Video Grading of Pancreatic Anastomoses During Robotic Pancreatoduodenectomy to Assess Both Learning Curve and the Risk of Pancreatic Fistula

Abstract

Objective: To assess the learning curve of pancreaticojejunostomy during robotic pancreatoduodenectomy (RPD) and to predict the risk of postoperative pancreatic fistula (POPF) by using the objective structured assessment of technical skills (OSATS), taking the fistula risk into account. Background: RPD is a challenging procedure that requires extensive training and confirmation of adequate surgical performance. Video grading, modified for RPD, of the pancreatic anastomosis could assess the learning curve of RPD and predict the risk of POPF. Methods: Post hoc assessment of patients prospectively included in 4 Dutch centers in a nationwide LAELAPS-3 training program for RPD. Video grading of the pancreaticojejunostomy was performed by 2 graders using OSATS (attainable score: 12-60). The main outcomes were the combined OSATS of the 2 graders and POPF (grade B/C). Cumulative sum analyzed a turning point in the learning curve for surgical skill. Logistic regression determined the cutoff for OSATS. Patients were categorized for POPF risk (ie, low, intermediate, and high) based on the updated alternative fistula risk scores. Results: Videos from 153 pancreatic anastomoses were included. Median OSATS score was 48 (interquartile range: 41-52) points and with a turning point at 33 procedures. POPF occurred in 39 patients (25.5%). An OSATS score below 49, present in 77 patients (50.3%), was associated with an increased risk of POPF (odds ratio: 4.01, P = 0.004). The POPF rate was 43.6% with OSATS < 49 versus 15.8% with OSATS ≥ 49. The updated alternative fistula risk scores category "soft pancreatic texture" was the second strongest prognostic factor of POPF (odds ratio: 3.37, P = 0.040). Median cumulative surgical experience was 17 years (interquartile range: 8-21). Conclusions: Video grading of the pancreatic anastomosis in RPD using OSATS identified a learning curve and a reduced risk of POPF in case of better surgical performance. Video grading may provide a valid method to surgical training, quality control, and improvement.

Learning curves in laparoscopic distal pancreatectomy: a different experience for each generation

“…To establish learning curves for the groups of either ‘self-taught’ or ‘trained’ surgeons rather than for 8 individual surgeons, the methodology of a similar study by Halls et al . 34 was followed, although there are also examples of other recent publications that performed multi-surgeon or multicenter CUSUM analysis 35 , 36 . First, data from all patients were combined to construct risk-adjusted regression models for operative time and major complications using univariable and multivariable regression analyses with backward selection.…”

Employing Advanced Technology to Reduce Postoperative Pancreatic Fistula

“…This work represents another excellent example of how the ease of video review with robotic surgery can drive quality improvement and support technical advancement of robotic pancreatoduodenectomy. 9 – 13 Further, this approach may not just drive future improvements, but monitoring pancreatic stump perfusion in real-time in the operating room could support modifying the anastomosis if necessary.…”