Textbook outcomes in robotic pancreaticoduodenectomy: a European multicenter analysis on surgical performance and...

Robotic pancreatoduodenectomy (RPD) has emerged as a safe and feasible alternative to open surgery, extending the benefits of minimally invasive surgery to complex pancreatic procedures. However, standardized and comparable metrics to evaluate surgical quality in RPD remain limited. This study aimed to evaluate surgical and oncologic textbook outcomes (TO and TOO) and to identify predictors of success across multiple European centers.

All consecutive RPDs performed between 2010 and 2024 in six European pancreatic centers were retrospectively analyzed. Textbook outcome (TO) was defined as the absence of major complications (Clavien-Dindo ≥ III), clinically relevant pancreatic fistula, post-pancreatectomy hemorrhage or bile leak, 30-day or in-hospital mortality, and 30-day readmission. An extended composite (TO + LOS) additionally incorporated prolonged hospital stay (> 14 days). In patients with pancreatic ductal adenocarcinoma (PDAC), textbook oncologic outcome (TOO) included six oncologic and perioperative quality items.

A total of 403 RPDs were analyzed. Overall morbidity and major complications occurred in 61% and 26% of patients, respectively. TO and TO + LOS were achieved in 63% and 52% of cases, with no significant intercountry differences among countries. Independent predictors of TO were female sex (OR 2.32, p < 0.001), neoadjuvant therapy (OR 2.85, p = 0.018), preoperative biliary drainage (OR 1.87, p = 0.012), and shorter operative time (p < 0.001). Among 247 PDAC cases, TOO was achieved in 33.6%, mainly limited by inadequate lymph node retrieval.

RPD achieves reproducible and high-quality composite outcomes across experienced European centers. Our findings suggests that these composite measures may provide a reliable tool for quality assessment in RPD, reflecting the combined impact of patient selection and perioperative management.