Lessons learned and pitfalls during the early robotic pancreatoduodenectomy experience

We thank our colleagues for their insightful comments on our study. Their remarks are greatly appreciated and offer an opportunity to clarify methodological aspects and further contextualize our results within the field of pancreatic surgery.

Indeed, as highlighted by colleagues in the second point of commentary, we agree that the early phase of robotic pancreatoduodenectomy (RPD) program usually involves careful selection in favor of smaller or non-pancreatic tumors, aiming to facilitate the learning curve during the initial period. However, as reported in the literature and proven in our initial experience, such cases are frequently associated with a soft pancreatic texture and narrow duct, two risk factors independently associated with a higher incidence of postoperative pancreatic fistula (POPF) (1,2). In our matched cohort, tumor size in the RPD group was significantly smaller than in the open group (23.5±13.6 vs. 28.6±14.8 mm, P=0.009), with a lower proportion of neoadjuvant therapy administration (11.7% vs. 33.3%, P=0.002). Despite apparent technical simplicity of these cases, this patient profile resulted in a higher incidence of POPF in early RPD cases (43.3% overall, with grade B/C 13.3%). This paradox supported by author’s observation underlines that presumed technical simplicity does not always result in lower morbidity (1,2). As our experience grew and case selection became broader, a concomitant decrease in major complications and improved outcomes was observed, findings confirmed by multicentric studies (3,4) and our learning curve analysis.

With respect to the first remark, we acknowledge the residual imbalance between groups, primarily in terms of tumor size and use of neoadjuvant therapy. These differences reflect a real-world clinical selection in high-volume centers, rather than methodological shortcomings. While propensity score matching allowed us to minimize confounding in demographic and general health variables, oncological and treatment-related characteristics remain more challenging to match in observational series (3).

While the NEPAFOX trial suggested reduced postoperative morbidity with neoadjuvant FOLFIRINOX in resectable pancreatic cancer (5), its applicability to POPF risk is limited. Crucially, the study did not report essential surgical risk parameters, such as pancreatic gland texture, main pancreatic duct diameter or anthropometric data like body mass index, nor did it apply a validated fistula risk score (FRS). These variables are well-established independent predictors of POPF and are incorporated in validated tools such as the FRS and the updated alternative FRS (1,6). Furthermore, NEPAFOX exclusively included pancreatic adenocarcinoma, whereas our matched series was histologically heterogeneous, including both pancreatic and non-pancreatic malignancies with distinct gland characteristics and risk profiles (5). For these reasons, the protective effect observed in NEPAFOX cannot be directly extrapolated to our population.

Limited access to robotic platforms is increasingly common and necessarily shapes both patient selection and the pace of the surgical learning curve. The progressive improvement in outcomes seen as our experience expanded is in line with data from recent multicenter studies, highlighting the importance of structured implementation and ongoing evaluation during adoption of RPD (4). Thus, the observed imbalances are an intrinsic feature of real-world surgery and should be transparently reported and considered when interpreting comparative outcomes.

In conclusion, residual confounding is inherent to observational research in complex surgical settings. Nevertheless, our findings support the stepwise and transparent adoption and implementation of RPD, even in environments with limited robotic access. Recognizing selection biases, whether toward smaller tumors, non-pancreatic lesions, or patients not receiving neoadjuvant therapy, is essential for accurate interpretation of outcomes and for guiding safe adoption strategies. We thank our colleagues once again for their valuable engagement, which we believe contributes meaningfully to the interpretation of our study and to the ongoing advancement of pancreatic surgery.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, HepatoBiliary Surgery and Nutrition. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-602/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Miller BC, Christein JD, Behrman SW, et al. A multi-institutional external validation of the fistula risk score for pancreatoduodenectomy. J Gastrointest Surg 2014;18:172-79; discussion 179-80. [Crossref] [PubMed]
2. Bruna CL, Emmen AMLH, Wei K, et al. Effects of Pancreatic Fistula After Minimally Invasive and Open Pancreatoduodenectomy. JAMA Surg 2025;160:190-8. [Crossref] [PubMed]
3. Klotz R, Mihaljevic AL, Kulu Y, et al. Robotic versus open partial pancreatoduodenectomy (EUROPA): a randomised controlled stage 2b trial. Lancet Reg Health Eur 2024;39:100864. [Crossref] [PubMed]
4. Zwart MJW, van den Broek B, de Graaf N, et al. The Feasibility, Proficiency, and Mastery Learning Curves in 635 Robotic Pancreatoduodenectomies Following a Multicenter Training Program: "Standing on the Shoulders of Giants". Ann Surg 2023;278:e1232-41. [Crossref] [PubMed]
5. Goetze TO, Reichart A, Bankstahl US, et al. Adjuvant Gemcitabine Versus Neoadjuvant/Adjuvant FOLFIRINOX in Resectable Pancreatic Cancer: The Randomized Multicenter Phase II NEPAFOX Trial. Ann Surg Oncol 2024;31:4073-83. [Crossref] [PubMed]
6. Mungroop TH, Klompmaker S, Wellner UF, et al. Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy: Pan-European Validation. Ann Surg 2021;273:334-40. [Crossref] [PubMed]