Assessing the Outcomes of Robotic Pancreatoduodenectomy According to the Benchmark Cutoffs for the Open Approach: International Multicenter Study

Introduction: Several studies from high-volume centers have reported on the safety and feasibility of robotic pancreatoduodenectomy (RPD). Since no randomized trials have compared RPD versus open pancreatoduodenectomy (OPD) it is unclear how outcomes after these two approaches compare. Recently, outcome benchmarks for OPD were established to allow for unbiased outcome comparisons. Methods: An international multicenter retrospective cohort study, including consecutive patients after RPD in high-volume centers (first case – 31 December 2019) was conducted. Outcomes of the benchmark cases (low-risk patients) and patients with ASA≥3 were compared to the OPD benchmark cutoffs, reported by Sánchez-Velázquez et al. Lastly, clinical outcomes were stratified based on learning curve phases and annual volume. Results: Overall, 2186 patients from 18 centers in 8 countries were included, the percentage of benchmark cases was 53.5% (n=1169). Median annual volume of RPD per center was 24. Operative outcomes of the RPD-benchmark cases were compared to the OPD-benchmark cutoffs: operative time (5.5 vs ≤7.5 hours), POPF grade B/C rate (13.6% vs ≤19%), Clavien-Dindo ≥3 rate (14.4% vs ≤30%), in-hospital or 30-day mortality (1.1% vs ≤1.6%) and R1 rate for PDAC (12.4% vs ≤39%). As expected, patients with ASA≥3 had worse outcomes (7.1 hours, 16.7%, 22.4%, 3.5%, and 32%, respectively). Conclusions: Outcomes of RPD in this international cohort meet the established OPD-benchmark cutoffs. Moreover, 11 out of 14 available OPD-benchmark cutoffs are also met in patients with ASA≥3. These findings suggest that RPD can be performed safely in both low-risk and high-risk patients in high-volume centers.