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Outcomes After Minimally-invasive Versus Open Pancreatoduodenectomy: A Pan-European Propensity Score Matched Study
Sjors Klompmaker1, Jony van Hilst1, Ulrich F Wellner2,3
1Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, the Netherlands.
Objective:
To assess short-term outcomes after minimally invasive (laparoscopic, robot-assisted, and hybrid) pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) among European centers.
Background:
Current evidence on MIPD is based on national registries or single expert centers. International, matched studies comparing outcomes for MIPD and OPD are lacking.
Methods:
Retrospective propensity score matched study comparing MIPD in 14 centers (7 countries) performing ≥10 MIPDs annually (2012-2017) versus OPD in 53 German/Dutch surgical registry centers performing ≥10 OPDs annually (2014-2017). Primary outcome was 30-day major morbidity (Clavien-Dindo ≥3).
Results:
Of 4220 patients, 729/730 MIPDs (412 laparoscopic, 184 robot-assisted, and 130 hybrid) were matched to 729 OPDs. Median annual case-volume was 19 MIPDs (interquartile range, IQR 13-22), including the first MIPDs performed in 10/14 centers, and 31 OPDs (IQR 21-38). Major morbidity (28% vs 30%, P = 0.526), mortality (4.0% vs 3.3%, P = 0.576), percutaneous drainage (12% vs 12%, P = 0.809), reoperation (11% vs 13%, P = 0.329), and hospital stay (mean 17 vs 17 days, P > 0.99) were comparable between MIPD and OPD. Grade-B/C postoperative pancreatic fistula (POPF) (23% vs 13%, P < 0.001) occurred more frequently after MIPD. Single-row pancreatojejunostomy was associated with POPF in MIPD (odds ratio, OR 2.95, P < 0.001), but not in OPD. Laparoscopic, robot-assisted, and hybrid MIPD had comparable major morbidity (27% vs 27% vs 35%), POPF (24% vs 19% vs 25%), and mortality (2.9% vs 5.2% vs 5.4%), with a fewer conversions in robot-assisted- versus laparoscopic MIPD (5% vs 26%, P < 0.001).
Conclusions:
In the early experience of 14 European centers performing ≥10 MIPDs annually, no differences were found in major morbidity, mortality, and hospital stay between MIPD and OPD. The high rates of POPF and conversion, and the lack of superior outcomes (ie, hospital stay, morbidity) could indicate that more experience and higher annual MIPD volumes are needed.
Insights
Minimally invasive pancreatoduodenectomy (MIPD) showed similar short-term outcomes to open pancreatoduodenectomy (OPD) in early European center experiences. However, higher rates of postoperative pancreatic fistula (POPF) suggest a need for increased experience and volume for MIPD.
Area of Science:
- Gastroenterology and Hepatology
- Surgical Oncology
- Minimally Invasive Surgery
Background:
- Existing evidence on minimally invasive pancreatoduodenectomy (MIPD) primarily comes from national registries or single institutions.
- A lack of international, matched studies comparing MIPD and open pancreatoduodenectomy (OPD) outcomes hinders comprehensive understanding.
Purpose of the Study:
- To evaluate and compare short-term outcomes between minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD).
- To assess outcomes across European centers with established experience in MIPD.
Main Methods:
- A retrospective propensity score-matched study was conducted involving 14 European centers performing ≥10 MIPDs annually (2012-2017).
- MIPD cases (n=729) were matched with OPD cases (n=729) from 53 German/Dutch registry centers performing ≥10 OPDs annually (2014-2017).
- The primary outcome was 30-day major morbidity, defined as Clavien-Dindo grade ≥3.
Main Results:
- Major morbidity (28% vs 30%), mortality (4.0% vs 3.3%), and hospital stay (17 days vs 17 days) were comparable between MIPD and OPD groups.
- Postoperative pancreatic fistula (POPF) (Grade B/C) occurred significantly more frequently after MIPD (23% vs 13%).
- Robot-assisted MIPD showed fewer conversions compared to laparoscopic MIPD (5% vs 26%).
Conclusions:
- In the initial experience of high-volume European centers, MIPD demonstrated comparable short-term outcomes to OPD regarding major morbidity, mortality, and hospital stay.
- Higher rates of POPF and conversions in MIPD suggest that increased surgical experience and higher annual volumes may be necessary to optimize outcomes.
- Further research is warranted to establish the optimal learning curve and volume thresholds for MIPD.
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