Survival After Minimally Invasive vs Open Surgery for Pancreatic Adenocarcinoma

Abstract

ImportanceOnly a few high-volume centers have reported on long-term oncologic outcomes after minimally invasive pancreatic surgery (MIPS) for pancreatic adenocarcinoma, but none of them have shown superior long-term overall survival (OS) compared with open pancreatic surgery (OPS).ObjectiveTo study long-term survival after MIPS and OPS with curative intent among patients with pancreatic adenocarcinoma.Design, Setting, and ParticipantsThis comparative effectiveness study used a retrospective analysis of a prospectively maintained electronic database of patient data collected between January 2010 and December 2019. Consecutive patients from a high-volume pancreatic cancer referral center were included. Data analysis was conducted from March to October 2022. Median follow-up time was 56.8 months.ExposuresPatients were matched using propensity score models to study long-term survival.Main Outcomes and MeasuresSurvival outcomes were analyzed using the Cox proportional hazards model. Variables used for propensity score correction were TNM stage, tumor dimension, lymph node status, type of operation, simultaneous vascular resection, neoadjuvant chemotherapy, adjuvant chemotherapy, sex, age, and American Society of Anesthesiologists score. Additional corrections were made for year of surgery and type of adjuvant chemotherapy.ResultsAfter propensity score matching the sample of 396 patients, there were 198 patients in the MIPS group (89 [44.9%] men; median [range] age, 68 [32-87] years) and 198 in the OPS group (94 [47.5%] men; median [range] age, 67 [39-84] years). Median OS in the MIPS group was 30.7 (95% CI, 26.2-36.8) months compared with 20.3 (95% CI, 17.6-23.5) months after OPS (hazard ratio [HR], 0.70; 95% CI, 0.56-0.87; P = .002). Median disease-free survival (DFS) after MIPS vs OPS was 14.8 (95% CI, 11.8-17.0) months vs 10.7 (95% CI, 9.0-12.1) months (HR, 0.71; 95% CI, 0.57-0.89; P = .003). Additional corrections for year of surgery and type of adjuvant chemotherapy showed better OS (year of surgery: HR, 0.74; 95% CI, 0.57-0.96; P = .02; adjuvant chemotherapy: HR, 0.71; 95% CI, 0.56-0.90; P = .005) and DFS (year of surgery: HR, 0.77; 95% CI, 0.59-0.99; P = .04; adjuvant chemotherapy: HR, 0.72; 95% CI, 0.57-0.92; P = .009) for patients undergoing minimally invasive vs open surgery.Conclusions and RelevanceIn this study of 396 patients with borderline resectable and resectable pancreatic adenocarcinoma, MIPS was associated with better OS and DFS than OPS. Centralization of MIPS should be stimulated, and pancreatic surgeons should be encouraged to pass the learning curve before implementing MIPS for pancreatic adenocarcinoma in daily clinical practice.

Short-term Outcomes of Robotic Versus Open Pancreatoduodenectomy

“…However, more patients in the MIPS group received the more effective mFOLFIRINOX therapy (26% vs 5%). Still, survival advantages for MIPS persisted, even when statistically correcting for the type of adjuvant chemotherapy 40 …”

“…Still, survival advantages for MIPS persisted, even when statistically correcting for the type of adjuvant chemotherapy. 40…”

Evolution of laparoscopic pancreaticoduodenectomy at Westmead Hospital

“…Laparoscopic pancreaticoduodenectomy has been a major technical breakthrough worldwide, with recent systematic reviews and small randomized control trials reporting the feasibility and safety of LPD in high‐volume centres. Its proposed benefits include lower blood loss, lower morbidity, and shorter hospital stay 12–17 . The reluctance to adopt LPD in many institutions however is understandable given the surgical complexity 16 .…”

“…Its proposed benefits include lower blood loss, lower morbidity, and shorter hospital stay. [12][13][14][15][16][17] The reluctance to adopt LPD in many institutions however is understandable given the surgical complexity. 16 In our previous study, we reported the use of HLPD as an intermediate step to achieving laparoscopic resection before attempting TLPD.…”

Multidisciplinary team diagnosis and treatment of pancreatic cancer: Current landscape and future prospects

“…At present, the development direction of surgery is gradually toward precision and minimally invasive, which requires us to better use endoscopic technology and surgical robot, as well as the combination of the both. Regarding some experts worried that minimally invasive treatment cannot reach the R0 margin affect the OS, disease-free survival (DFS), etc., Halit et al ( 46 ) reported a study of 396 patients with borderline resectable and resectable pancreatic adenocarcinoma, minimally invasive pancreatic surgery (MIPS) was associated with better OS and DFS than open pancreatic surgery (OPS). Centralization of MIPS should be stimulated, and pancreatic surgeons should be encouraged to pass the learning curve before implementing MIPS for pancreatic adenocarcinoma in daily clinical practice.…”