Robotic versus laparoscopic distal pancreatectomy for upfront resectable pancreatic cancer: An international retrospective cohort study

Abstract

Purpose Upfront resectable pancreatic cancer in the left pancreas is increasingly resected through the minimally invasive approach. Robotic distal pancreatectomy (RDP) is an upcoming alternative for laparoscopic distal pancreatectomy (LDP). Yet, the oncological efficacy of RDP is uncertain. The aim of this study is to compare the oncological and surgical outcomes between RDP and LDP. Methods An international retrospective cohort study in consecutive patients treated with RDP or LDP in upfront resectable pancreatic cancer in 34 high-volume (>50 MIDP total experience) centers from 11 countries (2010-2019). The primary outcomes were R0 resection and lymph node yield. Kaplan-Meier estimates were used for survival rates. Results Overall, 542 patients were included, 103 (19%) underwent RDP and 439 (81%) LDP. Preoperative characteristics were similar. RDP was associated with a higher median lymph-node yield (18 vs 16, P=0.021) and a comparable R0-resection rate (76% vs 69%, P=0.40). RDP was associated with a longer operative time (290 min vs 240 min, P<0.001) and less conversions (5% vs 17%, P=0.001) without emergency conversions (i.e. for bleeding), compared to 29% for LDP. A higher rate of major morbidity (Clavien-Dindo ≥3) (26% vs 16%, P=0.017) was observed after RDP, but 30-day mortality (2% vs 1%, P=0.24) and in-hospital mortality (2% vs 0.4%, P=0.26) did not differ significantly. Median length of stay was longer following RDP (10 vs 8 days, P=0.001). The 3-year survival rate [34% vs 38%, P=0.73] and median overall survival [28 months (95% CI, 9-47) vs 31 months (95% CI, 25-37), P=0.73] did not differ significantly. Conclusion For upfront resectable pancreatic cancer, RDP was associated with a similar R0 resection rate, but a higher lymph node yield compared to LDP. Given the contradicting outcomes in conversion rate, morbidity rate, operative time, and hospital stay, randomized trials are required in centers that have surpassed the learning curve.