Minimally invasive versus open distal pancreatectomy for ductal adenocarcinoma (DIPLOMA): a pan-European propensity score matched study

Abstract

Background: A recent survey revealed that many European surgeons have concerns about the oncological safety of minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC). Methods: A pan-European retrospective cohort study was performed on patients who underwent MIDP or open distal pancreatectomy (ODP) for PDAC (2007-2015). MIDP patients were matched to ODP patients (1:1) based on propensity scores obtained via multivariable logistic regression including only preoperatively variables: sex, age, BMI, ASA, prior abdominal surgery, surgery year, tumor location and size. Primary outcome was radical (R0) resection rate. Results: In total, 1336 patients were included from 33 centers in 11 countries. Mortality was 2% and median survival 29 months. Of 369(28%) MIDP patients, 239 could be matched to an ODP patient. Conversion rate was 21%(n=44). After matching, R0 resection rate was 66%(n=149) for MIDP vs 52%(n=119) for ODP (p=0.002), lymph node retrieval was 13(IQR=7-23) vs 19(IQR=12-26)(p<0.001), the use of adjuvant chemotherapy was 72% vs 67% (p=0.28) and median overall survival (31 vs 26 months (p=0.51). Major complication rate (Clavien-Dindo 3-4) was 16%(n=36) vs 24%(n=53)(p=0.06), 90-day mortality 1%(n=2) vs 2%(n=4)(P=0.44) and hospital stay 7(IQR=5-10) vs 9(IQR=7-14) days (p<0.001). Conclusion: This pan-European propensity score matched analysis suggests short term benefits for MIDP over ODP. A randomized controlled trial is, however, needed to confirm the oncologic safety of MIDP for PDAC.

Essential updates 2018/2019: Current topics in the surgical treatment of pancreatic ductal adenocarcinoma

“…An increasing number of studies have reported on the oncological safety and long‐term prognosis of LDP for PDAC. Table 2 summarizes the previously reported oncologic factors and disease prognosis associated with LDP and open distal pancreatectomy (ODP) for PDAC 80‐94 . Propensity score matching (PSM) analysis using data from the NCDB indicated that the R0 resection rate, number of retrieved lymph nodes, and long‐term prognosis were equivalent for LDP and ODP 95 .…”

Minimally invasive distal pancreatectomy and the cost of conversion

“…11 A European cohort study of 1212 distal pancreatectomies for adenocarcinoma was also recently reported; 28% were laparoscopic, and 0.3% were robotic surgery, with a conversion to open rate of 19%. 8 Thus, overall, these data support a continued push towards MIS for distal pancreatectomy, even when performed for adenocarcinoma.…”

Predictors for Survival in an International Cohort of Patients Undergoing Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

“…Furthermore, based on the findings in the present study and other studies, the minimally invasive approach does allow for Gerota’s fascia resection, R0 resection, and adequate lymph node yield. 11 , 15 , 35 – 37 Although these results seem promising, more data from randomized controlled trials should be awaited. Currently, three randomized controlled trials are ongoing to compare minimally invasive and open distal pancreatectomy in patients with PDAC and should provide more insight in this matter: the DIPLOMA trial, performed in Europe and the USA (ISRCTN44897265), one trial in China (NCT03792932), and one trial in Korea (NCT03957135).…”

“…The variables included in the analyses were defined as presented in the published DIPLOMA cohort. 15 A list of all variables can be found in the Appendix . Minimally invasive distal pancreatectomy was defined as laparoscopic or robot-assisted distal pancreatectomy.…”