Identifying Perioperative Anesthetic Factors associated with Postoperative Morbidity in Robot-Assisted vs. Open Pancreatoduodenectomy: A Cohort Study

Abstract Background: Robot-assisted pancreatoduodenectomy (RAPD) is a challenging procedure for the perioperative anesthesiologist, e.g. because of prolonged pneumoperitoneum exposure and reversed-Trendelenburg positioning. Purpose of this retrospective cohort study is to identify differences in perioperative anesthesia-related factors between RAPD and open pancreatoduodenectomy (OPD) and to determine perioperative anesthetic factors associated with major morbidity (Clavien Dindo ≥ III) after RAPD. Methods: All consecutive patient undergoing pancreatoduodenectomy were retrospectively included during a two year inclusion period. Anesthesia charts were studied on fluid management details, rates of vasopressor administration and arterial blood gas results. All factors were compared between both surgical approaches. Within RAPD, factors were subsequently compared between patients with major (Clavien Dindo ≥ III) vs. without major postoperative morbidity and between procedures with high and low intraoperative blood loss. Perioperative factors associated with considerable postsurgical morbidity (Clavien Dindo ≥ III) were identified by constructing a logistic regression model.Results: RAPD was associated with higher administration of intraoperative vasopressors (9.5% of operative time vs. 0% in OPD, p=0.005) and a higher net intraoperative fluid balance (2497.6 vs. 1572.3 ml, p<0.001). OPD patients more frequently and quantitatively received colloids compared to RAPD patients (79.0% vs. 51.6%, p<0.001, 1000.0 vs. 500.0 ml, p<0.001). Intraoperative erythrocyte transfusion rate was 6.3% (4/64) for RAPD compared to 30.6% (19/62) for OPD (p<0.001). Colloid administration during surgery and hyperlactatemia after 12 hour postoperative admission were associated with major (Clavien Dindo ≥ III) morbidity after RAPD (OR 5.06 with 95% CI 1.49-17.20, p=0.009 and OR 3.18 with 95% CI 1.01-9.91, p=0.047, respectively).Conclusions: RAPD is a challenging procedure for the perioperative anesthesiologist e.g. considering a higher perioperative demand for vasopressors. Perioperative anesthetic factors, including hemodynamics and fluid strategy might alter postoperative morbidity. However, current data is insufficient to make specific recommendations.