P36. Increased mortality with early adoption of robotic pancreaticoduodenectomy: a national EHR study

Introduction: Robotic pancreaticoduodenectomy (RPD) is increasingly performed in the United States. Understanding factors associated with safe adoption is critical to reducing perioperative mortality during the learning curve.


Methods: Using the Epic Cosmos database, we identified all adult patients age (≥18) who underwent PD between 2017 and 2025. Modified Poisson regression was used to assess factors associated with 30-day mortality, adjusting for age, sex, race, ethnicity, insurance, marital status, rural/urban residence, socioeconomic status, diagnosis, and procedure type. Among surgeons performing RPD, those with ≥2 cases were analyzed to determine mortality trends across case-number thresholds. Mortality risk was assessed by cumulative RPD and non-robotic PD experience, adjusting for age and diagnosis.


Results: Among 25,255 patients (median age 69 [IQR 61-75]), 1,623 (6.4%) underwent RPD. The proportion of robotic cases increased from 4.0% in 2020 to 10.3% in 2025. Thirty-day mortality was higher after RPD than non-robotic RPD (3.0% vs. 2.3%; aRR = 1.44 [1.05-1.93], p=0.02). In RPD, mortality decreased with increasing provider experience: 4.18% (0-2 cases), 2.75% (3-5), 2.48% (6-10), 2.01% (11-19), and 1.41% ( >20) (Figure). The mortality rate after ≥20 RPD cases approximated that of non-robotic PD at top-volume centers (1.6%). Increased RPD experience was associated with improved mortality, approaching statistical significance (doubling robotic experience: aRR = 0.80 [0.65-0.99], p=0.04). Non-robotic PD experience was not associated with mortality improvement (doubling non-robotic experience: 0.91 [0.78-1.07], p=0.26).

 


Conclusions: Nationwide, early adoption of RPD is associated with increased 30-day mortality, which decreases substantially with increasing surgeon experience. Mortality rates among experienced RPD surgeons approach those of high-volume centers performing open PD. These findings suggest that structured, competency-based training pathways are needed to ensure safe dissemination of RPD.