The Feasibility, Proficiency, and Mastery Learning Curves in 635 Robotic Pancreatoduodenectomies Following A Multicenter Training Program
Authors: Zwart Maurice J.W. , van den Broek Bram , de Graaf Nine , Suurmeijer J. Annelie , Augustinus Simone , te Riele Wouter W. , van Santvoort Hjalmar C. , Hagendoorn Jeroen , Borel Rinkes Inne H.M. , van Dam Jacob L. , Takagi Kosei , Tran T.C. Khé , Schreinemakers Jennifer , van der Schelling George , Wijsman Jan H. , de Wilde Roeland F. , Festen Sebastiaan , Daams Freek , Luyer Misha D. , de Hingh Ignace H.J.T. , Mieog J. Sven D. , Bonsing Bert A. , Lips Daan J. , Hilal M Abu , Busch Olivier R. , Saint-Marc Olivier , Zeh Herbert J. , Zureikat Amer H. , Hogg Melissa E. , Koerkamp Bas Groot , Molenaar I. Quintus , Besselink Marc G. ,   for the Dutch Pancreatic Cancer Group
Published: June 2023

Objective:
To assess the feasibility, proficiency, and mastery learning curves for RPD in ‘second generation’ RPD centers following a multicenter training program adhering to the IDEAL framework.

Background:
The long learning curves for robotic pancreatoduodenectomy (RPD) reported from ‘pioneering’ expert centers may discourage centers interested in starting a RPD program. However, the feasibility, proficiency, and mastery learning curves may be shorter in ‘second generation’ centers who participated in dedicated RPD training programs, although data are lacking. We report on the learning curves for RPD in ‘second generation’ centers trained in a dedicated nationwide program.

Methods:
Post-hoc analysis of all consecutive patients undergoing RPD in seven centers that participated in the LAELAPS-3 training program, each with a minimum annual volume of 50 pancreatoduodenectomies, using the mandatory Dutch Pancreatic Cancer Audit (March 2016-December 2021). Cumulative sum (CUSUM) analysis determined cut-offs for the three learning curves: operative time for the feasibility (1), risk-adjusted major complication (Clavien-Dindo grade ≥III) for the proficiency (2), and textbook outcome for the mastery (3) learning curve. Outcomes before and after the cut-offs were compared for the proficiency and mastery learning curves. A survey was used to assess changes in practice and the most valued ‘lessons learned’.

Results:
Overall, 635 RPD were performed by 17 trained surgeons, with a conversion rate of 6.6% (n=42). The median annual volume of RPD per center was 22.5±6.8. From 2016-2021, the nationwide annual use of RPD increased from 0% to 23% whereas the use of laparoscopic PD decreased from 15% to 0%. The rate of major complications was 36.9% (n=234), surgical site infection (SSI) 6.3% (n=40), postoperative pancreatic fistula (grade B/C) 26.9% (n=171), and 30-day/in-hospital mortality 3.5% (n=22). Cut-offs for the feasibility, proficiency, and mastery learning curves were reached at 15, 62, and 84 RPD. Major morbidity and 30-day/in-hospital mortality did not differ significantly before and after the cut-offs for the proficiency and mastery learning curves. Previous experience in laparoscopic pancreatoduodenectomy shortened the feasibility (-12 RPDs, -44%), proficiency (-32 RPDs, -34%), and mastery phase learning curve (-34 RPDs, -23%), but did not improve clinical outcome.

Conclusions:
The feasibility, proficiency, and mastery learning curves for RPD at 15, 62, and 84 procedures in ‘second generation’ centers after a multicenter training program were considerably shorter as previously reported from ‘pioneering’ expert centers. The learning curve cut-offs and prior laparoscopic experience did not impact major morbidity and mortality. These findings demonstrate the safety and value of a nationwide training program for RPD in centers with sufficient volume.