Robotic versus open pancreatoduodenectomy in patients with obesity: propensity score-matched multicentre study

Background: Obesity increases morbidity after major abdominal surgery. Although the use of robotic pancreatoduodenectomy (RPD) is increasing, evidence of its outcomes in patients with obesity remains limited. This study compared perioperative outcomes of RPD versus open pancreatoduodenectomy (OPD) in patients with obesity. Methods: This was a retrospective multicentre cohort study of patients with a body mass index (BMI) ≥ 30 kg/m2 undergoing RPD or OPD between 2012 and 2024. Propensity score matching (PSM) was used to minimize selection bias. The primary outcome was severe complications (Clavien-Dindo ≥ IIIa). Secondary outcomes included blood loss, clinically relevant postoperative pancreatic fistula (CR-POPF), clinically relevant delayed gastric emptying (CR-DGE), wound infection, length of hospital stay (LOS), 90-day mortality, and R0 resection. Factors independently associated with severe complications and CR-POPF were investigated using multivariable logistic regression. Fistula risk was classified based on the Updated Alternate Fistula Risk Score (Pancreatic Fistula Risk Score, PFRS). Results: In all, 591 patients from 31 centres were analysed. After PSM, 166 patients undergoing RPD were compared to 166 undergoing OPD. In the PSM cohort, RPD was associated with significantly lower rates of severe complications (15.7% versus 27.7%; P = 0.007), CR-POPF (8.4% versus 18%; P = 0.011), CR-DGE (9% versus 18.7%; P = 0.022), and wound infection (4.2% versus 21%; P < 0.001). Median blood loss was lower in the RPD than OPD group (100 versus 200 ml; P < 0.001), as was median LOS (11 versus 17 days; P < 0.001). No differences were observed in 90-day mortality or R0 resection rates. Charlson co-morbidity index (odds ratio (OR) 0.68, 95% confidence interval (CI) 0.59-0.83, P = 0.003), robotic approach (OR 0.39, 95%CI 0.18-0.60, P = 0.002), and institutional experience of ≥ 20 robotic resections (OR 0.36, 95%CI 0.27-0.52, P = 0.007) were independently associated with lower CR-POPF risk, whereas a higher PFRS was associated with increased CR-POPF risk (OR 1.73, 95%CI 1.02-1.85, P = 0.032). Similarly, institutional experience of ≥ 20 robotic resections was independently associated with a lower incidence of severe complications (OR 0.39, 95%CI 0.22-0.81, P = 0.003), whereas a higher PFRS independently predicted severe complications (OR 1.93, 95%CI 1.07-2.31, P = 0.006). Conclusions: RPD is a safe and effective alternative to OPD in patients with obesity when performed in experienced centres. These findings support the adoption of RPD in select high-BMI populations in experienced institutions.