Do the simplest robotic procedures carry the highest morbidity?

We read with great interest the article by Antoine Castel et al. entitled “Safety and learning curve of robotic pancreatoduodenectomy with limited robotic platform access: a propensity score matched comparison with open surgery in a high volume center” (1). We commend the authors for this valuable contribution.

However, we would like to draw attention to two significant residual imbalances between the groups after matching, which may impact the interpretation of postoperative outcomes:

First, the open surgery group presented with significantly larger tumor sizes. Larger tumors are associated with more technically challenging resections, potentially increasing complication rates and introducing bias in comparative safety outcomes.

Second, a notably higher proportion of patients in the open group received preoperative chemotherapy. This factor is not benign: neoadjuvant chemotherapy has been reported to induce pancreatic fibrosis, which results in a firmer gland texture. Firmer pancreatic parenchyma is associated with a lower risk of postoperative pancreatic fistula (POPF), one of the most relevant complications after pancreaticoduodenectomy. This effect has been supported by recent evidence, notably the NEPAFOX trial demonstrated that Neoadjuvant chemotherapy was associated with less postoperative morbidity compared to upfront surgery group in resectable pancreatic cancer (2).

Indeed, in our experience of robotic pancreaticoduodenectomy we started our learning curve with small tumors or non-pancreatic tumors such as neuroendocrine or duodenal tumors. These tumors were easier to operate on but no less morbid, quite the contrary, as reported by the leakage score (3).

Therefore, the higher rate of complications observed in the robot-assisted group may be partially explained not only by the learning curve but also by the differences persisting between groups despite the propensity score allowing for the reduction of biases.

In conclusion, while we acknowledge the robust methodology of this work, we believe these residual confounding factors—namely, tumor size and neoadjuvant treatment—should be more explicitly addressed in the discussion, as they may significantly influence the interpretation of comparative safety outcomes.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-553/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.

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References

1. Castel A, De Rosa RV, Esvan M, et al. Safety and learning curve of robotic pancreatoduodenectomy with limited robotic platform access: a propensity score-matched comparison with open surgery in a high-volume center. Hepatobiliary Surg Nutr 2025;14:937-948. [Crossref] [PubMed]
2. 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]
3. 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]