title: Assessment of quality outcomes for robotic pancreaticoduodenectomy: identification of the learning curve.
abstract: OBJECTIVE
  Quality assessment is an important instrument to ensure optimal surgical outcomes, particularly during the adoption of new surgical technology. The use of the robotic platform for complex pancreatic resections, such as the pancreaticoduodenectomy, requires close monitoring of outcomes during its implementation phase to ensure patient safety is maintained and the learning curve identified.
  
  
  OBJECTIVE
  To report the results of a quality analysis and learning curve during the implementation of robotic pancreaticoduodenectomy (RPD).
  
  
  METHODS
  A retrospective review of a prospectively maintained database of 200 consecutive patients who underwent RPD in a large academic center from October 3, 2008, through March 1, 2014, was evaluated for important metrics of quality. Patients were analyzed in groups of 20 to minimize demographic differences and optimize the ability to detect statistically meaningful changes in performance.
  
  
  METHODS
  Robotic pancreaticoduodenectomy.
  
  
  METHODS
  Optimization of perioperative outcome parameters.
  
  
  RESULTS
  No statistical differences in mortality rates or major morbidity were noted during the study. Statistical improvements in estimated blood loss and conversions to open surgery occurred after 20 cases (600 mL vs 250 mL [P = .002] and 35.0% vs 3.3% [P < .001], respectively), incidence of pancreatic fistula after 40 cases (27.5% vs 14.4%; P = .04), and operative time after 80 cases (581 minutes vs 417 minutes [P < .001]). Complication rates, lengths of stay, and readmission rates showed continuous improvement that did not reach statistical significance. Outcomes for the last 120 cases (representing optimized metrics beyond the learning curve) included a mean operative time of 417 minutes, median estimated blood loss of 250 mL, a conversion rate of 3.3%, 90-day mortality of 3.3%, a clinically significant (grade B/C) pancreatic fistula rate of 6.9%, and a median length of stay of 9 days.
  
  
  CONCLUSIONS
  Continuous assessment of quality metrics allows for safe implementation of RPD. We identified several inflexion points corresponding to optimization of performance metrics for RPD that can be used as benchmarks for surgeons who are adopting this technology.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Brian A
authors.initials: BA
authors.lastname: Boone
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Mazen
authors.initials: M
authors.lastname: Zenati
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Melissa E
authors.initials: ME
authors.lastname: Hogg
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Steve
authors.affiliation: Department of Surgery, Beth Israel Deaconess, Boston, Massachusetts.
authors.forename: Arthur James
authors.initials: AJ
authors.lastname: Moser
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: David L
authors.initials: DL
authors.lastname: Bartlett
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Herbert J
authors.initials: HJ
authors.lastname: Zeh
authors.affiliation: Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Amer H
authors.initials: AH
authors.lastname: Zureikat
mesh_terms: D000368:Aged; D004502:Education, Medical, Continuing; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000193:education / Q000592:standards*; D011785:Quality Assurance, Health Care / Q000379:methods*; D012189:Retrospective Studies; D012371:Robotics / Q000193:education / Q000592:standards*