Multi-institutional comparison of open, laparoscopic, hand-assisted laparoscopic, and robotic techniques for distal pancreatectomy

Abstract

Objective: The literature comparing minimally invasive distal pancreatectomy (DP) to open DP is mostly limited to one or two minimally invasive surgical (MIS) techniques. Previous studies have addressed outcomes between robotic, laparoscopic, and open DP but have not included hand-assisted laparoscopic surgery. We evaluated outcomes of these four DP techniques in a multi-center study. Methods: Data was collected from a prospectively maintained pancreas surgery consortium database at three high-volume pancreatic centers. We analyzed pre-operative, oncologic, and post-operative outcomes including complications, pancreatic fistula of any grade, and clinically relevant fistula in each DP procedure type. Results: 261 patients underwent DP. 36% underwent open, 25% laparoscopic, 14% hand-assisted, and 25% robotic DP. The most common diagnosis was cystic lesion (39%) followed by pancreatic adenocarcinoma (PDAC) (27%). Open DP was more common in patients with PDAC (p=0.001) and with greater co-morbidities, particularly HTN (p=0.02) and smoking history (p=0.02). EBL and transfusions were greater with open DP. Length of procedure was greater with MIS. Soft gland texture was more common in the MIS groups (Table 1). There was no difference in post-operative complications except for increased fistula of any grade with MIS (p=0.02). However, there was no difference in clinically relevant fistula (p=0.4). There was no difference in LOS, R0 resection, or lymph node yield. Conclusion: There is no difference in post-operative complications and oncologic outcomes between open and various MIS modalities for DP. The increased use of open DP for PDAC patients is likely a result of selection bias.Table 1ResultsOpenLapHALRoboticp-valueBaseline characteristicsHTN56 (61%)25 (44%)21 (60%)23 (38%)0.02Smoking history53 (58%)30 (47%)13 (35%)19 (28%)0.02Initial diagnosis PDAC43 (45%)7 (11%)10 (27%)9 (14%)0.001Perioperative characteristicsEBL (mL)43823960225<0.0005Transfusion10 (11%)2 (3%)02 (3%)0.009Soft gland texture69 (75%)49 (83%)32 (91%)58 (98%)0.001Post-operative complicationsFistula any grade21 (23%)25 (48%)12 (39%)17 (33%)0.02CR-POPF (ISGPS Grade B/C)9 (10%)10 (19%)3 (10%)7 (14%)0.4Patients with any complications44 (42%)33 (28%)15 (41%)23 (36%)0.3Patients with Accordion ≥ grade 3 complications20 (21%)13 (20%)5 (14%)11 (20%)0.8 Open table in a new tab