Increased Mortality with Surgeon Adoption of Robotic Pancreaticoduodenectomy: A National EHR Study of Outcomes.

Abstract

BACKGROUND: Robotic pancreaticoduodenectomy (RPD) is increasingly performed in the United States. Understanding factors associated with safe adoption of RPD is critical to reducing perioperative mortality during the learning curve. METHODS: Using the Epic Cosmos database, the study identified adult patients (age ≥18 years) who underwent pancreaticoduodenectomy (PD) between 2019 and 2025. Modified Poisson regression was used to assess factors associated with 30-day mortality using adjustment for age, sex, race, ethnicity, insurance, marital status, rural/urban residence, socioeconomic status, and diagnosis. Among surgeons performing two or more RPDs, mortality trends were analyzed across case-number thresholds. Mortality risk was assessed by cumulative RPD and open PD (OPD) experience, with adjustment for age and diagnosis. RESULTS: Among 23,995 patients with a median age of 69 years (interquartile range [IQR], 62-75 years), 1578 (6.6 %) underwent RPD. Use of RPD increased from 4% of PD in 2019 to 10% in 2025. The 30-day mortality was higher for RPD than for OPD (2.7 % vs 2.0 %; adjusted relative risks [aRR], 1.43 (IQR, 1.02-1.95; p = 0.029). In RPD, mortality decreased with increasing surgeon prior experience: 3.9 % (Q1: 0-1 cases), 3.9 % (Q2: 2-4 cases), 2.22 % (Q3: 5-8 cases), 2.67 % (Q4: 9-18 cases), 0.92 % (Q5: 19-71 cases). Increased RPD experience was associated with decreased mortality (per doubling RPD experience: aRR, 0.78 (95 % confidence interval [CI], 0.63-0.96; p = 0.02). The patients who underwent PD between 2023 and 2025 showed no adjusted increase in mortality with robotic technique (aRR, 1.04; 95 % CI, 0.61-1.65; p = 0.85). CONCLUSIONS: Nationwide, adoption of RPD is associated with increased 30-day mortality, which decreases substantially with increasing surgeon RPD experience. These findings suggest that structured, competency-based training pathways are needed to ensure safe dissemination of novel technology, including RPD.