A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula

Matthew T. McMillan, Amer H. Zureikat, Melissa E. Hogg, Stacy J. Kowalsky, Herbert J. Zeh, Michael H. Sprys, Charles M. Vollmer

Research output: Contribution to journalArticle

30 Citations (Scopus)

Abstract

IMPORTANCE The adoption of robotic pancreatoduodenectomy (RPD) is gaining momentum; however, its impact on major outcomes, including pancreatic fistula, has yet to be adequately compared with open pancreatoduodenectomy (OPD). OBJECTIVE To demonstrate that use of RPD does not increase the incidence of clinically relevant pancreatic fistula (CR-POPF) compared with OPD. DESIGN, SETTING, AND PARTICIPANTS Datawere accrued from 2846 patients who underwent pancreatoduodenectomies (OPDs, n = 2661; RPDs, n = 185), performed by 51 surgeons at 17 institutions worldwide (2003-2015). All RPDs were conducted at a high-volume, academic, pancreatic surgery specialty center-in a standardized fashion-by surgeons who had surpassed the RPD learning curve. Propensity score matching was used to minimize bias from nonrandomized treatment assignment. The RPD and OPD cohorts were matched by propensity scores accounting for factors significantly associated with either undergoing robotic surgery or CR-POPF occurrence on logistic regression analysis. These variables included pancreatic gland texture, pancreatic duct diameter, intraoperative blood loss, pathologic findings of disease, and intraoperative drain placement. INTERVENTIONS Use of RPD or OPD. MAIN OUTCOMES AND MEASURES The major outcome of interestwas CR-POPF occurrence, which is the most common and morbid complication following pancreatoduodenectomy. RESULTS The overall cohort was 51.5%male, with a median age of 64 years (interquartile range, 56-72 years). The propensity score-matched cohort comprised 152 RPDs and 152 OPDs; all covariate imbalances were alleviated. After adjusting for potential confounders, undergoing RPD was associated with a reduced risk for CR-POPF incidence (OR, 0.4 [95%CI, 0.2-0.7]; P = .002) relative to OPD. Other predictors of risk-adjusted CR-POPF occurrence included soft pancreatic parenchyma (OR, 4.7 [95%CI, 3.4-6.6]; P < .001), pathologic findings of high-risk disease (OR, 1.4 [95%CI, 1.1-1.9]; P = .01), small pancreatic duct diameter (vs≥5 mm: 2 mm, OR, 2.1 [95%CI, 1.4-3.1]; P < .001;≤1 mm, OR, 1.8 [95%CI, 1.0-3.0]; P = .03), elevated intraoperative blood loss (vs≤400 mL: 401-700mL, OR, 1.5 [95%CI, 1.1-2.0]; P = .01; >1000 mL, OR, 2.1 [95%CI, 1.4-2.9]; P < .001), omission of intraoperative drain(s) (OR, 0.5 [95%CI, 0.3-0.8]; P = .005), and octreotide prophylaxis (OR, 3.1 [95%CI, 2.3-4.0]; P < .001). Patients undergoing RPD demonstrated similar CR-POPF rates compared with patients in the OPD cohort (6.6%vs 11.2%; P = .23). This relationship held for both grade B (6.6%vs 9.2%; P = .52) and grade C (0% vs 2.0%; P = .25) POPFs. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication (73.7%vs 66.4%; P = .21), severe complications (Accordion grade-3, 23.05% vs 23.7%; P > .99), hospital stay (median: 8 vs 8.5 days; P = .31), 30-day readmission (22.4% vs 21.7%; P > .99), and 90-day mortality (3.3%vs 1.3%; P = .38). CONCLUSIONS AND RELEVANCE To our knowledge, this is the first propensity score-matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.

Original languageEnglish (US)
Pages (from-to)327-335
Number of pages9
JournalJAMA Surgery
Volume152
Issue number4
DOIs
StatePublished - Apr 2017
Externally publishedYes

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Pancreatic Fistula
Propensity Score
Pancreaticoduodenectomy
Robotics
Incidence
Learning Curve
Pancreatic Ducts

ASJC Scopus subject areas

  • Surgery

Cite this

McMillan, M. T., Zureikat, A. H., Hogg, M. E., Kowalsky, S. J., Zeh, H. J., Sprys, M. H., & Vollmer, C. M. (2017). A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula. JAMA Surgery, 152(4), 327-335. https://doi.org/10.1001/jamasurg.2016.4755

A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula. / McMillan, Matthew T.; Zureikat, Amer H.; Hogg, Melissa E.; Kowalsky, Stacy J.; Zeh, Herbert J.; Sprys, Michael H.; Vollmer, Charles M.

In: JAMA Surgery, Vol. 152, No. 4, 04.2017, p. 327-335.

Research output: Contribution to journalArticle

McMillan, MT, Zureikat, AH, Hogg, ME, Kowalsky, SJ, Zeh, HJ, Sprys, MH & Vollmer, CM 2017, 'A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula', JAMA Surgery, vol. 152, no. 4, pp. 327-335. https://doi.org/10.1001/jamasurg.2016.4755
McMillan, Matthew T. ; Zureikat, Amer H. ; Hogg, Melissa E. ; Kowalsky, Stacy J. ; Zeh, Herbert J. ; Sprys, Michael H. ; Vollmer, Charles M. / A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula. In: JAMA Surgery. 2017 ; Vol. 152, No. 4. pp. 327-335.
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abstract = "IMPORTANCE The adoption of robotic pancreatoduodenectomy (RPD) is gaining momentum; however, its impact on major outcomes, including pancreatic fistula, has yet to be adequately compared with open pancreatoduodenectomy (OPD). OBJECTIVE To demonstrate that use of RPD does not increase the incidence of clinically relevant pancreatic fistula (CR-POPF) compared with OPD. DESIGN, SETTING, AND PARTICIPANTS Datawere accrued from 2846 patients who underwent pancreatoduodenectomies (OPDs, n = 2661; RPDs, n = 185), performed by 51 surgeons at 17 institutions worldwide (2003-2015). All RPDs were conducted at a high-volume, academic, pancreatic surgery specialty center-in a standardized fashion-by surgeons who had surpassed the RPD learning curve. Propensity score matching was used to minimize bias from nonrandomized treatment assignment. The RPD and OPD cohorts were matched by propensity scores accounting for factors significantly associated with either undergoing robotic surgery or CR-POPF occurrence on logistic regression analysis. These variables included pancreatic gland texture, pancreatic duct diameter, intraoperative blood loss, pathologic findings of disease, and intraoperative drain placement. INTERVENTIONS Use of RPD or OPD. MAIN OUTCOMES AND MEASURES The major outcome of interestwas CR-POPF occurrence, which is the most common and morbid complication following pancreatoduodenectomy. RESULTS The overall cohort was 51.5{\%}male, with a median age of 64 years (interquartile range, 56-72 years). The propensity score-matched cohort comprised 152 RPDs and 152 OPDs; all covariate imbalances were alleviated. After adjusting for potential confounders, undergoing RPD was associated with a reduced risk for CR-POPF incidence (OR, 0.4 [95{\%}CI, 0.2-0.7]; P = .002) relative to OPD. Other predictors of risk-adjusted CR-POPF occurrence included soft pancreatic parenchyma (OR, 4.7 [95{\%}CI, 3.4-6.6]; P < .001), pathologic findings of high-risk disease (OR, 1.4 [95{\%}CI, 1.1-1.9]; P = .01), small pancreatic duct diameter (vs≥5 mm: 2 mm, OR, 2.1 [95{\%}CI, 1.4-3.1]; P < .001;≤1 mm, OR, 1.8 [95{\%}CI, 1.0-3.0]; P = .03), elevated intraoperative blood loss (vs≤400 mL: 401-700mL, OR, 1.5 [95{\%}CI, 1.1-2.0]; P = .01; >1000 mL, OR, 2.1 [95{\%}CI, 1.4-2.9]; P < .001), omission of intraoperative drain(s) (OR, 0.5 [95{\%}CI, 0.3-0.8]; P = .005), and octreotide prophylaxis (OR, 3.1 [95{\%}CI, 2.3-4.0]; P < .001). Patients undergoing RPD demonstrated similar CR-POPF rates compared with patients in the OPD cohort (6.6{\%}vs 11.2{\%}; P = .23). This relationship held for both grade B (6.6{\%}vs 9.2{\%}; P = .52) and grade C (0{\%} vs 2.0{\%}; P = .25) POPFs. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication (73.7{\%}vs 66.4{\%}; P = .21), severe complications (Accordion grade-3, 23.05{\%} vs 23.7{\%}; P > .99), hospital stay (median: 8 vs 8.5 days; P = .31), 30-day readmission (22.4{\%} vs 21.7{\%}; P > .99), and 90-day mortality (3.3{\%}vs 1.3{\%}; P = .38). CONCLUSIONS AND RELEVANCE To our knowledge, this is the first propensity score-matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.",
author = "McMillan, {Matthew T.} and Zureikat, {Amer H.} and Hogg, {Melissa E.} and Kowalsky, {Stacy J.} and Zeh, {Herbert J.} and Sprys, {Michael H.} and Vollmer, {Charles M.}",
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T1 - A propensity score-matched analysis of robotic vs open pancreatoduodenectomy on incidence of pancreatic fistula

AU - McMillan, Matthew T.

AU - Zureikat, Amer H.

AU - Hogg, Melissa E.

AU - Kowalsky, Stacy J.

AU - Zeh, Herbert J.

AU - Sprys, Michael H.

AU - Vollmer, Charles M.

PY - 2017/4

Y1 - 2017/4

N2 - IMPORTANCE The adoption of robotic pancreatoduodenectomy (RPD) is gaining momentum; however, its impact on major outcomes, including pancreatic fistula, has yet to be adequately compared with open pancreatoduodenectomy (OPD). OBJECTIVE To demonstrate that use of RPD does not increase the incidence of clinically relevant pancreatic fistula (CR-POPF) compared with OPD. DESIGN, SETTING, AND PARTICIPANTS Datawere accrued from 2846 patients who underwent pancreatoduodenectomies (OPDs, n = 2661; RPDs, n = 185), performed by 51 surgeons at 17 institutions worldwide (2003-2015). All RPDs were conducted at a high-volume, academic, pancreatic surgery specialty center-in a standardized fashion-by surgeons who had surpassed the RPD learning curve. Propensity score matching was used to minimize bias from nonrandomized treatment assignment. The RPD and OPD cohorts were matched by propensity scores accounting for factors significantly associated with either undergoing robotic surgery or CR-POPF occurrence on logistic regression analysis. These variables included pancreatic gland texture, pancreatic duct diameter, intraoperative blood loss, pathologic findings of disease, and intraoperative drain placement. INTERVENTIONS Use of RPD or OPD. MAIN OUTCOMES AND MEASURES The major outcome of interestwas CR-POPF occurrence, which is the most common and morbid complication following pancreatoduodenectomy. RESULTS The overall cohort was 51.5%male, with a median age of 64 years (interquartile range, 56-72 years). The propensity score-matched cohort comprised 152 RPDs and 152 OPDs; all covariate imbalances were alleviated. After adjusting for potential confounders, undergoing RPD was associated with a reduced risk for CR-POPF incidence (OR, 0.4 [95%CI, 0.2-0.7]; P = .002) relative to OPD. Other predictors of risk-adjusted CR-POPF occurrence included soft pancreatic parenchyma (OR, 4.7 [95%CI, 3.4-6.6]; P < .001), pathologic findings of high-risk disease (OR, 1.4 [95%CI, 1.1-1.9]; P = .01), small pancreatic duct diameter (vs≥5 mm: 2 mm, OR, 2.1 [95%CI, 1.4-3.1]; P < .001;≤1 mm, OR, 1.8 [95%CI, 1.0-3.0]; P = .03), elevated intraoperative blood loss (vs≤400 mL: 401-700mL, OR, 1.5 [95%CI, 1.1-2.0]; P = .01; >1000 mL, OR, 2.1 [95%CI, 1.4-2.9]; P < .001), omission of intraoperative drain(s) (OR, 0.5 [95%CI, 0.3-0.8]; P = .005), and octreotide prophylaxis (OR, 3.1 [95%CI, 2.3-4.0]; P < .001). Patients undergoing RPD demonstrated similar CR-POPF rates compared with patients in the OPD cohort (6.6%vs 11.2%; P = .23). This relationship held for both grade B (6.6%vs 9.2%; P = .52) and grade C (0% vs 2.0%; P = .25) POPFs. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication (73.7%vs 66.4%; P = .21), severe complications (Accordion grade-3, 23.05% vs 23.7%; P > .99), hospital stay (median: 8 vs 8.5 days; P = .31), 30-day readmission (22.4% vs 21.7%; P > .99), and 90-day mortality (3.3%vs 1.3%; P = .38). CONCLUSIONS AND RELEVANCE To our knowledge, this is the first propensity score-matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.

AB - IMPORTANCE The adoption of robotic pancreatoduodenectomy (RPD) is gaining momentum; however, its impact on major outcomes, including pancreatic fistula, has yet to be adequately compared with open pancreatoduodenectomy (OPD). OBJECTIVE To demonstrate that use of RPD does not increase the incidence of clinically relevant pancreatic fistula (CR-POPF) compared with OPD. DESIGN, SETTING, AND PARTICIPANTS Datawere accrued from 2846 patients who underwent pancreatoduodenectomies (OPDs, n = 2661; RPDs, n = 185), performed by 51 surgeons at 17 institutions worldwide (2003-2015). All RPDs were conducted at a high-volume, academic, pancreatic surgery specialty center-in a standardized fashion-by surgeons who had surpassed the RPD learning curve. Propensity score matching was used to minimize bias from nonrandomized treatment assignment. The RPD and OPD cohorts were matched by propensity scores accounting for factors significantly associated with either undergoing robotic surgery or CR-POPF occurrence on logistic regression analysis. These variables included pancreatic gland texture, pancreatic duct diameter, intraoperative blood loss, pathologic findings of disease, and intraoperative drain placement. INTERVENTIONS Use of RPD or OPD. MAIN OUTCOMES AND MEASURES The major outcome of interestwas CR-POPF occurrence, which is the most common and morbid complication following pancreatoduodenectomy. RESULTS The overall cohort was 51.5%male, with a median age of 64 years (interquartile range, 56-72 years). The propensity score-matched cohort comprised 152 RPDs and 152 OPDs; all covariate imbalances were alleviated. After adjusting for potential confounders, undergoing RPD was associated with a reduced risk for CR-POPF incidence (OR, 0.4 [95%CI, 0.2-0.7]; P = .002) relative to OPD. Other predictors of risk-adjusted CR-POPF occurrence included soft pancreatic parenchyma (OR, 4.7 [95%CI, 3.4-6.6]; P < .001), pathologic findings of high-risk disease (OR, 1.4 [95%CI, 1.1-1.9]; P = .01), small pancreatic duct diameter (vs≥5 mm: 2 mm, OR, 2.1 [95%CI, 1.4-3.1]; P < .001;≤1 mm, OR, 1.8 [95%CI, 1.0-3.0]; P = .03), elevated intraoperative blood loss (vs≤400 mL: 401-700mL, OR, 1.5 [95%CI, 1.1-2.0]; P = .01; >1000 mL, OR, 2.1 [95%CI, 1.4-2.9]; P < .001), omission of intraoperative drain(s) (OR, 0.5 [95%CI, 0.3-0.8]; P = .005), and octreotide prophylaxis (OR, 3.1 [95%CI, 2.3-4.0]; P < .001). Patients undergoing RPD demonstrated similar CR-POPF rates compared with patients in the OPD cohort (6.6%vs 11.2%; P = .23). This relationship held for both grade B (6.6%vs 9.2%; P = .52) and grade C (0% vs 2.0%; P = .25) POPFs. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication (73.7%vs 66.4%; P = .21), severe complications (Accordion grade-3, 23.05% vs 23.7%; P > .99), hospital stay (median: 8 vs 8.5 days; P = .31), 30-day readmission (22.4% vs 21.7%; P > .99), and 90-day mortality (3.3%vs 1.3%; P = .38). CONCLUSIONS AND RELEVANCE To our knowledge, this is the first propensity score-matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.

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