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Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA)

A Pan-European Propensity Score Matched Study

van Hilst, Jony MD, MSc*; de Rooij, Thijs MSc*; Klompmaker, Sjors MD*; Rawashdeh, Majd MD; Aleotti, Francesca MD; Al-Sarireh, Bilal MD, PhD§; Alseidi, Adnan MD; Ateeb, Zeeshan MD||; Balzano, Gianpaolo MD; Berrevoet, Frederik MD, PhD**; Björnsson, Bergthor MD, PhD††; Boggi, Ugo MD‡‡; Busch, Olivier R. MD, PhD*; Butturini, Giovanni MD, PhD§§; Casadei, Riccardo MD, PhD¶¶; Del Chiaro, Marco MD, PhD||; Chikhladze, Sophia MD||||; Cipriani, Federica MD; van Dam, Ronald MD, PhD***; Damoli, Isacco MD†††; van Dieren, Susan PhD*; Dokmak, Safi MD‡‡‡; Edwin, Bjørn MD, PhD§§§; van Eijck, Casper MD, PhD¶¶¶; Fabre, Jean-Marie MD, PhD||||||; Falconi, Massimo MD; Farges, Olivier MD, PhD‡‡‡; Fernández-Cruz, Laureano MD****; Forgione, Antonello MD, PhD††††; Frigerio, Isabella MD§§; Fuks, David MD, PhD‡‡‡‡; Gavazzi, Francesca MD§§§§; Gayet, Brice MD, PhD‡‡‡‡; Giardino, Alessandro MD§§; Groot Koerkamp, Bas MD, PhD¶¶¶; Hackert, Thilo MD¶¶¶¶; Hassenpflug, Matthias MD¶¶¶¶; Kabir, Irfan MD||||||||; Keck, Tobias MD*****; Khatkov, Igor MD, PhD†††††; Kusar, Masa MD‡‡‡‡‡; Lombardo, Carlo MD‡‡; Marchegiani, Giovanni MD†††; Marshall, Ryne MD; Menon, Krish V. MD, PhD§§§§§; Montorsi, Marco MD§§§§; Orville, Marion MD‡‡‡; de Pastena, Matteo MD†††; Pietrabissa, Andrea MD¶¶¶¶¶; Poves, Ignaci MD, PhD||||||||||; Primrose, John MD, PhD; Pugliese, Raffaele MD††††; Ricci, Claudio MD¶¶; Roberts, Keith MD, PhD******; Røsok, Bård MD, PhD§§§; Sahakyan, Mushegh A. MD, PhD§§§; Sánchez-Cabús, Santiago MD, PhD****; Sandström, Per MD, PhD††; Scovel, Lauren MD; Solaini, Leonardo MD††††††; Soonawalla, Zahir MS, FRCS||||||||; Souche, F. Régis MD||||||; Sutcliffe, Robert P. MD******; Tiberio, Guido A. MD††††††; Tomazic, Aleš MD, PhD‡‡‡‡‡; Troisi, Roberto MD, PhD**; Wellner, Ulrich MD*****; White, Steven MD‡‡‡‡‡‡; Wittel, Uwe A. MD||||; Zerbi, Alessandro MD§§§§; Bassi, Claudio MD†††; Besselink, Marc G. MD, MSc, PhD*; Abu Hilal, Mohammed MD, PhD, FRCS, FACS for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)

doi: 10.1097/SLA.0000000000002561
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Objective: The aim of this study was to compare oncological outcomes after minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) in patients with pancreatic ductal adenocarcinoma (PDAC).

Background: Cohort studies have suggested superior short-term outcomes of MIDP vs. ODP. Recent international surveys, however, revealed that surgeons have concerns about the oncological outcomes of MIDP for PDAC.

Methods: This is a pan-European propensity score matched study including patients who underwent MIDP (laparoscopic or robot-assisted) or ODP for PDAC between January 1, 2007 and July 1, 2015. MIDP patients were matched to ODP patients in a 1:1 ratio. Main outcomes were radical (R0) resection, lymph node retrieval, and survival.

Results: In total, 1212 patients were included from 34 centers in 11 countries. Of 356 (29%) MIDP patients, 340 could be matched. After matching, the MIDP conversion rate was 19% (n = 62). Median blood loss [200 mL (60–400) vs 300 mL (150–500), P = 0.001] and hospital stay [8 (6–12) vs 9 (7–14) days, P < 0.001] were lower after MIDP. Clavien-Dindo grade ≥3 complications (18% vs 21%, P = 0.431) and 90-day mortality (2% vs 3%, P > 0.99) were comparable for MIDP and ODP, respectively. R0 resection rate was higher (67% vs 58%, P = 0.019), whereas Gerota's fascia resection (31% vs 60%, P < 0.001) and lymph node retrieval [14 (8–22) vs 22 (14–31), P < 0.001] were lower after MIDP. Median overall survival was 28 [95% confidence interval (CI), 22–34] versus 31 (95% CI, 26–36) months (P = 0.929).

Conclusions: Comparable survival was seen after MIDP and ODP for PDAC, but the opposing differences in R0 resection rate, resection of Gerota's fascia, and lymph node retrieval strengthen the need for a randomized trial to confirm the oncological safety of MIDP.

*Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, Amsterdam, the Netherlands

Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom

Department of Surgery, San Raffaele Hospital, Milan, Italy

§Department of Surgery, Morriston Hospital, Swansea, United Kingdom

Department of Surgery, Virginia Mason Medical Center, Seattle, United States

||Department of Surgery, Karolinska Institute, Stockholm, Sweden

**Department of General and HPB surgery and liver transplantation, Ghent University Hospital, Ghent, Belgium

††Department of Surgery, Linköping University, Linköping, Sweden

‡‡Department of Surgery, Universitá di Pisa, Pisa, Italy

§§Department of Surgery, Pederzoli Hospital, Peschiera, Italy

¶¶Department of Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy

||||Department of Surgery, Universitätsklinikum Freiburg, Freiburg, Germany

***Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands

†††Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy

‡‡‡Department of Surgery, Hospital of Beaujon, Clichy, France

§§§Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway

¶¶¶Department of Surgery, Erasmus MC, Rotterdam, the Netherlands

||||||Department of Surgery, Hopital Saint Eloi, Montpellier, France

****Department of Surgery, Hospital Clínic de Barcelona, Barcelona, Spain

††††Department of Surgery, Niguarda Ca’ Granda Hospital, Milan, Italy

‡‡‡‡Department of Surgery, Institut Mutualiste Montsouris, Paris, France

§§§§Department of Surgery, Humanitas University Hospital, Milan, Italy

¶¶¶¶Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany

||||||||Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom

*****Clinic for Surgery, UKSH Campus Lübeck, Lübeck, Germany

†††††Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation

‡‡‡‡‡Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia

§§§§§Department of Surgery, King's College Hospital NHS Foundation Trust, London, United Kingdom

¶¶¶¶¶Department of Surgery, University hospital Pavia, Pavia, Italy

||||||||||Department of Surgery, Hospital del Mar, Barcelona, Spain

******Department of Surgery, University Hospital Birmingham, Birmingham, United Kingdom

††††††Surgical Clinic, Department of clinical and experimental sciences, University of Brescia, Brescia, Italy

‡‡‡‡‡‡Department of Surgery, The Freeman Hospital Newcastle Upon Tyne, Newcastle, United Kingdom.

Reprints: Mohammed Abu Hilal, MD, PhD, FRCS, FACS, Southampton University Hospital NHS Foundation Trust, Tremona Road, SO16 2YD, Southampton, UK. E-mail: abuhilal9@gmail.com; Marc G. Besselink, MD, MSc, PhD, Academic Medical Center, Department of surgery, G4-196, PO BOX 22660, 1100 DD Amsterdam, The Netherlands. E-mail: m.g.besselink@amc.nl; Jony van Hilst, MD, MSc, Academic Medical Center, Department of surgery, G4-136, PO BOX 22660, 1100 DD Amsterdam, The Netherlands. E-mail: j.vanhilst@amc.nl.

M.G.B. and M.A.H. are principal investigators and shared senior authors.

The abstract of this manuscript was presented during the following meetings: Pancreas Club 2017, ALPS 2017, Dutch society for Gastroenterology 2017, and European-African Hepato-Pancreato-Biliary Association 2017 (best paper prize).

Collaborators: G Sergeant, department of surgery, Jessa Ziekenhuis, Hasselt, Belgium; S Berti, department of surgery, St. Andrea Hospital, La Spezia, Italy.

Disclosure: The authors report no conflicts of interest.

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