Adoption and outcomes of robotic pancreatectomy in the United States: An instrumental variable analysis.

BACKGROUND

The use of minimally invasive surgery approaches has lagged in pancreatic surgery. Single-center studies support using robotic approaches for pancreatectomy, but as pancreatectomy expands outside specialty centers, current data may not reflect all practice settings.

METHODS

We queried Medicare claims for fee-for-service beneficiaries undergoing distal pancreatectomy or pancreaticoduodenectomy from 2011 to 2023, capturing a varied population across practice settings. We used instrumental variable analysis to compare risk-adjusted 90-day postoperative outcomes between open, laparoscopic, and robotic approaches. The instrumental variable used was hospital referral region-level prior year pancreatectomy robotic use. Hospitals were volume stratified based on the Leapfrog Group's cutoff of 20 operations annually.

RESULTS

We identified 55,514 beneficiaries: 43,230 pancreaticoduodenectomy (756 robotic, 753 laparoscopic, and 41,721 open) and 12,284 distal pancreatectomy (1,131 robotic, 981 laparoscopic, and 10,172 open). Laparoscopic pancreatectomy increased after initial adoption between 2014 and 2016 before plateauing. Robotic-assisted pancreaticoduodenectomy and distal pancreatectomy increased 12-fold and 3.6-fold over the study period, respectively, resulting in a 10-percentage point increase in minimally invasive surgery pancreatectomies. Robotic-assisted pancreatectomy was associated with significantly lower rates of serious complications (10.4% vs 16.8%), reoperation (5.7% vs 7.8%), and 90-day mortality (5.2% vs 7.7%) compared with open procedures. Outcomes were similar between robotic and laparoscopic procedures. While outcomes were overall better at high-volume centers, outcomes did not vary by approach within low-volume hospitals. Ninety-day total episode spending was lower for robotic as compared with open operations.

CONCLUSION

There has been rapid growth in robotic-assisted pancreatectomy over the past 2 decades, resulting in improved penetration of minimally invasive surgery approaches. The use of robotic-assisted pancreatectomy is not associated with worse outcomes compared with open and laparoscopic procedures, including at low-volume institutions. These findings support the use of the robotic approach for this complex operation.