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A. J. Sinnamon and P. J. Hodul
transverse mesocolon unnecessarily. Similarly, judgment should be exercised to distinguish adhesions to be divided as opposed to tumor to be resected en bloc. The
stomach may now be reected cranially and supported with a mounted retractor,
providing complete exposure of the pancreatic neck and body.
Mobilization of the distal transverse colon and splenic exure is typically
required to complete exposure of the inferior border of the pancreas, although the
amount of mobilization needed is variable. To mobilize the splenic exure, dissection can be performed in two directions which converge at the spleen. Laterally,
electrocautery dissection along the white line of Toldt while gently retracting the
colon medially will separate the mesocolon from retroperitoneum. This may proceed in an inferior-to-superior direction. Medially, the distal transverse colon may
be mobilized inferiorly by continuing division of the gastrocolic ligament toward
the splenocolic ligamentous attachments. These attachments are typically wellvascularized; we generally use a bipolar energy device for hemostatic division.
These two paths of dissection will meet near the spleen and then the fully mobilized
splenic exure may be safely retracted with a mounted retractor, gently placed to
avoid traction injury.
Radical Antegrade Modular Pancreatosplenectomy (RAMPS)
If electing to proceed with a RAMPS approach, attention is next paid to the patient’s
midline. The root of the splenic artery is typically identied superior and posterior
to the superior border of the pancreas, although there is signicant variability, and
this may be more posterior to the body. The left gastric vein will often drain at the
level of the portosplenic conuence and may require ligation and division to clearly
identify the splenic artery, but this is not necessary in all cases. Great care should be
taken to delineate the root of the splenic artery from the root of the common hepatic
artery, as these may be easily mistaken, particularly if both are running in a horizontal fashion. Identication and removal of the hepatic artery lymph node will expose
the underlying common hepatic artery. Longitudinal dissection along the hepatic
artery will identify the gastroduodenal artery; careful dissection just medial to this
and above the superior border of the pancreas will expose the portal vein. To identify the SMV at the inferior neck of the pancreas, the right gastroepiploic and middle colic veins are identied and followed along their course to lead to their drainage
into the SMV.This is best achieved by retracting the distal stomach anteriorly and
toward the liver while simultaneously retracting the transverse colon inferiorly.
These branches may be ligated and divided as needed to provide exposure.
Now that the portal vein has been identied superiorly and the SMV inferiorly, a
retropancreatic tunnel may be developed to isolate the pancreas if planning to transect it at the surgical neck. This is achieved by carefully dissecting along the
22 Open Distal Pancreatectomy
399
avascular plane posterior to the pancreatic neck at the level of the SMV until the
tunnel meets the exposed portal vein superiorly. This dissection may be performed
with a blunt dissector of the surgeon’s preference, with deliberate, downward
strokes to separate the vein away from the pancreas. Once this dissector has reached
the level of the previously exposed portal vein, the pancreatic neck may be circled
with a vessel loop or umbilical tape, if preferred, for division.
Once the pancreas has been circled, the splenic artery may be ligated and divided
using clips, ties, or a vascular stapler. The pancreatic parenchyma may be subsequently divided. It is our preference to divide the pancreas using a triple-height
linear stapler. Judgment must be exercised to use the appropriate thickness stapler
load. Alternatively, if the pancreas is to be transected sharply, which may be necessary for an excessively thick pancreas, the pancreatic duct should be identied and
directly closed with a U-stitch. The remainder of the gland may be closed in a running or U-stitch pattern. While initial prospective trial data showed no difference in
rate of postoperative leak between staple and suture method for pancreatic transection, meta-analysis of the accumulated available data suggests that stapled transection is associated with a lower leak rate [22, 23].
Once the pancreas is transected, the distal aspect may be retracted laterally
exposing the splenic vein, which may be ligated and divided. It should be noted that
transection of the pancreas may be performed before division of the splenic artery
if it is positioned posterior to the pancreatic body and therefore not easily accessed.
In general, it is preferable to divide the artery before the vein to minimize hypertension within the spleen and allow for autotransfusion as the spleen drains. At this
point, there remains no arterial ow to the spleen with division of the short gastric
vessels and splenic artery so risk of hemorrhage is minimized.
After the splenic vein is divided, the root of the SMA should lie directly posteriorly allowing removal of the overlying lymph nodes en bloc with the specimen.
Dissection along the inferior and superior borders of the pancreas allows for further
retraction of the pancreatic body laterally. It is critical to remain cognizant of the
fourth portion of the duodenum at this location to avoid injury. Dissection then continues just to the patient left of the SMA and proceeds posteriorly, deep to the anterior renal fascia to obtain a negative retroperitoneal margin. If an anterior RAMPS
is planned, dissection continues laterally, staying just supercial to the adrenal
gland and kidney. If a posterior RAMPS is planned for a more invasive tumor, dissection continues laterally, staying deep to the left adrenal and removing this en
bloc. During this lateral dissection, any remaining attachments between the splenic
exure and inferior pancreas and spleen are divided using bipolar energy as they are
commonly vascularized. Eventually the only remaining attachments to the specimen to be freed are the ligamentous attachments of the spleen to the left diaphragm.
These are divided, taking care not to cause a full thickness injury to the diaphragm
that would need repair. The specimen is then removed from the eld.
400
A. J. Sinnamon and P. J. Hodul
Retrograde Distal Pancreatectomy andSplenectomy
The initial steps of a standard retrograde approach include division of the gastrocolic and gastrosplenic ligaments to expose the anterior aspect of the pancreas as
described above.
A retrograde approach begins with takedown of the splenic exure to expose the
inferior border of the pancreas. The inferior and superior borders of the pancreas are
mobilized by incising the overlying peritoneum allowing the pancreas to be lifted
from the retroperitoneum. The splenic artery may then be identied superior to
pancreas and subsequently ligated and divided. Early ligation of the short gastric
vessels and splenic artery in this way now allows for relatively safe lateral-to-medial
dissection beginning by dividing the attachments of the spleen to the diaphragm
laterally. The spleen is then rotated medially, and the pancreas is dissected free from
the anterior renal fascia in a lateral-to-medial manner. A deeper retroperitoneal margin may be taken as needed. This approach to dissection leaves the pancreas and
spleen in the air ready for transection at the end. The splenic vein may be safely
ligated and divided with the same re of a linear stapler as the pancreas, or it may
be taken separately. The specimen is then removed from the eld. A retrograde
approach may be preferable for cases when a more limited distal pancreatectomy is
to be performed, as dissection at the level of the pancreatic neck may not be
necessary.
Regardless of whether performing an antegrade or retrograde dissection, the
resection bed is copiously irrigated and examined for hemostasis after removal of
the specimen. The adjacent colon is examined for possible injury. The transection
margin may be examined by frozen pathologic analysis during this time. A surgical
drain is placed taking a long, looping course under the diaphragm with the end at the
pancreatic resection line for management of possible postoperative leak. The looping course under the diaphragm helps to prevent dislodgement of the drain to a site
where it is no longer effectively draining the pancreas. It is our preference to routinely harvest a falciform pedicle ap for coverage of the transection line, as discussed below. This may be secured in place with one or two sutures to the tissue
adjacent to the pancreas.
Technical Pearls andPitfalls
Early Ligation ofSplenic Arterial Supply
If it is technically feasible to ligate the splenic artery early in the operation after
committing to resection, this should help to signicantly reduce the risk of signicant splenic bleeding later. As the short gastric vessels are divided during initial
exposure of the pancreas, ligation of the splenic artery leaves the spleen with no
22 Open Distal Pancreatectomy
arterial supply and reduces pressure in the system. If it is still undetermined whether
the surgeon will be committing to resection, a vessel loop or loose silk tie may be
placed around the splenic artery early in the operation for urgent ligation at a later
point for uncontrolled bleeding. This may even be performed before opening of the
gastrocolic ligament, as the root of the splenic artery may alternatively be accessed
by entering the lesser sac by opening the pars accida along the lesser curve of the
stomach. As noted above, arterial ligation should be performed before division of
the splenic vein to allow drainage of the spleen.
401
Splenic Artery Calcication
As discussed above, it should be re-emphasized that review of preoperative imaging
should be very mindful of signicant calcications in the splenic artery. This might
be overlooked while focusing on pancreatic pathology. A heavily calcied splenic
artery will be noncompliant with a vascular stapler and may result in catastrophic
hemorrhage. Intraoperative palpation for a soft segment of artery when there is
known calcic disease is critical.
Splenic Vein Stump Length
If performing a distal pancreatectomy with transection of the pancreas at the surgical neck, it is preferable to divide the splenic vein ush with the SMV, if possible.
There is evidence that the length of the residual splenic vein stump is a risk factor
for postoperative thrombosis. This is presumably due to stagnant ow causing a
nidus for thrombus formation. While thrombosis of the SMV stump is itself not
problematic, forward propagation into the portal vein is potentially problematic.
Ligamentum Teres/Falciform Pedicle Flap
Care should be taken to preserve the falciform ligament/ligamentum teres during
initial laparotomy so that it may be used as a vascularized ap to cover the transected pancreatic stump. A sizeable ap may be obtained by dissecting the ligament
down to the umbilicus distally before dividing it and freeing the ligament from its
membranous hepatic attachments to gain length. Leaving some preperitoneal fat on
the distal aspect allows for an appreciable ap for coverage. Prospective data has
shown the ligamentum teres ap to be associated with reduced rate of clinically
relevant postoperative pancreatic stula [24].
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A. J. Sinnamon and P. J. Hodul
Reinforced Staple Line forTransection
Several products include reinforced stapler loads with the goal to reduce the rate of
leak at the transection margin. While initial trial results were promising for reducing
the rate of clinically relevant postoperative leak, more recent trial data has shown no
difference in leak rate between reinforced and standard staplers [25–27]. There is
evidence that reinforced staplers may be effective in the subset of patients with a
thin pancreas [26]. We do not routinely use a reinforced stapler load for transection
of the pancreatic parenchyma, but will selectively do so for cases with particularly
soft pancreas.
References
1. McClusky DA 3rd, Skandalakis LJ, Colborn GL, Skandalakis JE. Harbinger or hermit?
Pancreatic anatomy and surgery through the ages--part 2. World J Surg. 2002;26(11):1370–81.
2. Link GV.The treatment of chronic pancreatitis by pancreatostomy: a new operation. Ann Surg.
1911;53(6):768–82.
3. Mayo WJ.I. The surgery of the pancreas: I.Injuries to the pancreas in the course of operations on the stomach. II.Injuries to the pancreas in the course of operations on the spleen.
III.Resection of half the pancreas for tumor. Ann Surg. 1913;58(2):145–50.
4. Whipple AO.Islet cell tumors of the pancreas. Can Med Assoc J. 1952;66(4):334–42.
5. Strasberg SM, Drebin JA, Linehan D. Radical antegrade modular pancreatosplenectomy.
Surgery. 2003;133(5):521–7.
6. Mitchem JB, Hamilton N, Gao F, Hawkins WG, Linehan DC, Strasberg SM.Long-term results
of resection of adenocarcinoma of the body and tail of the pancreas using radical antegrade
modular pancreatosplenectomy procedure. J Am Coll Surg. 2012;214(1):46–52.
7. Strasberg SM, Linehan DC, Hawkins WG.Radical antegrade modular pancreatosplenectomy
procedure for adenocarcinoma of the body and tail of the pancreas: ability to obtain negative
tangential margins. J Am Coll Surg. 2007;204(2):244–9.
8. Latorre M, Ziparo V, Nigri G, Balducci G, Cavallini M, Ramacciato G.Standard retrograde
pancreatosplenectomy versus radical antegrade modular pancreatosplenectomy for body and
tail pancreatic adenocarcinoma. Am Surg. 2013;79(11):1154–8.
9. Park HJ, You DD, Choi DW, Heo JS, Choi SH. Role of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas. World J Surg.
2014;38(1):186–93.
10. Trottman P, Swett K, Shen P, Sirintrapun J. Comparison of standard distal pancreatectomy and splenectomy with radical antegrade modular pancreatosplenectomy. Am Surg.
2014;80(3):295–300.
11. Abe T, Ohuchida K, Miyasaka Y, Ohtsuka T, Oda Y, Nakamura M. Comparison of surgical
outcomes between radical antegrade modular pancreatosplenectomy (RAMPS) and standard retrograde pancreatosplenectomy (SPRS) for left-sided pancreatic cancer. World J Surg.
2016;40(9):2267–75.
12. Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology
reporting template: consensus statement of the Society of Abdominal Radiology and the
American Pancreatic Association. Radiology. 2014;270(1):248–60.
13. Pannegeon V, Pessaux P, Sauvanet A, Vullierme MP, Kianmanesh R, Belghiti J.Pancreatic
stula after distal pancreatectomy: predictive risk factors and value of conservative treatment.
Arch Surg. 2006;141(11):1071–6; discussion 1076.
22 Open Distal Pancreatectomy
14. Sell NM, Pucci MJ, Gabale S, etal. The inuence of transection site on the development of
pancreatic stula in patients undergoing distal pancreatectomy: a review of 294 consecutive
cases. Surgery. 2015;157(6):1080–7.
15. Silvestri M, Coignac A, Delicque J, etal. Level of pancreatic division and postoperative pancreatic stula after distal pancreatectomy: a retrospective case-control study of 157 patients
with non-pancreatic ductal adenocarcinoma lesions. Int J Surg. 2019;65:128–33.
16. Shatz DV, Schinsky MF, Pais LB, Romero-Steiner S, Kirton OC, Carlone GM. Immune
responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide
vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma. 1998;44(5):760–5; discussion 765–6.
17. Shatz DV, Romero-Steiner S, Elie CM, Holder PF, Carlone GM.Antibody responses in postsplenectomy trauma patients receiving the 23-valent pneumococcal polysaccharide vaccine at
14 versus 28 days postoperatively. J Trauma. 2002;53(6):1037–42.
18. Bruns H, Rahbari NN, Lofer T, etal. Perioperative management in distal pancreatectomy:
results of a survey in 23 European participating centres of the DISPACT trial and a review of
literature. Trials. 2009;10:58.
19. Brown SR, Goodfellow PB. Transverse verses midline incisions for abdominal surgery.
Cochrane Database Syst Rev. 2005;(4):CD005199.
20. Doucas H, Sutton CD, Zimmerman A, Dennison AR, Berry DP. Assessment of pancreatic
malignancy with laparoscopy and intraoperative ultrasound. Surg Endosc. 2007;21(7):1147–52.
21. Versteijne E, Suker M, Groothuis K, etal. Preoperative chemoradiotherapy versus immediate
surgery for resectable and borderline resectable pancreatic cancer: results of the Dutch randomized phase III PREOPANC trial. J Clin Oncol. 2020;38(16):1763–73.
22. Diener MK, Seiler CM, Rossion I, etal. Efcacy of stapler versus hand-sewn closure after
distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet.
2011;377(9776):1514–22.
23. Zhang H, Zhu F, Shen M, etal. Systematic review and meta-analysis comparing three techniques
for pancreatic remnant closure following distal pancreatectomy. Br J Surg. 2015;102(1):4–15.
24. Hassenpug M, Hinz U, Strobel O, et al. Teres ligament patch reduces relevant morbidity after distal pancreatectomy (the DISCOVER randomized controlled trial). Ann Surg.
2016;264(5):723–30.
25. Hamilton NA, Porembka MR, Johnston FM, etal. Mesh reinforcement of pancreatic transection decreases incidence of pancreatic occlusion failure for left pancreatectomy: a singleblinded, randomized controlled trial. Ann Surg. 2012;255(6):1037–42.
26. Kondo N, Uemura K, Nakagawa N, etal. A multicenter, randomized, controlled trial comparing reinforced staplers with bare staplers during distal pancreatectomy (HiSCO-07 trial). Ann
Surg Oncol. 2019;26(5):1519–27.
27. Wennerblom J, Ateeb Z, Jonsson C, et al. Reinforced versus standard stapler transection on
postoperative pancreatic stula in distal pancreatectomy: multicentre randomized clinical trial.
Br J Surg. 2021;108(3):265–70.
403
Chapter 23
Laparoscopic Distal Pancreatectomy
ElenaPanettieri, EduardoA.Vega, ArianaChirban, andClaudiusConrad
History
Early Exploration
The location of the pancreas in the retroperitoneum and its complex anatomical
relationships led to a late adoption of laparoscopic distal pancreatectomy (LDP).
Initially, LDP was only considered for patients with benign conditions such as cystic lesions or neuroendocrine tumors [1–3]. There were concerns about the ability to
E. Panettieri
Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of
Medicine, Boston, MA, USA
Hepatobiliary Surgery, Fondazione “Policlinico Universitario A.Gemelli”, IRCCS, Università
Cattolica del Sacro Cuore, Rome, Italy
e-mail: elena.panettieri@unicatt.it
E. A. Vega
Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of
Medicine, Boston, MA, USA
e-mail: eduardo.vega@steward.org
A. Chirban
Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of
Medicine, Boston, MA, USA
University of California, San Diego, School of Medicine, La Jolla, CA, USA
e-mail: achirban@health.ucsd.edu
C. Conrad (
Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of
Medicine, Boston, MA, USA
Carle Cancer Institute, Carle Illinois College of Medicine, Urbana, IL, USA
e-mail: cc@claudiusconrad.com
*)
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_23
405© The Author(s), under exclusive license to Springer Nature
406
E. Panettieri et al.
obtain safe oncological surgical margins or an adequate lymphadenectomy for pancreatic ductal adenocarcinoma (PDAC). Further, there were concerns regarding
port-site tumor seeding [4]. In the early period, PDAC was an incidental postoperative pathological nding and not identied preoperatively [1–3].
The rst cases of laparoscopic distal pancreatectomy (LDP) were described in
1994 by Sir Alfred Cuschieri [5, 6]. In his case-series of 5 patients, LDP of 70% of
the gland with associated splenectomy was performed. The team used a 5-port technique, and the indication was intractable chronic pain from pancreatitis [7].
In 2006, D’Angelica etal. [8] reported their experience with minimally invasive
distal pancreatectomy using a hand-assisted technique. The hand port enabled the
surgeon to palpate the tumor and critical anatomic structures. Alternatively, the surgical assistant could use the hand port, allowing the surgeon to operate with two
laparoscopic instruments while providing retraction. In their series of 17 cases, this
approach demonstrated feasibility.
Trends Over Time
In 2010, a 7-year experience with LDP was reported. At the beginning of the period
(2003), pure LDP was performed in 29% of cases, which increased to 40% in 2008,
and 38% in 2009, with a rise in conversion rate [9]. Over the same time, there was
a signicant decrease in utilization of the hand-assisted technique from 80% to
17%. Regarding pancreatic remnant stump closure, there was a shift toward greater
use of staplers and staples with a bioabsorbable staple line reinforcement
(Seamguard®), corresponding with a decrease in sutured stump closure in both LDP
and open distal pancreatectomy (ODP).
In 2012, an 11-year experience with LDP was reported, whereby the cohort was
divided in an “early experience” (2000–2007) and a “recent experience” (2008–2011)
group [10]. The most common indication was a cystic tumor (50.8%). It was
observed that centrally located tumors of the pancreatic body (23% vs. 66.1%) and
neck (3.3% vs. 8.1%) were increasingly resected using LDP, whereas the rate of tail
neoplasm resection decreased (73.7% vs. 25.8%) (p<0.001). The rate of patients
with a Charlson’s Comorbidity Score [11]≥3 rose from 16.7% to 40.9% (p=0.003).
The medial-to-lateral dissection (described in detail later) became more popular in
the recent period (39.4% vs. 53%, p=0.12), as well as stapler reinforcement with
the Seamguard
cases, the hand-assisted technique was less commonly performed (68.1% vs. 25.6%,
p<0.001) and operative time reduced from 172±69.1 to 141±60.3min (p=0.007).
Despite an increase in complexity over time, there were no differences in overall
complications, postoperative pancreatic stula (POPF), length of stay (LOS), or
mortality.
®
(4.7% vs. 28.8%, p<0.001). Despite the growing complexity of
23 Laparoscopic Distal Pancreatectomy
407
Morbidity
Since these rst reports, LDP has consistently been reported to lead to improved
short-term outcomes when compared to ODP. For example, the Central Pancreas
Consortium performed a matched comparison of 200 ODPs and 142 LDPs in 2008
[12]. Their results demonstrated lower average blood loss (BL) (357 vs. 588mL,
p<0.01), fewer complications (40% vs. 57%, p<0.01), and shorter LOS (5.9 vs.
9.0days, p<0.01) in patients undergoing LDP.There were no differences detected
in terms of positive margin status (8% vs. 7%, p= 0.8), operative time (216 vs.
230min, p=0.3), or POPF rates (18% vs. 11%, p=0.1). A later review and metaanalysis by Venkat etal. [13] conrmed lower BL by 355mL (p<0.001), decreased
LOS by 4days (p<0.001), and a lower incidence of postoperative complications
(33.9% vs. 44.2%, p=0.02) in patients undergoing LDP vs. ODP.There were no
signicant differences between operative time, margin status, POPF, or postoperative mortality.
Safety
An overview of seven meta-analyses on LDP reported on outcomes and safety of
published data between 2011 and 2016 [14]. The report demonstrated with a level
of evidence 3a (recommendation grade B) that mortality of LDP is not inferior to
ODP.This is particularly true for cases of benign/low-grade malignant tumors of the
body/tail (six meta-analyses). LOS has been consistently reported to be shorter after
LDP, but given the heterogeneity of studies analyzed, the authors concluded that
LDP is only associated with a slightly shorter LOS than ODP (three meta-analyses—grade B recommendation). The rate of overall complications is lower after
LDP for benign/low-grade malignant tumors (three meta-analyses with a 3a level of
evidence, grade B recommendation). Regarding POPF, LDP is not inferior to ODP
(seven meta-analysis—grade B recommendation). Only one meta- analysis by the
same authors [15] described no differences in terms of overall survival (OS) and
number of harvested lymph nodes for PDAC.
At the 2016 International Hepato-Pancreato-Biliary Association (IHPBA) conference, a panel of experts discussed the evidence and outcomes of minimally invasive distal pancreatectomy (MIDP) [16], suggesting that despite the high number of
papers available, the superior efcacy of LDP vs. ODP remains controversial.
Further randomized controlled prospective data comparing MIDP to ODP is
available. The important multicenter patient-blinded randomized controlled superiority trial [17] by the Dutch Pancreatic Cancer Group compared ODP with
MIDP.Despite the latter also including robotic procedures, results notably demonstrated faster recovery and reduced BL for MIDP. While no differences were
408
E. Panettieri et al.
reported in terms of overall complications, and delayed gastric emptying. An
improved quality of life was also shown without increased hospital costs among
MIDP patients.
Notably, results from two clinical trials were recently published.
The prospective single-center, superiority, parallel, open-label, randomized control trial “Laparoscopic versus open distal pancreatectomy (LAPOP)” [18] focused
on quality of life after ODP vs. LDP after a 1:1 randomization. Twenty-six patients
in the open group and 28in the laparoscopic group were included in the quality of
life analysis and received the QLQ-C30 and PAN26 questionnaires at 5–6weeks,
6months, 1year, and 2years after surgery. The two questionnaires were developed
to assess emotional and social well-being and physical symptoms among cancer and
PDAC patients, respectively. LDP patients’ answers demonstrated better results in
terms of emotional functioning, pain, insomnia, pancreatic pain, future worries, and
indigestion. Some of these differences persisted up to 2years after surgery. In particular, social functioning, insomnia, and pancreatic pain were signicantly worse
after ODP at that time point.
The “Minimally invasive versus open distal pancreatectomy for pancreatic duc-
tal adenocarcinoma (DIPLOMA)” [19] multicenter, randomized, non-inferiority
trial aimed to compare MIDP with ODP to assess radical resection rate for potentially resectable PDAC located in the pancreatic body or tail. Surgical margins
included the posterior and transection margins. LDP rate in the MIDP group was
73.5%. An R0 resection was achieved in 83 (72.8%) patients in the MIDP group and
in 76 (69.1%) patients in the ODP group (difference 3.7%, 90% CI −6.2% to 13.6%;
p
non-inferiority
=0.039). Median lymph node yield was comparable (22.0 [16.0–30.0] vs
23.0 [14.0–32.0] nodes, p=0.86). Other postoperative outcomes were comparable,
including median time to functional recovery and OS. It is important to note that
patients receiving neoadjuvant treatment were well balanced between the two
groups and that sensitivity analysis showed no impact of the inclusion of these
patients on outcomes.
Finally, the Miami International Evidence-based Guidelines on Minimally
Invasive Pancreas Resection [20] concluded that MIDP for benign and low-grade
malignant tumors should be considered over ODP (grade 1B, expert agreement
95%, quality score 85%, audience agreement 100%). MIDP for PDAC is thought to
be feasible, safe, and equivalent in experienced hands when performed for PDAC
(grade 2B, expert agreement 95%, quality score 87%, audience agreement 96%).
Oncologic Safety
Upon conrming the safety and reduction in morbidity of LDP in selected patients,
LDP for PDAC was explored by the Central Pancreas Consortium [21]. Of 212
patients undergoing distal pancreatectomy, 23 (11%) underwent LDP.Comparing
LDP to ODP, before matching, only BL >500 mL was independently associated
with a positive margin resection. After matching, a signicantly higher body mass