Evolution of Pancreatic Transection Strategy in Minimally Invasive Distal Pancreatectomy

Area of Science:

• Minimally Invasive Surgery
• Surgical Oncology
• Gastrointestinal Surgery

Background:

• Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication following distal pancreatectomy (DP), particularly minimally invasive DP (MIDP).
• Institutional practice changes over time can impact surgical outcomes, but their cumulative effect on MIDP requires characterization.
• This study aimed to assess the impact of stepwise institutional refinements on MIDP outcomes.

Purpose of the Study:

• To evaluate the association between stepwise institutional refinements in MIDP and postoperative outcomes.
• To determine if practice changes in pancreatic transection and perioperative management reduce CR-POPF incidence.

Main Methods:

• Retrospective analysis of 124 patients undergoing MIDP (2019-2025) at a single center.
• Comparison of early and late phases reflecting implemented practice changes: reinforced stapler, robotic assistance, continuous negative-pressure drainage.
• Propensity score matching (PSM) based on pancreatic thickness and texture.

Main Results:

• CR-POPF incidence decreased significantly in the late phase (5.3% vs. 24.4%, p=0.012).
• Lower and more rapid decline in drain fluid amylase (DFA) levels observed in the late phase.
• Significantly shorter postoperative length of stay (LOS) in the late phase (median 8 vs. 11 days, p<0.001).
• Findings remained consistent after PSM.

Conclusions:

• Stepwise institutional refinements in MIDP, including transection technique and drain management, are linked to improved postoperative outcomes.
• A quality-improvement approach focusing on atraumatic transection and rational drain management can potentially reduce CR-POPF after MIDP.