New perspectives on robotic pancreaticoduodenectomy: An analysis of the National Cancer Database

BACKGROUNDPancreatic ductal adenocarcinoma is a common malignancy. Despite all advancements, the prognosis remains, poor with an overall 5-year survival of only 10.8%. Recently, a robotic platform has become an attractive tool for treating pancreatic cancer (PC). While recent studies indicated improved lymph node (LN) harvest during robotic pancreaticoduodenectomy (PD), data on long-term outcomes are insufficient. AIMTo evaluate absolute LN harvest during PD. Secondary outcomes included evaluating the association between LN harvest and short- and long-term oncological outcomes for three different surgical approaches. METHODSWe conducted an analysis of the National Cancer Database, including patients diagnosed with PC who underwent open, laparoscopic, or robotic PD in 2010-2018. One-way analysis of variance was used to compare continuous variables, chi-square test - for categorical. Overall survival was defined as the time between surgery and death. Median survival time was estimated with the Kaplan-Meier method, and groups were compared with the Wilcoxon test. A Cox proportional hazards model was used to assess the association of covariates with survival after controlling for patient characteristics and procedure type. RESULTS17169 patients were included, 8859 (52%) males; mean age 65; 14509 (85%) white. 13816 (80.5%) patients had an open PD, 2677 (15.6%) and 676 (3.9%) - laparoscopic and robotic PD respectively. Mean comorbidity index (Charlson-Deyo Score) 0.50. On average, 18.84 LNs were harvested. Mean LN harvest during open, laparoscopic and robotic PD was 18.59, 19.65 and 20.70 respectively (P < 0.001). On average 2.49 LNs were positive for cancer and did not differ by the procedure type (P = 0.26). Vascular invasion was noted in 42.6% of LNs and did differ by the approach: 42.1% for open, 44.0% for laparoscopic and 47.2% for robotic PD (P = 0.015). Median survival for open PD was 26.1 mo, laparoscopic - 27.2 mo, robotic - 29.1 mo (P = 0.064). Survival was associated with higher LN harvest, while higher number of positive LNs was associated with higher mortality. CONCLUSIONOur study suggests that robotic PD is associated with increased intraoperative LN harvest and has comparable short-term oncological outcomes and survival compared to open and laparoscopic approaches.