• Bram L J van den Broek, Maurice J W Zwart, Bert A Bonsing, Olivier R Busch, Jacob L van Dam, de HinghIgnace H J TIHJTDepartment of Surgery, Catharina Medical Center, Eindhoven, Netherlands., Melissa E Hogg, Misha D Luyer, MieogJ Sven DJSDDepartment of Surgery, Leiden University Medical Center, Leiden, Netherlands., Luna A Stibbe, Kosei Takagi, TranT C KheTCKDepartment of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands., Roeland F de Wilde, Herbert J Zeh, Amer H Zureikat, Bas Groot Koerkamp, Marc G Besselink, and Dutch Pancreatic Cancer Group.
• Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.
• Ann. Surg. 2023 Nov 1; 278 (5): e1048e1054e1048-e1054.

ObjectiveTo assess the learning curve of pancreaticojejunostomy during robotic pancreatoduodenectomy (RPD) and to predict the risk of postoperative pancreatic fistula (POPF) by using the objective structured assessment of technical skills (OSATS), taking the fistula risk into account.BackgroundRPD is a challenging procedure that requires extensive training and confirmation of adequate surgical performance. Video grading, modified for RPD, of the pancreatic anastomosis could assess the learning curve of RPD and predict the risk of POPF.MethodsPost hoc assessment of patients prospectively included in 4 Dutch centers in a nationwide LAELAPS-3 training program for RPD. Video grading of the pancreaticojejunostomy was performed by 2 graders using OSATS (attainable score: 12-60). The main outcomes were the combined OSATS of the 2 graders and POPF (grade B/C). Cumulative sum analyzed a turning point in the learning curve for surgical skill. Logistic regression determined the cutoff for OSATS. Patients were categorized for POPF risk (ie, low, intermediate, and high) based on the updated alternative fistula risk scores.ResultsVideos from 153 pancreatic anastomoses were included. Median OSATS score was 48 (interquartile range: 41-52) points and with a turning point at 33 procedures. POPF occurred in 39 patients (25.5%). An OSATS score below 49, present in 77 patients (50.3%), was associated with an increased risk of POPF (odds ratio: 4.01, P =0.004). The POPF rate was 43.6% with OSATS < 49 versus 15.8% with OSATS ≥49. The updated alternative fistula risk scores category "soft pancreatic texture" was the second strongest prognostic factor of POPF (odds ratio: 3.37, P =0.040). Median cumulative surgical experience was 17 years (interquartile range: 8-21).ConclusionsVideo grading of the pancreatic anastomosis in RPD using OSATS identified a learning curve and a reduced risk of POPF in case of better surgical performance. Video grading may provide a valid method to surgical training, quality control, and improvement.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

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