International Validation of Reduced Major Morbidity After Minimally Invasive Distal Pancreatectomy Compared With Open Pancreatectomy

Abstract

in collaboration with the Dutch Pancreatic Cancer GroupObjective: To quantify the nationwide impact of minimally invasive distal pancreatectomy (MIDP) on major morbidity as compared with open distal pancreatectomy (ODP). Background: A recent randomized controlled trial (RCT) demonstrated significant reduction in time to functional recovery after MIDP compared with ODP, but was not powered to assess potential risk reductions in major morbidity. Methods: International cohort study using the American College of Surgeons' National Quality Improvement Program (ACS-NSQIP) (88 centers; 2014-2016) to evaluate the association between surgical approach (MIDP vs ODP) and 30-day composite major morbidity (CMM; death or severe complications) with external model validation using Dutch Pancreatic Cancer Group data (17 centers; 2005-2016). Multivariable logistic regression assessed the impact of nationwide MIDP rates between 0% and 100% on postoperative CMM at conversion rates between 0% and 25%, using estimated marginal effects. A sensitivity analysis tested the impact at various scenarios and patient populations. Results: Of 2921 ACS-NSQIP patients, 1562 (53%) underwent MIDP with 18% conversion, and 1359 (47%) underwent ODP. MIDP was independently associated with reduced CMM [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.42-0.60, P < 0.001], confirmed by external model validation (n ¼ 637, P < 0.003). The association between rising MIDP implementation rates and falling postoperative morbidity was linear between 0% (all ODP) and 100% (all MIDP). The absolute risk reduction for CMM was 11% (95% CI 7.3%-15%) at observed conversion rates and improved to 14% (95% CI 11%-18%) as conversion approached 0%. Similar effects were seen across subgroups. Conclusion: This international study predicted a nationwide 11% risk reduction for CMM after MIDP versus ODP, which is likely to improve as conversion rates decrease. These findings confirm secondary outcomes of the recent LEOPARD RCT.

Robotic-assisted versus open total pancreatectomy: a propensity score-matched study

“…Furthermore, no patients in the RTP group were converted to an open procedure. A recent study showed that conversion rates in minimally invasive pancreatic surgery are improving and appear to be significantly lower in robotic cases (50). It appears that precision in instrument movement and tissue manipulation achieved with the robot is crucial in that aspect.…”

Current Status of Laparoscopic and Robotic Pancreatic Surgery and Its Adoption in Singapore

“…25 Studies have shown that LDP offers several advantages over open surgery, especially in short-term perioperative outcomes including less postoperative pain, quicker recovery and decreased blood loss. [12][13][14]26,27 However, most of these studies were retrospective case-control series. In the only RCT (LEOPARD) that compared minimally invasive DP and open DP by the Dutch Pancreatic Cancer Group, Rooij et al found that the former was significantly associated with decreased blood loss and reduced time to functional recovery at the expense of longer operating time.…”

“…21 Similarly, a recent large international cohort study that analysed 1562 minimally invasive DP with 18% open conversion vs 1359 open DP from the American College of Surgeons National Quality Improvement Program demonstrated a risk reduction rate of 11% in composite major morbidity. 27 Although DP is commonly performed with en bloc splenectomy, recent studies have recommended spleen preservation since it reduces the risk of postsplenectomy infection and thrombocytosis, haematologic abnormalities and overall morbidity. 28,29 Most pancreatic surgeons concur that the spleen should be preserved as far as possible in benign and borderline malignant neoplasms, 5,22 and 2 techniques have been described for spleen-preserving DP: 1) in the Warshaw technique, the splenic artery and vein are resected, leaving only the short gastric vessels for perfusion of the spleen; and 2) in the Kimura technique, the splenic vessels are spared.…”

“…24 Numerous retrospective studies have shown that a major advantage of robotic distal pancreatectomy (RDP) over LDP is that it offers superior spleen preservation rate. [25][26][27][28][29][30][31][32][33][34] It is hypothesised that improved dexterity of the robotic system facilitates suturing in tight spaces and more accurate control of the splenic tributaries, thereby allowing more accurate dissection of splenic vessels from the pancreatic parenchyma. 4,5 These advantages improve the rate of spleen and splenic vessel preservation in DP.…”

Improvement in distal pancreatectomy for tumors in the body and tail of the pancreas

“…They performed appropriate adjustments for the confounding factors by indication. Their results suggested that MIDP was independently associated with reduced composite major morbidity, which includes death and severe complications [17]. With robotic-assisted procedures, a significant increase in the frequency of resections was performed for asymptomatic tumors.…”