Improved Quality Metrics for Robotic Pancreaticoduodenectomy With Increased Performance


Key Points

  • Significant improvements were observed for estimated blood loss and incidence of conversion to open surgery after 20 cases, incidence of pancreatic fistula after 40 cases, and operative time and lymph node harvest after 80 cases.
  • Continuous but nonsignificant improvement was observed for complication rate, length of stay, and readmission rate.

In a retrospective single-institution study reported in JAMA Surgery, Boone et al found significant improvements in blood loss, incidence of conversion to open surgery, pancreatic fistula incidence, and operative time with increased number of patients treated with robotic pancreaticoduodenectomy.

Study Details

The study involved data from 200 consecutive patients undergoing robotic pancreaticoduodenectomy at the University of Pittsburgh between October 2008 and March 2014. The robotic pancreaticoduodenectomys were performed for pancreatic ductal adenocarcinomas (41%), neuroendocrine tumors (8.5%), periampullary cancer (30%), indeterminate cystic lesions (12.5%), benign lesions (6%), gastrointestinal stromal tumors (1%), and metastatic disease (1%). Changes in quality metrics were analyzed by consecutive groups of 20 patients.

Timeline for Improvements

No significant changes in mortality rate or major morbidity were observed. Significant improvements were observed in estimated blood loss (600 vs 250 mL, P = .002) and incidence of conversion to open surgery (35.0% vs 3.3%, P < .001) after 20 cases, incidence of pancreatic fistula after 40 cases (27.5% vs 14.4%, P = .04), and operative time after 80 cases (581 vs 417 minutes, P < .001).

The number of lymph nodes harvested during resection to treat malignancy significantly increased after 80 cases (17 vs 26, P < .001). Complication rate, length of stay, and readmission rate showed continuous improvement that did not reach statistical significance.

The findings suggested optimization of outcomes during the first 80 of the 200 cases. Outcomes over the last 120 cases included mean operative time of 417 minutes, median estimated blood loss of 250 mL, a conversion to open surgery rate of 3.3%, 90-day mortality of 3.3%, clinically significant pancreatic fistula rate of 6.9%, and median length of stay of 9 days.

The investigators concluded: “Continuous assessment of quality metrics allows for safe implementation of [robotic pancreaticoduodenectomy]. We identified several inflexion points corresponding to optimization of performance metrics for [robotic pancreaticoduodenectomy] that can be used as benchmarks for surgeons who are adopting this technology.”

Amer H. Zureikat, MD, of University of Pittsburgh, is the corresponding author for the JAMA Surgery article.

The study was supported by a grant from the National Cancer Institute. Arthur James Moser, MD, and Melissa E. Hogg, MD, reported receiving grants from Intuitive Surgical Inc.

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