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

Table 1 Demographic characteristics of adult patients who underwent pancreaticoduodenectomy, n (%)

Characteristic	Total (n = 17169)	Type of procedure			P value
		Open (n = 13816)	Laparoscopic1 (n = 2677)	Robotic2 (n = 676)
Age, mean (95%CI)3	64.9 (64.7, 65.0)	64.81 (64.62, 64.99)	64.97 (64.55, 65.39)	65.36 (64.47, 66.25)	0.38
Sex					0.93
Female	8310 (48.4)	6694 (48.45)	1287 (48.08)	329 (48.67)
Male	8859 (51.6)	7122 (51.55)	1390 (51.92)	347 (52.33)
Race4					0.18
White	14509 (84.5)	11658 (84.38)	2284 (85.32)	567 (83.88)
Black	1739 (10.1)	1435 (10.39)	237 (8.85)	67 (9.91)
Other	766 (4.5)	597 (4.32)	133 (4.97)	36 (5.33)
Unknown	155 (0.9)	126 (0.91)	23 (0.86)	6 (0.89)
Hispanic ethnicity					0.009
Yes	981 (5.7)	809 (5.86)	145 (5.42)	27 (3.99)
No	16188 (94.29)	13007 (94.14)	2532 (95.58)	649 (96.01)
Charlson-Deyo score					0.52
0	10977 (63.9)	8867 (64.18)	1692 (63.21)	418 (61.83)
1	4471 (26.0)	3578 (25.90)	710 (26.52)	183 (27.07)
2	1134 (6.6)	904 (6.54)	175 (6.54)	55 (8.14)
3 or more	587 (3.4)	467 (3.38)	100 (3.74)	20 (2.96)
Surgical procedure					0.07
With partial gastrectomy	14068 (81.94)	11357 (82.20)	2152 (80.39)	559 (82.69)
Without partial gastrectomy	3101 (18.06)	2459 (17.80)	525 (19.61)	117 (17.31)

¹Includes minimally invasive and minimally invasive converted to open.

²Includes robotic-assisted and robotic-assisted converted to open.

³Ages greater than 90 were recoded to 90.

⁴Includes patients who identified themselves as Korean, Filipino, Chinese, Japanese, Pakistani, Hawaiian, American Indian, Asian, or other smaller ethnic groups.

Table 2 Tumor characteristics for adult patients who underwent pancreaticoduodenectomy, n (%)

	Total (n = 17169)	Type of procedure			P value
		Open (n = 13816)	Laparoscopic1 (n = 2677)	Robotic2 (n = 676)
Year of diagnosis					< 0.0001
2010	1374 (8.0)	1212 (8.77)	148 (5.53)	14 (2.07)
2011	1514 (8.82)	1238 (8.96)	250 (9.34)	26 (3.85)
2012	1601 (9.32)	1347 (9.75)	225 (8.40)	29 (4.29)
2013	1738 (10.12)	1466 (10.61)	244 (9.11)	28 (4.14)
2014	1816 (10.58)	1469 (10.63)	286 (10.68)	61 (9.02)
2015	1986 (11.57)	1587 (11.49)	314 (11.73)	85 (12.57)
2016	2154 (12.55)	1665 (12.05)	374 (13.97)	115 (17.01)
2017	2099 (12.23)	1625 (11.67)	361 (13.49)	113 (16.72)
2018	2887 (16.82)	2207 (15.97)	475 (17.74)	205 (30.33)
Histology					< 0.0001
Adenocarcinoma	7085 (41.27)	5688 (41.17)	1177 (43.97)	220 (32.54)
Duct carcinoma	6775 (39.46)	5482 (39.68)	1005 (37.54)	288 (42.60)
Other	3309 (19.27)	2646 (19.15)	495 (18.49)	168 (24.85)
Primary Site (C25.2 excluded)					< 0.0001
Head of pancreas	15196 (88.51)	12365 (89.50)	2253 (84.16)	578 (85.50)
Body of pancreas	671 (3.91)	446 (3.23)	174 (6.50)	51 (7.54)
Pancreatic duct	83 (0.48)	62 (0.45)	18 (0.67)	3 (0.44)
Islet of Langerhans or endocrine pancreas	37 (0.22)	26 (0.19)	11 (0.41)	0
Other/unspecified	11182 (6.88)	917 (6.64)	221 (8.26)	44 (6.51)
AJCC Clinical Stage					0.0002
0	321 (1.87)	261 (1.89)	48 (1.79)	12 (1.78)
1	230 (1.34)	202 (1.46)	21 (0.78)	7 (1.04)
1A	1979 (11.53)	1593 (11.53)	297 (11.09)	89 (13.17)
1B	4539 (26.44)	3715 (26.89)	703 (26.26)	121 (17.90)
2	135 (0.79)	122 (0.88)	11 (0.41)	2 (0.30)
2A	3320 (19.34)	2686 (19.44)	511 (19.09)	123 (18.20)
2B	3154 (18.37)	2522 (18.25)	514 (19.20)	109 (16.12)
3	612 (3.56)	507 (3.67)	97 (4.62)	8 (1.18)
Unknown	2888 (16.82)	2208 (15.98)	475 (17.74)	205 (30.33)
Grade					< 0.0001
Well differentiated	1993 (13.95)	1627 (14.01)	287 (13.03)	79 (16.77)
2 – Moderately differentiated	6093 (42.66)	4903 (42.23)	990 (44.96)	200 (42.46)
3 – Poorly differentiated	3976 (27.84)	3256 (28.05)	614 (27.88)	106 (22.51)
4 - Undifferentiated	190 (1.33)	158 (1.36)	23 (1.04)	9 (1.91)
Not determined	2030 (14.21)	1665 (14.34)	288 (13.08)	77 (16.35)
Tumor size in mm, mean (95%CI)	33.21 (32.95, 33.48)	31.95 (30.69, 33.21)	33.13 (32.44, 33.82)	33.29 (33.00, 33.58)	0.015

¹Includes minimally invasive and minimally invasive converted to open.

²Includes robotic-assisted and robotic-assisted converted to open. AJCC: American Joint Committee on Cancer.

Table 3 Lymph node harvest and short-term oncologic outcomes for patients who underwent pancreaticoduodenectomy, n (%)

Characteristic	Total (n = 17169)	Type of procedure			P value
		Open (n = 13816)	Laparoscopic1 (n = 2677)	Robotic2 (n = 676)
Mean Lymph nodes harvested (95%CI)	18.84 (18.69, 18.98)	18.59 (18.43, 18.75)	19.65 (19.29, 20.02)	20.70 (19.89, 21.51)	< 0.0001
Mean Lymph nodes positive (95%CI)	2.49 (2.44, 2.55)	2.48 (2.48, 2.54)	2.58 (2.45, 2.72)	2.37 (2.11, 2.64)	0.26
Vascular invasion					0.0115
Yes	7313 (42.6)	5816 (42.1)	1178 (44.0)	319 (47.2)
No	7764 (45.2)	6259 (45.3)	1208 (45.1)	297 (43.9)
Unknown	2092 (12.2)	1741 (12.6)	291 (10.9)	60 (8.9)
AJCC Pathological Stage					0.02
0	341 (1.99)	281 (2.03)	45 (1.68)	15 (2.22)
1	79 (0.46)	68 (0.49)	9 (0.34)	2 (0.30)
1A	995 (5.80)	778 (5.63)	169 (6.31)	48 (7.10)
1B	1102 (6.42)	918 (6.64)	148 (5.53)	36 (5.33)
2	45 (0.26)	44 (0.32)	1 (0.04)	0
2A	2849 (16.59)	2322 (16.81)	435 (16.25)	92 (13.61)
2B	8430 (49.10)	6826 (49.41)	1335 (49.87)	269 (39.79)
3	317 (1.85)	262 (1.90)	47 (1.76)	8 (1.18)
Unknown	3011 (17.54)	2317 (16.77)	488 (18.23)	206 (30.47)
Surgical margins					0.75
No residual tumor (R0)	13728 (79.96)	11042 (79.92)	2150 (80.31)	536 (79.29)
Microscopic residual tumor (R1)	3232 (18.82)	2601 (18.83)	495 (18.49)	136 (20.12)
Macroscopic residual tumor (R2)	87 (0.51)	73 (0.53)	13 (0.49)	1 (0.15)
Cannot be accessed	122 (0.71)	100 (0.72)	19 (0.71)	3 (0.44)
Length of stay (95%CI)	10.77 (10.63, 10.90)	10.92 (10.77, 11.07)	10.29 (9.92, 10.66)	9.61 (8.97, 10.25)	< 0.0001
Readmission 30 d (readmitted)	1398 (8.14)	1113 (8.06)	227 (8.48)	58 (8.58)	0.71
Mortality 30 d (dead)	381 (2.67)	312 (2.69)	55 (2.50)	14 (2.99)	0.80
Mortality 90 d (dead)	752 (5.30)	634 (5.50)	97 (4.42)	21 (4.48)	0.09

¹Includes minimally invasive and minimally invasive converted to open.

²Includes robotic-assisted and robotic-assisted converted to open. AJCC: American Joint Committee on Cancer.

Table 4 Cox proportional hazards model of mortality after surgery for patients with pancreatic cancer

Characteristic	Parameter estimate	Hazard ratio	95%CI	P value
Age (yr)	0.01621	1.02	1.01-1.02	< 0.0001
Male sex	0.02903	1.03	0.98-1.08	0.20
Race: White	ref
Black	-0.0599	0.94	0.87-1.02	0.13
Other	-0.15749	0.85	0.76-0.96	0.009
Unknown	-0.16688	0.85	0.65-1.10	0.21
Hispanic ethnicity: No	ref
Yes	-0.15238	0.86	0.78-0.95	0.0037
Unknown	-0.03096	0.97	0.82-1.15	0.72
Tumor grade: 1	ref
2	0.45571	1.58	1.45-1.72	< 0.0001
3	0.70413	2.02	1.85-2.21	< 0.0001
4	0.80073	2.23	1.82-2.73	< 0.0001
Not determined, unknown	0.35723	1.43	1.28-1.60	< 0.0001
Surgical approach: Open	ref
MIS, MIS to open	-0.0402	0.96	0.90-1.02	0.19
Robotic, robotic to open	0.00838	1.01	0.88-1.15	0.90
Surgical margins: No residual tumor	ref
Macroscopic residual tumor	0.44741	1.56	1.19-2.05	0.0013
Microscopic residual tumor	0.34752	1.42	1.34-1.49	< 0.0001
Unknown, indeterminate	0.40122	1.49	1.15-1.94	0.0026
AJCC Pathological stage: 0	ref
1/1A/1B	0.49238	1.64	1.22-2.18	0.0008
2/2A/2B	0.90708	2.48	1.86-3.29	< 0.0001
3	1.10653	3.02	2.21-4.14	< 0.0001
Census block median income quartile: > 63332
$50354-$63332	0.06511	1.07	1.01-1.13	0.027
$40227-$50353	0.17171	1.19	1.12-1.26	< 0.0001
< $40227	0.19323	1.21	1.14-1.30	< 0.0001
Unknown	0.12115	1.13	0.61-2.10	0.70
Histology: Adenocarcinoma	ref
Duct carcinoma	-0.05251	0.95	0.91-0.99	0.027
All others	-0.72939	0.48	0.44-0.52	< 0.0001
Charlson-Deyo score: 0
1	0.10936	1.12	1.06-1.17	< 0.0001
2	0.18942	1.21	1.11-1.32	< 0.0001
3 or more	0.35643	1.43	1.26-1.62	< 0.0001
Lymph nodes examined	-0.01026	0.99	0.99-0.99	< 0.0001
Lymph nodes positive for cancer	0.05025	1.05	1.04-1.06	< 0.0001
Tumor size (mm)1	0.00479	1.01	1.00-1.01	< 0.0001
Year of diagnosis	-0.03434	0.97	0.96-0.98	< 0.0001
Weeks between diagnosis and surgery	0.00702	1.01	1.01-1.01	< 0.0001

¹Tumors greater than 200 were recoded to 200.

MIS: Minimally invasive surgery; AJCC: American Joint Committee on Cancer.