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Efforts to Mitigate Hospital Capacity: The Safety and Feasibility of Implementing an Enhanced Recovery and Early Discharge Pathway in a Robotic Pancreatoduodenectomy Program
Thomas Clancy, Zhi Ven Fong, Thinzar M. Lwin, Agim Aliaj, Jiping Wang
Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States

The COVID pandemic has placed a significant strain on hospital capacity, highlighting the importance of efficient utilization of healthcare resources. Enhanced Recovery After Surgery (ERAS) protocols have been implemented at our institution, demonstrating a decrease in complications and postoperative length of stay (LOS) in complex surgical procedures. We initiated a robotic pancreaticoduodenectomy (PD) program in 2020. We aim to assess the safety of an ERAS pathway in this program and compare outcomes with an open PD cohort as controls to determine the synergistic effects of robotic surgery and ERAS pathways on LOS.

Contemporary cohort analysis from 2020 to 2022.

Tertiary referral center.

Patients (or Other Participants):
Consecutive patients undergoing open or robotic pancreatoduodenectomy by a single surgeon.

Interventions (if any):
Robotic pancreatoduodenectomy.

Main Outcome Measure (s):
Length of hospital stay (LOS).

There were 113 consecutive patients who underwent PD, of which 29 (25.7%) were performed robotically. Pancreatic adenocarcinoma was the most common indication in both the open (57.1%) and robotic (51.7%, p=0.268) groups, with over 94% of them being borderline resectable tumors. The estimated blood loss was lower in the robotic PD group (median 100cc, IQR 100-175cc) when compared to the open PD group (median 200cc, IQR 125-400cc, p=0.003). When assessing postoperative outcomes, there were no differences in rates of pancreatic fistula (8.3% vs 3.5% in the robotic PD group, p=0.377) and delayed gastric emptying (14.3% vs 13.8% in the robotic PD group, p=0.948). However, the LOS was significantly shorter in the robotic PD group (median 5 days, IQR 4-7 days, p=0.006) when compared to the open PD group (median 6 days, IQR 5-8 days). A LOS of ≤4 days was observed in 34.5% of the robotic PD group compared to only 3.6% of patients in the open PD group (p<0.001), with no differences in the overall readmission rates (8.3% vs 13.8% in the robotic PD group, p=0.392).

An enhanced recovery and early discharge pathway could be safely implemented in a robotic PD program. Patients undergoing robotic PD have significantly shorter lengths of stay without increased complication or readmission rates compared to open PD. More than 1/3 of patients undergoing robotic PD achieved a LOS of ≤4 days.

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