Reply to 'letter to the editor of Annals of Surgical Oncology concerning "robotic versus open pancreatectomy: a systematic review and meta-analysis",' by Petrucciani Niccolò, et al. (ASO-2013-09-1427).

Abstract

We appreciate your efforts to invite us to respond to the letter by Petrucciani et al., and we thank Petrucciani and colleagues for their affirmative and suggestive comments. In response to their comments, the following paragraphs raise several points we wish to state. To begin with, we conclude with the first doubt of Petrucciani et al.—‘‘distal pancreatectomy (DP) robotic surgery does not necessarily gain from robotic surgery compared to pancreaticoduodenectomy (PD)’’. First, a variety of reports have demonstrated the safety and feasibility of robotic PD over open surgery in terms of estimated blood loss, overall complication rate, mortality, and hospital stay. In addition, the recent study by Daouadi et al. has demonstrated that robot-assisted minimally invasive distal pancreatectomy was superior to the laparoscopic technique. The results indicated that robot-assisted distal pancreatectomy (RADP) was equivalent to laparoscopic distal pancreatectomy (LDP) in nearly all measurable outcomes and safety, yet significantly reduced the risk of conversion to open resection, despite a statistically greater probability of malignancy in the robotic cohort. With regard to the question ‘‘cost effective?’’ mentioned by Petrucciani et al., the study by Waters et al. has shown that direct hospital costs were comparable among open distal pancreatectomy (ODP), LDP and RADP. The results suggested a shorter length of stay in robotic versus laparoscopic or open approaches. They concluded that RADP was safe and cost effective in the selected cases. Third, the aim of this meta-analysis was to perform a systematic review and meta-analysis of studies comparing the safety and efficacy of robotic pancreatectomy versus open pancreatectomy but not laparoscopic pancreatectomy. Fourth, we applied a random-effect model to take between-study variation into consideration. This does not necessarily rule out the effect of heterogeneity among studies, but one may expect a very limited influence. Admittedly, the number of studies comparing the safety and efficacy of RADP versus ODP was limited. With the accumulation and advancement of studies, further studies comparing robotic PD versus open PD, and comparing RADP versus ODP, respectively, will be necessary and more convincing. Furthermore, Petrucciani et al. doubted whether the higher rate of R0 resections for robotic pancreatectomy compared with open pancreatectomy was due to the technical characteristics of the robot or to a difference in patient selection. Actually, this question was asked by one reviewer. We admit that there was an inevitable selection bias in the published literature as the baseline characteristics of patients and the indications for operative procedure in the two groups were not identical in all studies, tending to favor the robotic technique. However, we have scrutinized the included studies in this systematic review and meta-analysis, and all the studies with the exception of the conference abstract by Hammill et al., This comment refers to the article available at doi:10.1245/s10434014-3555-3.