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Background <p>Conversion to laparotomy during robotic pancreatoduodenectomy (RPD) carries important clinical implications, yet its incidence, predictors, and consequences in elderly and/or obese patients remain poorly characterized. This study aimed to define the conversion rate, identify preoperative predictors, and assess the impact of conversion on postoperative outcomes in elderly and/or obese surgically high-risk patients undergoing attempted RPD.</p> Methods <p>A retrospective analysis was performed using a multi-institutional database. Patients were included if they underwent attempted RPD and met at least one high-risk criterion: age ≥ 80&#xa0;years and/or BMI ≥ 30&#xa0;kg/m<sup>2</sup>. Conversion was defined as any unplanned transition from robotic to open surgery after initiation of the robotic procedure. Reasons for conversion were assigned using a hierarchical, mutually exclusive framework: intraoperative complication, patient instability, vascular involvement, or strategic surgeon decision.</p> Results <p>Among 311 patients, 36 (11.6%) required conversion to laparotomy. The most common recorded reason was strategic surgeon decision (<i>n</i> = 18, 50.0%), followed by vascular involvement (<i>n</i> = 10, 27.8%), intraoperative complications, and patient instability. On multivariable analysis, independent predictors of conversion were preoperative biliary drainage (OR 7.36; <i>p</i> = 0.021) and vascular involvement (OR 22.22; <i>p</i> = 0.027), while male sex was protective (OR 0.22; <i>p</i> = 0.032). Robotic experience &gt; 20 cases was associated with reduced conversion risk in an adjusted model (aOR 0.17; <i>p</i> = 0.027). Conversion was associated with longer hospital stay, higher 30-day and 90-day mortality, and increased postoperative complications. Clinically relevant postoperative pancreatic fistula rates were similar between groups overall.</p> Conclusions <p>In elderly and/or obese surgically high-risk patients selected for attempted RPD, conversion occurred in approximately one in nine cases and was associated with worse short-term outcomes. These findings support careful patient selection, recognition of vascular complexity, transparent counseling, and a low threshold for strategic conversion in expert robotic pancreatic programs. Conversion should not be interpreted uniformly as operative failure, because its implications differ according to mechanism and timing.</p>

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Conversion to open surgery during robotic pancreatoduodenectomy in surgical high-risk groups: patterns, risk factors, and outcomes in elderly and/or obese patients

  • 期刊论文

  • 发表日期：

    2026年7月9日

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  • Tiziana Marchese,
  • Valentina Valle,
  • Benedetto Ielpo,
  • Annalisa Comandatore,
  • Gregorio Di Franco,
  • Roberto Salvia,
  • Sharona Ross,
  • John B. Martinie,
  • Curtis J. Wray,
  • Marcello G. Spampinato,
  • Paraskevas Pakataridis,
  • Pier Cristoforo Giulianotti,
  • Luca Morelli,
  • Matteo Pastena,
  • Alessandro Esposito,
  • Fernando Burdío,
  • Patricia Sanchez-Velázquez,
  • Mathieu D’Hondt,
  • Edward Willems,
  • Giuseppe Ietto,
  • Roberto Delpini,
  • Thilo Hackert,
  • Fiete Gehrisch,
  • Kijan Afshar-Bakshloo,
  • Faik G . Uzunoglu,
  • Sharona Ross,
  • Garnet Vanterpool,
  • Frederik Berrevoet,
  • Lars Standaert,
  • Davide Citterio,
  • Vincenzo Mazzaferro,
  • Marco Cereda,
  • Takeaki Ishizawa,
  • Anna Malpaga,
  • Michele Ciola,
  • Filippo Gasparin,
  • Fabio Maroso,
  • Raffaele Romito,
  • Edoardo Poletto,
  • Andrea Ruzzenente,
  • Niccolò Furbetta,
  • Simone Guadagni,
  • Giovanni Marchegiani,
  • Francesco Cobellis,
  • Fabio Giannone,
  • Francesco Matarazzo,
  • Maximilian Scheiterle,
  • Rami Rhaiem,
  • Perrine Zimmermann,
  • Robert Memba Ikuga,
  • Marta Defez Martín,
  • Elio Jovine,
  • Laura Mastrangelo,
  • Emilio Vicente,
  • Valentina Ferri,
  • Yolanda Quijano,
  • Riccardo Caruso,
  • Spiros Delis,
  • Alessandro Iacomino,
  • Giacomo Zanus,
  • Federica Maffeis,
  • Teresa Perra,
  • Alberto Porcu,
  • Alessandro Anselmo,
  • Luigi Eduardo Conte,
  • Mariano Cesare Giglio,
  • Roberto Ivan Troisi,
  • Maria Pia Federica Dorma,
  • Edoardo Rosso,
  • Alessia Fassari,
  • Giuseppe Barbato,
  • Andrea Belli,
  • Riccardo Memeo,
  • Rosalinda Filippo,
  • Gianluca Garulli,
  • Marco Giordano,
  • Nikolaos Machairas,
  • Michele Masetti,
  • Maria Fortuna Offi,
  • Gregory Sergeant,
  • Yves Depaifve,
  • Brian K.P. Goh,
  • Ye Xin Koh,
  • Yoshio Masuda,
  • Patricia Sánchez-Velázquez,
  • Fernando Burdío,
  • Luca Tirloni,
  • Thiago Nogueira Costa

摘要

Background

Conversion to laparotomy during robotic pancreatoduodenectomy (RPD) carries important clinical implications, yet its incidence, predictors, and consequences in elderly and/or obese patients remain poorly characterized. This study aimed to define the conversion rate, identify preoperative predictors, and assess the impact of conversion on postoperative outcomes in elderly and/or obese surgically high-risk patients undergoing attempted RPD.

Methods

A retrospective analysis was performed using a multi-institutional database. Patients were included if they underwent attempted RPD and met at least one high-risk criterion: age ≥ 80 years and/or BMI ≥ 30 kg/m2. Conversion was defined as any unplanned transition from robotic to open surgery after initiation of the robotic procedure. Reasons for conversion were assigned using a hierarchical, mutually exclusive framework: intraoperative complication, patient instability, vascular involvement, or strategic surgeon decision.

Results

Among 311 patients, 36 (11.6%) required conversion to laparotomy. The most common recorded reason was strategic surgeon decision (n = 18, 50.0%), followed by vascular involvement (n = 10, 27.8%), intraoperative complications, and patient instability. On multivariable analysis, independent predictors of conversion were preoperative biliary drainage (OR 7.36; p = 0.021) and vascular involvement (OR 22.22; p = 0.027), while male sex was protective (OR 0.22; p = 0.032). Robotic experience > 20 cases was associated with reduced conversion risk in an adjusted model (aOR 0.17; p = 0.027). Conversion was associated with longer hospital stay, higher 30-day and 90-day mortality, and increased postoperative complications. Clinically relevant postoperative pancreatic fistula rates were similar between groups overall.

Conclusions

In elderly and/or obese surgically high-risk patients selected for attempted RPD, conversion occurred in approximately one in nine cases and was associated with worse short-term outcomes. These findings support careful patient selection, recognition of vascular complexity, transparent counseling, and a low threshold for strategic conversion in expert robotic pancreatic programs. Conversion should not be interpreted uniformly as operative failure, because its implications differ according to mechanism and timing.