Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. Results: After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. Conclusion: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.

Background: Laparoscopic distal pancreatectomy (LDP) is increasingly being performed as an alternative to open surgery. Whether the implementation and corresponding learning curve of LDP have an impact on patient outcome is unknown. The aim was to investigate the temporal trends in practice across UK centres. Methods: This was a retrospective multicentre observational cohort study of LDP in 11 tertiary referral centres in the UK between 2006 and 2016. The learning curve was analysed by pooling data for the first 15 consecutive patients who had LDP and examining trends in surgical outcomes in subsequent patients. Results: In total, 570 patients underwent LDP, whereas 888 underwent open resection. For LDP the median duration of operation was 240 min, with 200 ml blood loss. The conversion rate was 12⋅1 per cent. Neuroendocrine tumours (26⋅7 per cent) and mucinous cystic neoplasms (19⋅7 per cent) were commonest indications. The proportion of LDPs increased from 24⋅4 per cent in 2006-2009 (P1) to 46⋅0 per cent in 2014-2016 (P3) (P < 0⋅001). LDP was increasingly performed for patients aged 70 years or more (16 per cent in P1 versus 34⋅4 per cent in P3; P = 0⋅002), pancreatic ductal adenocarcinoma (6 versus 19⋅1 per cent; P = 0⋅005) and advanced malignant tumours (27 versus 52 per cent; P = 0⋅016). With increasing experience, there was a trend for a decrease in blood transfusion rate (14⋅1 per cent for procedures 1-15 to 3⋅5 per cent for procedures 46-75; P = 0⋅008), ICU admissions (32⋅7 to 19⋅2 per cent; P = 0⋅021) and median duration of hospital stay (7 (i.q.r. 5-9) to 6 (4-7) days; P = 0⋅002). After 30 procedures, a decrease was noted in rates of both overall morbidity (57⋅7 versus 42⋅2 per cent for procedures 16-30 versus 46-75 respectively; P = 0⋅009) and severe morbidity (18⋅8 versus 9⋅7 per cent; P = 0⋅031).Conclusion: LDP has increased as a treatment option for lesions of the distal pancreas as indications for the procedure have expanded. Perioperative outcomes improved with the number of procedures performed. * Other members of the Minimally Invasive Liver and Pancreatic Surgery Study Group -UK are co-authors of this study and can be found under the heading Collaborators

Objective:The aim of this study was to investigate the impact of conversion during minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC) on outcome by a propensity-matched comparison with open distal pancreatectomy (ODP).Background:MIDP is associated with faster recovery as compared with ODP. The high conversion rate (15%–25%) in patients with PDAC, however, is worrisome and may negatively influence outcome.Methods:A post hoc analysis of a retrospective cohort including distal pancreatectomies for PDAC from 34 centers in 11 countries. Patients requiring conversion were matched, using propensity scores, to ODP procedures (1:2 ratio). Indications for conversion were classified as elective conversions (eg, vascular involvement) or emergency conversions (eg, bleeding).Results:Among 1212 distal pancreatectomies for PDAC, 345 patients underwent MIDP, with 68 (19.7%) conversions, mostly elective (n = 46, 67.6%). Vascular resection (other than splenic vessels) was required in 19.1% of the converted procedures. After matching (61 MIDP-converted vs 122 ODP), conversion did not affect R-status, recurrence of cancer, nor overall survival. However, emergency conversion was associated with increased overall morbidity (61.9% vs 31.1%, P= 0.007) and a trend to worse oncological outcome compared with ODP. Elective conversion was associated with comparable overall morbidity.Conclusions:Elective conversion in MIDP for PDAC was associated with comparable short-term and oncological outcomes in comparison with ODP. However, emergency conversions were associated with worse both short- and long-term outcomes, and should be prevented by careful patient selection, awareness of surgeons’ learning curve, and consideration of early conversion when unexpected intraoperative findings are encountered.