Minimally invasive distal pancreatectomy: greatest benefit for the frail

Abstract

OBJECTIVE The benefits of minimally invasive distal pancreatectomy (MIDP) over open surgery continue to be investigated. Frailty is a known predictor of postoperative outcome. We hypothesized that the benefit of minimally invasive distal pancreatectomy is greatest for the frailest of patients. METHODS Data from the pancreas-targeted National Surgical Quality Improvement Program (NSQIP) database for 2014 were reviewed. A modified frailty index (mFI) with 11 preoperative variables previously validated for use in NSQIP was used to determine the correlation between frailty and postoperative outcomes, including Clavien grade IV complications. Patients were classified into non-frail (mFI=0) or frail (mIF>0), in which they were sub-classified into mildly frail (mFI 1 or 2), or severely frail (mFI =3). RESULTS A total of 1,038 distal pancreatectomies (DP) were included in the analysis, of which 387 were minimally invasive (MIDP: laparoscopic: 285, robotic: 102), 558 open DP (ODP) and 93 MIDP converted to open (MIDPcODP: laparoscopic: 80, robotic: 13). More than 90% of patients had a mFI of 0 or 1 (mFI 0=473 (45.6%), 1=466 (44.9%), 2=94 (9.1%), and 3=5 (0.5%) respectively). Overall, 4.6% of patients experienced Clavien grade IV complications and 1.1% a mortality. Non-frail patients experienced a similar rate of grade IV Clavien complications with MIDP vs ODP vs MIDPcOP (2.3 vs. 2.3 vs. 4.9%; p=0.6), whereas frail patients (mFI>0) had a lower rate of complications with MIDP (2.4 vs. 8.3 vs. 11.5; p=0.007). Worsening frailty correlated with an increase in complications (non-frail: 2.5%; mildly frail: 6.3%; severely frail: 20%; p=0.005). CONCLUSION MIDP is associated with a lower risk of Clavien grade IV complications compared to ODP for frail patients, especially for benign disease. Thus, minimally invasive approach may mitigate risk in frail patients.

Modified Frailty Index to Assess Risk in Elderly Patients Undergoing Distal Pancreatectomy: A Retrospective Single‐Center Study

“…This manuscript's strength is that for the first time, the comparison between MIDP and ODP in elderly patients was performed through a propensity score matching to reduce the selection bias. This study is also the first to apply the mFI to a single-center, homogeneous cohort of elderly patients undergoing DP (the report by Konstantinidis et al [ 22 ] is a registry-based study). Some limitations may flaw the results and the considerations: (i) the sample size of elderly who underwent MIDP is small; (ii) a selection bias (the percentage of elderly submitted to MIDP is approximately only 20 percent of the total of elderly underwent DP during the study period).…”

“…When the final diagnosis was of malignancy, Ca 19–9 values and neoadjuvant therapy were added. According to the mFI, patients were stratified into non-frail (mFI = 0), mildly frail (mFI = 1–2), or severely-frail (mFI > 2), as proposed by Konstantinidis et al [ 22 ]. This stratification was applied to the whole cohort of patients ≥70 years who underwent distal pancreatectomy, and matching was not used due to the small sample size of the MIDP group.…”

“…The Frailty Index [ 17 , 18 ], and its simplified form, the modified Frailty Index (mFI) [ 19 ] proved to predict major complications and mortality after pancreatic surgery effectively [ 20 , 21 ]. Of note, it seems that frail patients (mFI ≥1) benefit from MIDP, experiencing less severe complications than ODP patients [ 22 ].…”

What role does hand-assistance have in minimally invasive pancreatic surgery?

“…Conversely, the LEOPARD-2 trial was interrupted early because of safety concerns due to a disproportionally high number of deaths in the LPD arm [124] , while the PADULAP trial reported a lower major complication rate and a shorter LOS and similar oncological outcomes [125] . No major differences in outcomes have been reported between LPD and RPD [126,127] . In view of existing evidence, the Miami Guidelines concluded that insufficient data exist to recommend MIPD over OPD.…”

Minimally invasive distal pancreatectomy and the cost of conversion

“…There are a number of reported benefits for patients, including lower estimated blood loss, shorter length of functional recovery, and improved short‐term quality of life, which were recently demonstrated in a randomized controlled trial 7 . The MIS approach can also mitigate complication severity in the frail 9 …”