Impact of Surgical Approach on Post-Pancreatoduodenectomy Bleeding

OBJECTIVE: To determine the incidence of post-pancreatectomy hemorrhage (PPH) following robotic pancreatoduodenectomy (RPD) at high-volume US centers with experienced surgeons, and identify risk factors. SUMMARY BACKGROUND DATA: Recent randomized trials report variable PPH rates following RPD. As RPD utilization increases, understanding PPH risk is critical. METHODS: A retrospective cohort study across four high-volume robotic pancreas programs from 2007 to 2024, including all patients who underwent open pancreatoduodenectomy (OPD) or RPD. Primary outcome was PPH. Secondary outcomes included post-operative complications, length of stay, readmissions, 30- and 90-day mortality. Univariable and multivariable analysis (MVA) identified factors associated with PPH, post-operative pancreatic fistula (POPF), and mortality. RESULTS: Among 1925 patients (61.1% OPD, 38.9% RPD), OPD patients had lower BMI (P=0.0004) and larger tumors (P=0.0029). The RPD conversion rate was 8.8%. Despite a higher proportion of soft glands (38.9% vs. 33.1%, P<0.0001), RPD had less POPF (4.8% vs 9.3%, P=0.0003). OPD had worse post-operative outcomes but no difference in mortality. Rate, location, and severity of PPH did not differ by approach. On MVA, RPD was associated with decreased POPF risk (OR 0.44, P<0.0001), but increased PPH risk (OR 1.63, P=0.017). POPF was associated with increased PPH risk (OR 3.97, P<0.0001). Among patients with POPF, RPD remained associated with increased PPH risk (OR 3.15, P=0.0269). CONCLUSIONS: RPD reduces the risk of POPF, but may confer greater PPH risk, particularly in patients who develop POPF after RPD. These findings underscore the need for further investigation in the development of POPF after RPD.