruction in the open group (3.1% vs. 0%, p=0.039). Conclusion: The results of our analysis suggest that robotic pancreaticoduodenectomy has lower 90-day mortality, shorter LOS and lower rates of selected complications when compared to open pancreaticoduodenectomy. While randomized data are needed to strengthen our conclusions, our results make a compelling argument for the prioritization of the robotic platform in the surgical treatment of benign and premalignant pancreatic diseases, in the appropriate patient population.