Comparison of Pancreatic Fistula Between Robotic-Assisted and Open Pancreatoduodenectomy: A Comprehensive Evaluation Using an Alternative Fistula Risk Score

Background: Robotic-assisted pancreatoduodenectomy (RPD) offers ergonomic advantages, yet its effect on pancreatic fistula risk remains unclear. This study evaluated RPD safety using the alternative fistula risk score (aFRS). Methods: We retrospectively reviewed the pancreatoduodenectomy database at Seoul National University Hospital (2014–2023), comparing RPD with open pancreatoduodenectomy (OPD) in a 1:1 aFRS probability-matched analysis. Baseline characteristics and outcomes were compared overall and by aFRS risk groups. Results: In the matched cohort, RPD patients had a similar BMI but a higher incidence of soft pancreatic texture, smaller ducts, and increased aFRS probability compared to OPD. Overall, clinically relevant postoperative pancreatic fistula (CR-POPF) rates were similar (11% vs. 10%, p = 0.84). However, RPD had lower rates of delayed gastric emptying (3.1% vs. 5.4%, p = 0.024) and wound complications (1.9% vs. 5.5%, p < 0.001). Notably, in the high-risk aFRS group, RPD demonstrated significantly lower CR-POPF rates both before (12% vs. 18%, p = 0.049) and after matching (11% vs. 17%, p = 0.042). Conclusion: RPD is a safe and feasible approach, offering particular benefits in reducing CR-POPF among high-risk patients.