Surgical Endoscopy and Other Interventional Techniques

https://doi.org/10.1007/s00464-021-08437-7

Propensity score‑matched comparison of the oncological feasibility

and survival outcomes for pancreatic adenocarcinoma with robotic
and open pancreatoduodenectomy
Bor‑Uei Shyr1 · Bor‑Shiuan Shyr1 · Shih‑Chin Chen1 · Yi‑Ming Shyr1 · Shin‑E Wang1

Received: 16 December 2020 / Accepted: 5 March 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Background  This study is to clarify the feasibility of and justification for robotic pancreaticoduodenectomy (RPD) in patients
with pancreatic adenocarcinoma.
Methods  A 1-to-1 propensity score-matched comparison of RPD and open pancreaticoduodenectomy (OPD) was performed
based on six covariates commonly used to predict the survival outcome for pancreatic adenocarcinoma.
Results  A total of 130 patients were enrolled, with 65 in each study group after propensity score matching. The median
operating time was longer for RPD (8.3 h vs. 7.0 h, P = 0.002). However, RPD was associated with less blood loss, lower
overall surgical complication rate, and lower incidence of delayed gastric emptying. The resection radicality was oncologi-
cally similar between these two groups, but the median lymph node yield was higher for RPD (18 vs. 16, P = 0.038). Before
propensity score matching, the 5-year survival was better in RPD (27.0% vs. 17.6%, P = 0.006). After matching, there was
still a trend towards improved overall survival in the RPD group; however, the difference in 5-year survival between RPD
and OPD was not significant (24.5% vs. 19.7%, P = 0.088).
Conclusion  RPD is not only technically feasible with no increase in surgical risk but also oncologically justifiable without
compromising survival outcome. However, unlike randomized control trials, the limitations in this propensity score-matched
analysis only accounted for 6 observed covariates commonly used to predict the survival outcome in patients with pancreatic
adenocarcinoma, and confounders not included in this study could also affect our results.

Keywords  Oncological · Pancreaticoduodenectomy · Propensity score · Robotic · Survival

Pancreatic adenocarcinoma is a malignancy with a notori-
ously dismal outcome, mainly due to its aggressive biology
[1, 2]. Surgical resection remains the only hope of cure in
patients with this type of cancer. Pancreaticoduodenectomy
requires a high level of technical skill, is time consuming,
and is traditionally performed via an open approach. Open
pancreaticoduodenectomy (OPD) requires a long abdominal
incision, which is very painful for patients. Minimally inva-
sive surgery has become a worldwide trend in many surgi-
cal fields, including pancreatic surgery [3, 4]. Laparoscopic
pancreaticoduodenectomy was introduced early in 1994 [5],
* Shin‑E Wang
sewang0408@gmail.com
1
Division of General Surgery, Department of Surgery, Taipei
Veterans General Hospital and National Yang Ming Chiao
Tung University, 201 Section 2 Shipai Road, Taipei 112,
Taiwan
but its application has been limited by its technical complex-
ity and the high level of surgical skill required. Pancreatic
reconstruction requires precise placement of suture needles
into small lumens followed by intracorporeal knot tying in
delicate and often friable pancreatic parenchyma. Mastering
these complicated operative steps requires advanced lapa-
roscopic skills and involves a steep learning curve. Since
the da Vinci Robotic Surgical System (Intuitive Surgical,
Inc., Sunnyvale, CA, USA) was introduced into the pancre-
atic surgery, several limitations related to the laparoscopic
approach have been overcome. Providing high-quality three-
dimensional vision, an optical magnification of 10–15,
articulation of instruments with 540 degrees of motion,
greater precision with suture targeting, and elimination of
surgeon tremor, the robotic approach makes it possible to
perform more delicate and complex procedures, such as
pancreaticoduodenectomy [6]. However, robotic pancreati-
coduodenectomy (RPD) is not widely performed because of

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concerns about the cost of the instruments and the associated
technical challenges and surgical risks [3].
Although some retrospective studies have claimed that
RPD is technically feasible and safe [7–9], there have been
concerns about the lack of randomized trials demonstrat-
ing the survival and oncologic outcomes when a robotic
approach is used to work inside the closed and limited space
of the abdominal cavity in patients with pancreatic adeno-
carcinoma. To minimize the inevitable selection bias that
occurs in retrospective research, we performed a propensity
score-matched analysis to clarify the feasibility of and justi-
fication for RPD in pancreatic adenocarcinoma by compar-
ing the survival and oncologic outcomes of RPD and OPD.
Materials and methods
Patients with periampullary lesions who underwent pancrea-
ticoduodenectomy with a modified Blumgart pancreaticoje-
junostomy (PJ) procedure via a robotic approach (n = 322)
or open approach (n = 230) between 2012 and 2019 were
identified. Among these PD patients, only those with pancre-
atic head adenocarcinoma were recruited for study. All data
were prospectively collected and entered into a computer
database. The study was approved by our institutional review
board (IRB-TPEVGH no. 2020-08-009BC). The patient con-
sent was waived in view of the retrospective nature of the
research and the anonymity of the data.
The da Vinci Si or Xi Surgical System was used for RPD.
Patient selection for RPD was decided mainly by the avail-
ability of a robotic machine and patient preference after
detailed counseling about the innovative nature of RPD and
the possible advantages and disadvantages of this surgical
approach, which is presently not funded in our country. To
avoid technique bias, only pure RPD and OPD cases were
included in the final analysis; cases needing conversion to
open or hybrid surgery were excluded. The study included
only those with a pathologic diagnosis of pancreatic ductal
adenocarcinoma, with exclusion of other pancreatic pathol-
ogies and periampullary lesions. All perioperative data,
including patient demographics, pathologic data, periop-
erative parameters, and oncologic and survival outcomes
were compared between RPD and OPD. A propensity score-
matched analysis based on six factors predictive of survival
outcomes in pancreatic adenocarcinoma was conducted.
Endpoints
The primary aim of the study was to clarify the justifica-
tion for RPD in patients with pancreatic adenocarcinoma
by comparing the survival and oncologic outcomes of RPD
and OPD. The secondary aim was to evaluate the feasibility
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Surgical Endoscopy
of RPD for pancreatic adenocarcinoma by comparing the
surgical outcomes of RPD and OPD.
Propensity score‑matching strategy
Propensity score matching was performed to balance poten-
tial confounders between the two types of surgical approach
(OPD and RPD) and to minimize selection bias when esti-
mating causal treatment effects in this retrospective non-
randomized study. An individual propensity score was devel-
oped by logistic regression modeling based on six covariates
commonly used to predict survival outcomes in pancreatic
adenocarcinoma, including tumor size, lymph node metasta-
sis, disease stage, lymphovascular invasion, perineural inva-
sion, and tumor cell differentiation. The patients with pan-
creatic head adenocarcinoma in the OPD and RPD groups
were then paired using the exact matching method and in
a 1-to-1 ratio, with the matches starting from cases with
the largest propensity score. A specific caliper width of 0.2
standard deviation of the logit of the estimated propensity
score was used [3, 4].
Surgical technique
All procedures were performed using the same surgical tech-
nique by the same team led by the same surgeon (Shyr YM).
Shyr YM and Wang SE have extensive experience with both
surgical approaches, with more than 500 cases of pancrea-
ticoduodenectomy, and all the procedures were under the
supervision of these 2 experienced surgeons. There would be
no significant difference in the quality of lymphadenectomy.
Pancreaticoduodenectomy with a modified Blumgart PJ has
been described previously in detail [10, 11]. Briefly, after
pancreaticoduodenectomy, the jejunal limb was brought up
through mesocolon of transverse colon. Blumgart PJ was
performed using 2 or 3 transpancreatic U-sutures with 3–0
monofilament synthetic absorbable sutures made of poly-
dioxanone (PDS™), usually 1 placed cranial and 1 or 2
caudal to the pancreatic duct. Each of the U-sutures was
placed at a distance of about 5 mm to the next one. These
sutures with needles on them were left untied at this time,
but instead kept separately and held with clamps or robotic
instruments until all of the inner duct-to-mucosa interrupted
sutures were placed and tied. A series of simple interrupted
sutures with 4–0 absorbable synthetic monofilament suture
made of polydioxanone (MonoPlus®) were then carefully
and accurately placed for duct-to-mucosa anastomosis. After
the duct-to-mucosal interrupted sutures were tied, the outer
anterior horizontal mattress sutures on the jejunum using
previously held U-sutures were completed and tied one by
one on the anterior surface of the pancreas. Thus, the pan-
creatic remnant was completely covered and compressed
by jejunal serosa. Pancreatic duct stents were not routinely
Surgical Endoscopy
used except for a small pancreatic duct using a short internal
stent. Pylorus was preserved whenever possible. The extent
of lymphadenectomy included dissections around superior
mesenteric vein, the right side of superior mesenteric artery,
common hepatic artery, and hepatoduodenal ligament.
The techniques for lymph node and nerve plexus dissec-
tion applied in RPD and OPD were same. There were some
differences in the technique used between the OPD and RPD
groups. An energy device with a Harmonic® scalpel was
used to divide the small vessels, and the Hem-o-lok® system
(Teleflex Inc., Chelmsford, MA, USA) was selectively used
for the large vessels in RPD, whereas most of the vascular
pedicles were selectively ligated or cauterized in OPD with-
out use of a Harmonic scalpel. The nasogastric tube placed
during the operation was usually removed on postoperative
day 1 to 3 if the patient had no significant abdominal dis-
comfort. Oral intake was allowed as early as postoperative
day 2 to 4 when tolerated. Postoperative chemotherapy was
our routine adjuvant therapy, but no neoadjuvant chemo-
therapy was administrated for all patients.
Definitions of surgical risk
Surgical mortality was defined as death within 90 days of
surgery, including hospital readmission or during the same
admission as the operation. Postoperative pancreatic fistula
(POPF) was referred to as grade B and C based on the new
definition and grading system devised by the International
Study Group for Pancreatic Fistula [12]. Delayed gastric
emptying (DGE), postpancreatectomy hemorrhage, and
chyle leak were identified and classified using the standard-
ized criteria proposed by the International Study Group of
Pancreatic Surgery [13–15]. Postoperative complications
were graded according to the Clavien-Dindo classification
[16]. Resection was stratified into three categories based on
the resection margin status: R0, a resection without both
gross and microscopic evidence of cancer at the resection
margin, under a definition of margin > 0 mm instead of 1 mm
defined by the National Comprehensive Cancer Network;
R1, a resection with grossly negative but microscopically
positive cancer at the resection margin; R2, a resection with
grossly positive cancer at the resection margin [17].
Statistical analysis
All continuous data are presented as the median or as the
mean and standard deviation, and frequencies are presented
as appropriate according to the type of data. Nonparametric
statistical tests were used if the variables did not follow a
normal distribution. Categorical variables are presented as
the number and percentage. The mean values for continuous
variables were compared with a two-tailed Student’s t test.
Categorical variables were compared using Pearson’s χ2 test
or Fisher’s exact test contingency tables. Actuarial survival
rates were estimated using the Kaplan–Meier method. The
log-rank test was used to compare differences between the
survival curves. The statistical analyses were carried out
using SPSS for Windows version 21.0 software (IBM Corp.,
Armonk, NY, USA). For all analyses, a P value < 0.05 was
considered statistically significant.
Results
One hundred and thirty patients were enrolled in the study,
with 65 in each study group after propensity score matching
(Fig. 1). Before matching, there were 190 patients with pan-
creatic adenocarcinoma who had undergone RPD (n = 82)
or OPD (n = 108) with a modified Blumgart PJ (Table 1);
patients with other pancreatic pathology or periampullary
lesions who underwent RPD (n = 240) or OPD (n = 122)
were excluded. Body mass index was higher in the RPD
group than in the OPD group before (P = 0.003) and after
(P = 0.012) propensity score matching. After matching, there
was no significant between-group difference in any of the
other demographic data, including sex, age, chemotherapy,
vascular resection, tumor size, lymph node metastasis, lym-
phovascular invasion, perineural invasion, tumor cell differ-
entiation, disease stage, and borderline resectability.
The median operating time was longer for RPD than for
OPD before (8.5 h vs. 7.3 h, P < 0.001) and after (8.3 h
vs. 7.0 h, P = 0.002) propensity score matching. RPD was
associated with less blood loss, a lower overall surgical
complication rate, and a lower incidence of DGE than
that of OPD before and after propensity score matching
(Table 2). There was no significant difference between
RPD and OPD regarding other surgical risks, including
surgical mortality, severity of complications based on the
Clavien-Dindo classification, POPF, postpancreatectomy
hemorrhage, chyle leak, bile leak, and wound infection,
Fig. 1  Propensity score-matching study focusing on survival out-
comes after robotic pancreaticoduodenectomy (RPD) or open pan-
creaticoduodenectomy (OPD) in patients with pancreatic head adeno-
carcinoma
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 Surgical Endoscopy

Table 1  Demographics of Before propensity score P value After propensity score P value

patients with pancreatic head matching matching
cancer undergoing robotic and
open pancreaticoduodenectomy RPD OPD RPD OPD
with modified Blumgart
pancreaticojejunostomy Patients, n 82 108 65 65
Gender 0.108 0.218
 Female 38 (46.3%) 61 (56.5%) 31 (47.7%) 39 (60.0%)
Age, year old 0.850 0.871
 Median (range) 66 (29–89) 66 (23–86) 66 (29–89) 66 (23–86)
 Mean ± SD 66 ± 12 66 ± 11 66 ± 13 66 ± 11
BMI 0.003 0.012
 Median (range) 24 (17–33) 22 (14–33) 24 (17–33) 22 (14–29)
 Mean ± SD 24 ± 4 22 ± 3 24 ± 4 22 ± 3
Chemotherapy (+) 65 (79.3%) 89 (82.4%) 0.582 51 (78.5%) 54 (83.1%) 0.657
Vascular resection (+) 9 (11.0%) 25 (23.1%) 0.036 9 (13.8%) 11 (16.9%) 0.809
Tumor size, cm 0.152 0.827
 Median (range) 3 (1.3 –6.0) 3 (1.0–33.5) 3 (1.3–5.7) 3 (1.5–5.0)
 Mean ± SD 3.1 ± 0.9 3.7 ± 3.2 3.1 ± 0.8 3.1 ± 0.7
Lymph node metastasis (+) 49 (58.8%) 77 (71.3%) 0.121 46 (70.8%) 46 (70.8%) 1.000
Lymphovascular invasion (+) 68 (82.9%) 66 (61.1%) 0.001 56 (86.2%) 56 (86.2%) 1.000
Perineural invasion (+) 76 (92.7%) 104 (96.3%) 0.333 62 (95.4%) 62 (95.4%) 1.000
Tumor cell differentiation 0.865 0.979
 Well 1 (1.2%) 2 (1.9%) 1 (1.5%) 1 (1.5%)
 Moderate 61 (74.4%) 77 (71.3%) 48 (73.8%) 49 (75.4%)
 Poorly 20 (24.4%) 29 (26.9%) 16 (24.6%) 15 (23.1%)
Stage 0.951
 I 17 (20.7%) 8 (7.4%) 8 (12.3%) 8 (12.3%)
 II 48 (58.5%) 79 (73.1%) 43 (66.2%) 44 (67.7%)
 III 15 (18.3%) 20 (18.5%) 12 (18.5%) 12 (18.5%)
 IV 2 (2.4%) 1 (0.9%) 2 (3.1%) 1 (1.5%)
Resectability 0.631 1.000
 Resectable 79 (91.5%) 96 (88.9%) 59 (90.8%) 60 (92.3%)
 Borderline resectable 7 (8.5%) 12 (11.1%) 6 (9.2%) 5 (7.7%)

RPD robotic pancreaticoduodenectomy, OPD open pancreaticoduodenectomy, BMI body mass index

before or after propensity score matching. The radicality Discussion

of resection was oncologically similar between RPD and
OPD; however, more lymph nodes were harvested dur-
ing RPD, with a median lymph node yield of 18 vs. 16
before (P = 0.012) and after (P = 0.038) propensity score
matching.
Before propensity score matching, the 5-year sur-
vival outcome was better in the RPD group than in the
OPD group (27.0% vs. 17.6%, P = 0.00; Table 3). After
propensity score matching based on six factors predic-
tive of survival outcome, there was still a trend towards
improved overall survival in the RPD group, although the
between-group difference was not significant (P = 0.088).
The 1-year, 3-year, and 5-year overall survival rates were
79.9%, 42.8%, and 24.5% for RPD and 67.4%, 26.3%, and
19.7% for OPD (Fig. 2).
Pancreaticoduodenectomy is among the most technically
challenging of surgical procedures. It involves not only
extensive and protracted dissection but also meticulous
suturing technique for complex reconstructions, which
usually makes the inherent technical limitations of the
laparoscopic approach more evident [4, 18, 19]. Recently,
robotic surgery has been gaining momentum in many sur-
gical fields. Given its innovative nature, there are pres-
ently few reports in the literature on RPD when performed
for pancreatic adenocarcinoma [20, 21]. Thus far, RPD
has been compared with OPD only in small, retrospec-
tive, non-randomized cohort studies of variable quality
[20, 22–27]. Moreover, most of the studies have included

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Table 2  Surgical and oncological outcomes for pancreatic head cancer after robotic and open pancreaticoduodenectomy with modified Blumgart
pancreaticojejunostomy
Before propensity score matching P value After propensity score matching P value
RPD OPD RPD OPD

Patients, n (%) 82 108 65 65

Operation time, hour  < 0.001 0.020
 Median (range) 8.5 (4.5–14.0) 7.3 (4.2–12.5) 8.3 (4.5–14.0) 7.0 (4.2–12.5)
 Mean ± SD 8.7 ± 2.0 7.6 ± 1.9 8.5 ± 2.0 7.7 ± 2.0
Blood loss, c.c  < 0.001  < 0.001
 Median (range) 200 (0–1000) 485 (100–1900) 200 (0–1000) 500 (120–1900)
 Mean ± SD 243 ± 192 536 ± 350 251 ± 210 562 ± 368
Surgical Mortality (+) 1 (1.2%) 0 0.423 0 0 1.000
Surgical complication (+) 35 (42.7%) 63 (58.3%) 0.023 28 (43.1%) 41 (63.1%) 0.035
Complication classification 0.027 0.079
 Clavien–Dindo I 20 (24.4%) 50 (46.3%) 18 (27.7%) 32 (49.2%)
 Clavien–Dindo II 7 (8.5%) 8 (7.4%) 6 (9.2%) 5 (7.7%)
 Clavien–Dindo III 7 (8.5%) 5 (4.6%) 4 (6.2%) 4 (6.2%)
 Clavien–Dindo IV 0 0 0 0
 Clavien–Dindo V (death) 1 (1.2%) 0 0 0
POPF (grade B and C) 9 (11.0%) 5 (4.6%) 0.159 6 (9.2%) 2 (4.6%) 0.429
Delayed gastric emptying 1 (1.2%) 17 (15.7%) 0.001 1 (1.5%) 11 (16.9%) 0.004
PPH 3 (3.7%) 5 (4.6%) 1.000 3 (4.6%) 4 (6.2%) 1.000
Chyle leakage 19 (23.2%) 27 (25.0%) 0.865 15 (23.1%) 18 (27.7%) 0.687
Bile leakage 0 2 (1.9%) 0.507 0 2 (3.1%) 0.496
Wound infection 2 (2.4%) 6(5.6%) 0.470 2 (3.1%) 4 (6.2%) 0.680
Radicality
 R0 71 (91.5%) 96 (88.9%) 0.776 60 (92.3%) 61 (93.8%) 0.843
 R1 3 (3.7%) 4 (3.7%) 2 (3.1%) 1 (1.5%)
 R2 4 (4.9%) 8 (7.4%) 3 (4.6%) 3 (4.6%)
Lymph node harvested, n 0.012 0.038
Median (range) 18 (7–43) 16 (2–40) 18 (7–43) 16 (2–30)
Mean ± SD 18 ± 7 16 ± 7 18 ± 7 16 ± 6

RPD robotic pancreaticoduodenectomy, OPD open pancreaticoduodenectomy, POPF postoperative pancreatic fistula, PPH postpancreatectomy
hemorrhage, R0 curative resection with a margin > 0 mm, R1 microscopic residual cancer, R2 gross residual cancer

Table 3  Survival outcomes Before propensity score P value After propensity score P value
for pancreatic head cancer matching matching
after robotic and open
pancreaticoduodenectomy RPD OPD RPD OPD

Patients, n (%) 82 108 65 65

Survival time, month 0.006 0.088
 Median 17.7 14.3 18.6 13.2
 Range 1.7–57.4 0.7–93.2 1.7–57.4 0.7–93.2
 Mean ± SD 19.1 ± 12.7 20.0 ± 18.0 20.4 ± 13.5 18.0 ± 15.9
1-year survival 83.7% 68.6% 79.9% 67.4%
3-year survival 47.2% 27.7% 42.8% 26.3%
5-year survival 27.0% 17.6% 24.5% 19.7%

RPD robotic pancreaticoduodenectomy, OPD open pancreaticoduodenectomy

13

Fig. 2  Survival curves for patients with pancreatic head adenocarci-
noma after robotic pancreaticoduodenectomy (RPD) and open pan-
creaticoduodenectomy (OPD). A Before propensity score matching
and B after matching based on six covariates commonly used to pre-
both pancreatic head adenocarcinoma and other periamp-
ullary lesions; therefore, the survival outcomes could not
be addressed due to heterogeneous pathology.
In view of the lack of high-quality randomized con-
trolled trials, evidence for the feasibility of and justifica-
tion for RPD in pancreatic adenocarcinoma is still limited,
although it was confirmed to be feasible and safe by some
pioneer surgeons [4, 7, 22–24]. A propensity score-matched
study could be an alternative way of balancing OPD and
RPD for potential confounders and to minimize selection
bias when estimating causal treatment effects in retrospec-
tive non-randomized studies. So far, there were two studies
using a propensity score-matched analysis for pancreatic
adenocarcinoma [21, 28]. Baimas-George et al. [28] con-
ducted a propensity-matched study comparing operative
and oncologic outcomes between RPD and OPD in patients
with pancreatic adenocarcinoma, with 38 cases in each arm.
They demonstrated that RPD not only afforded a similar if
not superior immediate postoperative benefit by decreasing
DGE but also, importantly, that it might have an improved
oncologic outcome. They found a trend towards improved
median overall survival in their RPD group (30.4 months
vs. 23.0 months; P = 0.1105) and a longer time to recur-
rence (402 days vs. 284 days; P = 0.7471). They concluded
that while the feasibility and safety of RPD had been dem-
onstrated, the impact on oncologic outcome had yet to be
confirmed. The significantly higher lymph node yield and
decreased inflammatory response demonstrated for robotic
surgery might improve overall survival for pancreatic adeno-
carcinoma. Kauffman et al. [21] reported a propensity score-
matched analysis of robotic versus open pancreatoduodenec-
tomy for pancreatic cancer based on margin status, with 20
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Surgical Endoscopy
dict survival outcomes for pancreatic head adenocarcinoma, includ-
ing tumor size, lymph node metastasis, disease stage, lymphovascular
invasion, perineural invasion, and tumor cell differentiation
patients in RPD group and 24 in OPD. They concluded that
RPD and OPD achieved the same rate of R1 resections in
resectable pancreatic cancer. RPD was also non-inferior to
OPD with respect to all secondary study endpoints. How-
ever, the limitation of these two studies is small number of
patients in each arm.
While the early reports focused mainly on technical safety
and feasibility in selected patients, oncologic and survival
outcomes would be the prime concerns after RPD. Our pre-
vious propensity score-matched study has already demon-
strated the technical feasibility of RPD [7]. In that study,
our main purpose was to evaluate POPF and the surgical
risk; therefore, the propensity score-matched analysis was
based on four covariates commonly used in the Callery fis-
tula risk scoring system [29]. To our knowledge, the present
report is the first to compare the oncologic feasibility and
survival outcomes between RPD and OPD when performed
exclusively in pancreatic adenocarcinoma by the same sur-
gical team led by the same surgeon using the same surgical
technique. Compared with OPD, RPD was associated with
similar surgical risks, including surgical mortality, compli-
cations, POPF, PPH, chyle leakage, bile leak, and wound
infection, and the radicality of resection was comparable
between the two groups before and after propensity score
matching. Moreover, RPD had the benefits of less blood
loss, a lower DGE rate, and a higher lymph node yield. The
lower DGE rate could be due to less inflammation inside the
abdominal cavity by minimally invasive robotic approach.
This study confirms both the technical and oncologic feasi-
bility of RPD for pancreatic adenocarcinoma.
To minimize selection bias in this study, which focused
mainly on survival outcome, the propensity score-matched
Surgical Endoscopy
analysis was based on six measurable covariates com-
monly used to predict the survival outcome in patients
with pancreatic adenocarcinoma, including tumor size,
lymph node metastasis, disease stage, lymphovascular
invasion, perineural invasion, and tumor cell differentia-
tion. However, there were other potentially confounders
that were not taken into account, such as emotional sta-
tus of the patient and family support. The 5-year survival
outcome was better in our RPD group than in our OPD
group before propensity score matching (27.0% vs. 17.6%,
P = 0.006), and there was still a trend towards improved
overall survival following RPD after matching, although
the between-group difference was not significant (24.5%
vs. 19.7%, P = 0.088). These findings could reflect the sur-
gical radicality of RPD and its higher lymph node yield.
In conclusion, this study showed that the survival out-
come was better after RPD than after OPD before pro-
pensity score matching. There was still a trend towards
improved overall survival for RPD after matching,
although the difference between RPD and OPD was not
significant. The oncologic outcomes after RPD were
not inferior to those after OPD, with similar radicality
of resection and a higher lymph node yield. Moreover,
RPD had the benefits of less blood loss and a lower DGE
rate when compared with OPD. RPD is not only techni-
cally feasible with no increase in surgical risk but also
oncologically justifiable without compromising survival
outcome. However, there are some limitations of pro-
pensity score-matched analysis. One of the limitations in
this study is that propensity score-matched analysis only
accounted for 6 observed covariates commonly used to
predict the survival outcome in patients with pancreatic
adenocarcinoma. Unlike randomized control trials, the
remaining unobserved confounders might still be present,
thus, leading to biased results. Confounders not included
in the propensity score-matched analysis could also affect
our results. Large prospective randomized controlled tri-
als with long-term follow-up are needed to confirm the
oncologic feasibility and survival outcomes of RPD for
pancreatic adenocarcinoma.
Acknowledgements  The authors would like to acknowledge the sup-
port of the Biobank of Taipei Veterans General Hospital. This work
was financially supported by grants from the Taipei Veterans General
Hospital (V110B-023, V110C-010 and V110C-011), the Ministry of
Science and Technology (MOST 108-2314-B-075-051-MY3), and the
Ministry of Health and Welfare (MOHW107-TDU-B-212-114026A).
Declarations  Büchler MW (2007) Postpancreatectomy hemorrhage (PPH): an
Disclosures  Dr. Bor-Uei Shyr, Bor-Shiuan Shyr, Shih-Chin Chen, Yi-
Ming Shyr, and Shin-E Wang have no conflicts of interest or financial
ties to disclose.
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