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Ann Surg. 2019 Mar 28. doi: 10.1097/SLA.0000000000003291. [Epub ahead of print]

Procedure-specific Training for Robot-assisted Distal Pancreatectomy.

Author information

1
Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA.
2
Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
3
Department of Surgery, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands.
4
Department of Nursing, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
5
Medical Executive Committee, Beth Israel Deaconess Medical Center, Boston, MA.
6
The Transplant Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
7
Department of Surgery, Boston Medical Center, Boston University, Boston, MA.

Abstract

MINI: Cohort study (n = 237) describing a training program to teach robot-assisted distal pancreatectomy to surgeons at an academic institution and assess its impact on outcomes. After training, perioperative blood loss and length of stay improved, while complication rates remained unchanged. Propensity-score matching confirmed a 2-day reduction in length of stay after RADP.

OBJECTIVE:

To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality.

BACKGROUND:

RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce.

METHODS:

A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; <June 2012) and "after training" (RADP and ODP; >June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy.

RESULTS:

After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP.

CONCLUSION:

Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.

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