Video Grading of Pancreatic Anastomoses During Robotic Pancreatoduodenectomy to Assess both Learning Curve and the Risk of Pancreatic Fistula – A Post Hoc Analysis of the LAELAPS-3 Training Program

To 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) score, taking the fistula risk score into account. RPD 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. Post-hoc assessment of patients prospectively included in four Dutch centers in a nationwide LAELAPS-3 training program for RPD. Video grading of the pancreaticojejunostomy was performed by two graders using OSATS (attainable scores 12-60). The main outcomes were the combined OSATS of the two graders and POPF (grade B/C). CUSUM analyzed a turning point in the learning curve for surgical skill. Logistic regression determined the cut-off for OSATS. Patients were categorized for POPF risk (i.e. low, intermediate, high) based on the updated alternative fistula risk scores (uaFRS). Videos from 153 pancreatic anastomoses were included. Median OSATS score was 48 (IQR 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, OR 4.01, P=0.004. The POPF rate was 43.6% with OSATS < 49 versus 15.8% with OSATS ≥49. The uaFRS category "soft pancreatic texture" was the second strongest prognostic factor of POPF (OR 3.37, P=0.040). Median cumulative surgical experience was 17 years (IQR 8-21) at their first anastomosis. Video 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.