Improved outcomes with minimally invasive pancreaticoduodenectomy in patients with dilated pancreatic ducts: A prospective study

Abstract

Presenter: Sanket Srinivasa MD, PhD | Washington University, St. Louis Background: There is little known about what factors predict better outcomes for patients who undergo minimally invasive pancreaticoduodenectomy (MIPD) versus open pancreaticoduodenectomy (OPD). Identifying such characteristics may guide patient selection in MIPD. We hypothesized that patients with dilated pancreatic ducts have improved postoperative outcomes with MIPD compared to OPD. Methods: All patients undergoing pancreaticoduodenectomy between April 2016 and July 2019 were prospectively followed, and perioperative and pathologic covariates and outcomes were compared. Patients with dilated pancreatic ducts (≥3mm) who underwent MIPD (Robotic/ Laparoscopic) were propensity score matched to patients with dilated ducts who underwent OPD and outcomes compared. Likewise, patients with non-dilated pancreatic ducts ( < 3mm) who underwent MIPD were 1:3 propensity score matched to patients with non-dilated ducts who underwent OPD and outcomes compared. Multivariate logistic regression analysis was used to control for potential confounders and the primary outcome was a composite measure termed the ideal outcome (IO) which required patients to achieve negative margins; experience no complications or readmission and be discharged within seven days. Results: 312 patients underwent PD– 51 (16.4%) MIPD and 212 (83.7%) OPD. Patients who underwent MIPD had significantly longer operative times, less intraoperative blood loss, less postoperative urinary retention, and a lower rate of 90-day readmission. After 1:3 propensity score matching, patients with dilated pancreatic ducts who underwent MIPD (n=30) had significantly increased intraoperative times, less intraoperative blood loss, less postoperative bleeding/anemia complications, lower overall complication rate, and were discharged from the hospital 3.5 days faster compared to matched OPD patients (n=90) with dilated ducts. Among propensity score matched patients with non-dilated pancreatic ducts, patients undergoing MIPD (n=21) had significantly less intraoperative blood loss compared to matched patients undergoing OPD (n=63) with non-dilated ducts, but there were no other significant differences in outcomes. In total, 39 (14.9%) patients had IO with OPD and 11 (21.6%) patients had IO with MIPD (p=0.276). With multivariate analysis, there was a significant interaction between operative approach (MIPD vs OPD) and pancreatic duct size (non-dilated [ < 3mm] vs dilated [≥ 3mm]) with respect to these variables’ association with IO (p=0.042). MIPD in patients with dilated pancreatic ducts was independently associated with increased IO (OR= 3.04, p=0.021) (Table 3). However, MIPD in patients with non-dilated pancreatic ducts was not associated with IO (OR=0.82, p=0.802). Conclusion: MIPD is safe with comparable perioperative and oncologic outcomes to OPD. Patients with pancreatic ducts ≥3mm appear to derive the most benefit from MIPD in terms of less complications and shorter hospital stay.