Minimally invasive versus open distal pancreatectomy: a matched analysis using ACS-NSQIP

Minimally invasive vs. open radical cholecystectomy for gallbladder cancer: 30-day NSQIP outcomes analysis

BACKGROUND

Radical cholecystectomy (RC) is the standard procedure for gallbladder cancer (GBC) tumors stage TIb or higher. Advances in minimally invasive surgery (MIS) offer the potential for improved outcomes compared to the traditional open surgery. While small series have demonstrated the feasibility of an MIS approach, a detailed comparison of outcomes between the two approaches is lacking.

METHODS

The National Surgeon Quality Improvement Database (2010-2021) was queried to identify patients undergoing RC for GBC. Patients with T1b or higher disease were included. Thirty-day all-cause mortality and morbidity were evaluated. To assess associations between outcomes and covariates, we estimated risk ratios and risk differences using generalized linear models and adjusted the estimates using inverse propensity of treatment weights.

RESULTS

1303 patients were identified (239 MIS, 1064 Open) with 178 excluded due to the need for biliary reconstruction. There was no difference in the primary outcomes of mortality or major morbidity between the groups with four deaths occurring overall and major morbidity rates of MIS = 2.26% and Open = 2.45% (p = 0.7924). Patients who underwent MIS had significantly fewer days in the hospital (3.00 vs.5.00, p < 0.001). After weighting, the MIS group had significantly fewer blood transfusions (2.12% vs. 6.73%, p = 0.009) and superficial surgical site infections (0.45% vs. 3.29%, p = 0.020).

CONCLUSION

Our findings contribute to the growing body of evidence supporting MIS for RC as a potential alternative to open resections.

Minimally invasive versus open distal pancreatectomy for pancreatic Tumors: An updated meta-analysis and meta-regression

This study aims to compare the efficacy and safety of minimally invasive distal pancreatectomy (MIDP) and open distal pancreatectomy (ODP) for pancreatic neoplasms. A meta-analysis following PRISMA guidelines, registered on PROSPERO, included randomized controlled trials (RCTs) and propensity-score matched studies. Data from Cochrane Central, PubMed, and Embase were analyzed, focusing on procedure efficacy (e.g., length of hospital stay and reoperations), oncologic outcomes (e.g., R0 resections), surgical outcomes (e.g., blood loss and operative time), and postoperative outcomes (e.g., 90-day mortality, severe complications, pancreatic fistula). Among 23 studies, MIDP showed significantly reduced 90-day mortality (OR: 0.57, p = 0.03), severe (CDC ≥ III) complications (OR: 0.81, p = 0.04), hospital stay (MD: 2.38 days, p < 0.01), reoperations (OR: 0.65, p < 0.01) and blood loss (MD: 137.66 mL, p < 0.01) compared to ODP. No significant differences were found in postoperative pancreatic fistula (OR: 1.06, p = 0.74) or operative time (MD: 1.95 min, p = 0.87). ODP showed a significantly lower incidence of R0 resections (OR: 1.57, p < 0.01). Subgroup analyses of RCTs favored MIDP for 90-day mortality, severe complications, and hospital stay, but found no differences in pancreatic fistula or operative time. Meta-regression identified age and tumor size as influential covariates. MIDP offers superior outcomes in procedure efficacy, surgical and postoperative outcomes compared to ODP. These findings highlight MIDP as a safe and effective alternative for pancreatic surgery, supported by robust subgroup and sensitivity analyses.

Enhanced Pancreatic Transection in Minimally Invasive Distal Pancreatectomy: The Synergy of Slow-Firing and Staple Line Suturing

INTRODUCTION

Minimally invasive distal pancreatectomy (MIDP) is increasingly performed for pancreatic body and tail lesions. However, postoperative pancreatic fistula (POPF) remains a major complication, with reported rates of 13%-36%. Despite various technical approaches, including reinforced staplers and pre-firing compression, results have been inconsistent.

METHODS

We adopted a modified transection technique during MIDP using the ECHELON FLEX powered stapler with a slow-firing method, followed by staple line suturing. This retrospective study included 70 MIDP cases performed at Teine Keijinkai Hospital between January 2012 and August 2023. POPF was evaluated using the 2016 International Study Group of Pancreatic Surgery (ISGPS) criteria. Surgical outcomes were descriptively compared with a historical group in which reinforced staplers were used without suturing.

RESULTS

Among the 70 patients, 59 underwent pancreatic transection with the ECHELON FLEX and suturing. Clinically relevant POPF (Grade B or C) occurred in 5.1% of these patients. In contrast, the incidence was 45.5% in the 11 historical cases using reinforced staplers. No Grade C POPF was observed.

CONCLUSION

The combination of slow-firing transection and staple line suturing may help reduce POPF in MIDP. This simple and reproducible technique is a promising strategy for safe pancreatic stump management.

Surgical Approach and Length of Stay in Octogenarians Undergoing Pancreatic Resection for Malignancy

INTRODUCTION

Pancreatic surgery often has a lengthy recovery in the elderly. Minimally invasive surgery (MIS) can decrease length of stay (LOS), but it is unknown if this benefit applies to octogenarians (Age > 79).

METHODS

The NSQIP database was used to determine if MIS approaches were associated with reduced LOS among octogenarians undergoing pancreaticoduodenectomy (Whipple) or distal pancreatectomy (Distal). Operative approaches were classified as "Open" or "MIS" and propensity score (PS) matching was performed.

RESULTS

For the Whipple, 1665 Open and 101 MIS procedures occurred (median LOS 9, 8 days, p = 0.584). For Distal, 472 Open and 223 MIS procedures occurred (median LOS 6, 5 days, p < 0.01). After PS matching, there were 202 Whipple (101 per group) and 446 Distal (223 per group) patients. There was no difference in LOS by approach in the Whipple group (p = 0.546). The median LOS was 9 (IQR 7-15), Open and 8 (IQR 6-13), MIS. For Distal, there was a difference in LOS in the Open versus MIS approach (p < 0.01) and the median LOS was 6 (IQR 5-8) and 5 (IQR 4-6).

CONCLUSIONS

Among octogenarians the MIS approach was associated with decreased LOS in distal pancreatectomies, but not in pancreaticoduodenectomies.

The efficacy of wrapping with polyglycolic acid mesh and fibrin glue in preventing clinically relevant pancreatic fistula after minimally invasive distal pancreatectomy (WRAP Study): study protocol for a multicenter randomized controlled trial in Japan

BACKGROUND

Postoperative pancreatic fistula (POPF) continues to be the most common complication after distal pancreatectomy (DP). Recent advancements in surgical techniques have established minimally invasive distal pancreatectomy (MIDP) as the standard treatment for various conditions, including pancreatic cancer. However, MIDP has not demonstrated a clear advantage over open DP in terms of POPF rates, indicating the need for additional strategies to prevent POPF in MIDP. This trial (WRAP study) aims to evaluate the efficacy of wrapping the pancreatic stump with polyglycolic acid (PGA) mesh and fibrin glue in preventing clinically relevant (CR-) POPF following MIDP.

METHODS

This multicenter, randomized controlled trial will include patients scheduled for laparoscopic or robotic DP for tumors in the pancreatic body and/or tail. Eligible participants will be centrally randomized into either the control group (Group A) or the intervention group (Group B), where the pancreatic stump will be reinforced by PGA mesh and fibrin glue. In both groups, pancreatic transection will be performed using a bioabsorbable reinforcement-attached stapler. A total of 172 patients will be enrolled across 14 high-volume centers in Japan. The primary endpoint is the incidence of CR-POPF (International Study Group of Pancreatic Surgery grade B/C).

DISCUSSION

The WRAP study will determine whether the reinforcement of the pancreatic stump with PGA mesh and fibrin glue, a technique whose utility has been previously debated, could become the best practice in the era of MIDP, thereby enhancing its safety.

TRIAL REGISTRATION

This trial was registered with the Japan Registry of Clinical Trials on June 15, 2024 (jRCTs032240120).

Minimally invasive robot-assisted and laparoscopic distal pancreatectomy in a pan-European registry a retrospective cohort study

BACKGROUND

International guidelines recommend monitoring the use and outcome of minimally invasive pancreatic surgery (MIPS). However, data from prospective international audits on minimally invasive distal pancreatectomy (MIDP) are lacking. This study examined the use and outcome of robot-assisted (RDP) and laparoscopic (LDP) distal pancreatectomy in the E-MIPS registry.

PATIENTS AND METHODS

Post-hoc analysis in a prospective audit on MIPS, including consecutive patients undergoing MIDP in 83 centers from 19 European countries (01-01-2019/31-12-2021). Primary outcomes included intraoperative events (grade 1: excessive blood loss, grade 2: conversion/change in operation, grade 3: intraoperative death), major morbidity, and in-hospital/30-day mortality. Multivariable logistic regression analyses identified high-risk groups for intraoperative events. RDP and LDP were compared in the total cohort and high-risk groups.

RESULTS

Overall, 1672 patients undergoing MIDP were included; 606 (36.2%) RDP and 1066 (63.8%) LDP. The annual use of RDP increased from 30.5% to 42.6% ( P <0.001). RDP was associated with fewer grade 2 intraoperative events compared with LDP (9.6% vs. 16.8%, P <0.001), with longer operating time (238 vs. 201 min, P <0.001). No significant differences were observed between RDP and LDP regarding major morbidity (23.4% vs. 25.9%, P =0.264) and in-hospital/30-day mortality (0.3% vs. 0.8%, P =0.344). Three high-risk groups were identified; BMI greater than 25 kg/m 2 , previous abdominal surgery, and vascular involvement. In each group, RDP was associated with fewer conversions and longer operative times.

CONCLUSION

This European registry-based study demonstrated favorable outcomes for MIDP, with mortality rates below 1%. LDP remains the predominant approach, whereas the use of RDP is increasing. RDP was associated with fewer conversions and longer operative time, including in high-risk subgroups. Future randomized trials should confirm these findings and assess cost differences.

Nationwide use and Outcome of Minimally Invasive Distal Pancreatectomy in IDEAL Stage IV following a Training Program and Randomized Trial

OBJECTIVE

To assess the nationwide long-term uptake and outcomes of minimally invasive distal pancreatectomy (MIDP) after a nationwide training program and randomized trial.

BACKGROUND

Two randomized trials demonstrated the superiority of MIDP over open distal pancreatectomy (ODP) in terms of functional recovery and hospital stay. Data on implementation of MIDP on a nationwide level are lacking.

METHODS

Nationwide audit-based study including consecutive patients after MIDP and ODP in 16 centers in the Dutch Pancreatic Cancer Audit (2014 to 2021). The cohort was divided into three periods: early implementation, during the LEOPARD randomized trial, and late implementation. Primary endpoints were MIDP implementation rate and textbook outcome.

RESULTS

Overall, 1496 patients were included with 848 MIDP (56.5%) and 648 ODP (43.5%). From the early to the late implementation period, the use of MIDP increased from 48.6% to 63.0% and of robotic MIDP from 5.5% to 29.7% ( P <0.001). The overall use of MIDP (45% to 75%) and robotic MIDP (1% to 84%) varied widely between centers ( P <0.001). In the late implementation period, 5/16 centers performed >75% of procedures as MIDP. After MIDP, in-hospital mortality and textbook outcome remained stable over time. In the late implementation period, ODP was more often performed in ASA score III-IV (24.9% vs. 35.7%, P =0.001), pancreatic cancer (24.2% vs. 45.9%, P <0.001), vascular involvement (4.6% vs. 21.9%, P <0.001), and multivisceral involvement (10.5% vs. 25.3%, P <0.001). After MIDP, shorter hospital stay (median 7 vs. 8 d, P <0.001) and less blood loss (median 150 vs. 500 mL, P <0.001), but more grade B/C postoperative pancreatic fistula (24.4% vs. 17.2%, P =0.008) occurred as compared to ODP.

CONCLUSION

A sustained nationwide implementation of MIDP after a successful training program and randomized trial was obtained with satisfactory outcomes. Future studies should assess the considerable variation in the use of MIDP between centers and, especially, robotic MIDP.

Nationwide analysis of unplanned conversion during minimally invasive distal pancreatectomy for pancreatic adenocarcinoma

BACKGROUND

Utilization of minimally-invasive distal pancreatectomy (MIDP) for pancreatic adenocarcinoma has increased. While unplanned conversion to an open procedure during MIDP is associated with inferior short-term outcomes, the long-term consequences of conversion have not been adequately examined.

METHODS

Patients with pancreatic adenocarcinoma undergoing MIDP were selected from the National Cancer Database (2010-2015) and subdivided based on the occurrence of unplanned conversion. Post-operative outcomes and overall survival (OS) were examined. Conversion was additionally compared to a matched group of planned open resections.

RESULTS

Among 592 patients undergoing attempted MIDP, unplanned conversion occurred in 23.1%. Despite increased 90-day mortality among patients experiencing conversion, there was no difference in median OS between groups (25.0 vs 27.8 months, p = 0.095). For patients undergoing conversion, post-operative outcomes and long-term survival were similar when compared to a propensity-matched group of patients undergoing planned open resection. On multivariable analysis, treatment at an academic facility (OR 0.63) and a robotic approach (OR 0.50) were both significantly associated with completed MIDP.

CONCLUSION

Despite inferior post-operative outcomes compared to successful MIDP, unplanned conversion did not result in significantly reduced long term survival. MIDP can be attempted selectively but treatment at experienced centers via a robotic approach should be considered.

Minimally invasive versus open distal pancreatectomy for resectable pancreatic cancer (DIPLOMA): an international randomised non-inferiority trial

BACKGROUND

The oncological safety of minimally invasive surgery has been questioned for several abdominal cancers. Concerns also exist regarding the use of minimally invasive distal pancreatectomy (MIDP) in patients with resectable pancreatic cancer as randomised trials are lacking.

METHODS

In this international randomised non-inferiority trial, we recruited adults with resectable pancreatic cancer from 35 centres in 12 countries. Patients were randomly assigned to either MIDP (laparoscopic or robotic) or open distal pancreatectomy (ODP). Both patients and pathologists were blinded to the assigned approach. Primary endpoint was radical resection (R0, ≥1 mm free margin) in patients who had ultimately undergone resection. Analyses for the primary endpoint were by modified intention-to-treat, excluding patients with missing data on primary endpoint. The pre-defined non-inferiority margin of -7% was compared with the lower limit of the two-sided 90% confidence interval (CI) of absolute difference in the primary endpoint. This trial is registered with the ISRCTN registry (ISRCTN44897265).

FINDINGS

Between May 8, 2018 and May 7, 2021, 258 patients were randomly assigned to MIDP (131 patients) or ODP (127 patients). Modified intention-to-treat analysis included 114 patients in the MIDP group and 110 patients in the ODP group. An R0 resection occurred in 83 (73%) patients in the MIDP group and in 76 (69%) patients in the ODP group (difference 3.7%, 90% CI -6.2 to 13.6%; pnon-inferiority = 0.039). Median lymph node yield was comparable (22.0 [16.0-30.0] vs 23.0 [14.0-32.0] nodes, p = 0.86), as was the rate of intraperitoneal recurrence (41% vs 38%, p = 0.45). Median follow-up was 23.5 (interquartile range 17.0-30.0) months. Other postoperative outcomes were comparable, including median time to functional recovery (5 [95% CI 4.5-5.5] vs 5 [95% CI 4.7-5.3] days; p = 0.22) and overall survival (HR 0.99, 95% CI 0.67-1.46, p = 0.94). Serious adverse events were reported in 23 (18%) of 131 patients in the MIDP group vs 28 (22%) of 127 patients in the ODP group.

INTERPRETATION

This trial provides evidence on the non-inferiority of MIDP compared to ODP regarding radical resection rates in patients with resectable pancreatic cancer. The present findings support the applicability of minimally invasive surgery in patients with resectable left-sided pancreatic cancer.

FUNDING

Medtronic Covidien AG, Johnson & Johnson Medical Limited, Dutch Gastroenterology Society.