Minimally Invasive Distal Pancreatectomy Yields Better Outcomes

January 13, 2014

By James E. Barone

NEW YORK (Reuters Health) Jan 13 - Compared to open distal pancreatectomy (ODP), minimally invasive distal pancreatectomy (MIDP) results in fewer complications and a shorter hospital stay with no increase in mortality, splenectomy, or total charges, a new study shows.

"In the hands of an experienced pancreatic and laparoscopic surgeon and for appropriately selected patients, MIDP has evolved into a safe option in the treatment of benign and malignant pancreatic diseases," senior author Dr. Jason K. Sicklick told Reuters Health.

Dr. John A. Stauffer, a pancreatic surgeon at the Mayo Clinic in Jacksonville, Florida who has done research on this topic but wasn't involved in this study, told Reuters Health, "This manuscript adds additional evidence to support the advantages of MIDP over the traditional open approach and highlights the fact that MIDP is a grossly underutilized treatment for diseases of the distal pancreas within the United States."

The work, done by surgeons at the University of California in San Diego, was published online January 13 in JAMA Surgery.

The researchers analyzed data from the Nationwide Inpatient Sample (NIS) for the years 1998 through 2009, on all elective cases of distal pancreatectomy in adults.

Of the 8,957 distal pancreatectomies that were identified, 382 (4.3%) were MIDPs. Over the years studied, the percentage of MIDPs rose from 2.4% in 1998 to 7.3% in 2009.

"The delay in the widespread adoption of minimally invasive techniques in the treatment of pancreatic disease was likely engendered, in part, by the inherent technical challenges presented by the retroperitoneal location of the pancreas, its notoriously unforgiving nature, its close proximity to major vascular structures, and early concerns regarding oncologic outcomes," said Dr. Sicklick.

"The study shows a very low rate of application of MIDP, but fortunately, also demonstrates an increase rate of use over the study period even without taking into account the most recent four years," said Dr. Stauffer.

Patients who underwent MIDP were slightly but significantly older compared to the ODP group (60.7 vs. 58.3 years; p=0.002). They were also more likely to have had surgery at a teaching hospital (85.6% vs. 73.4%; p<0.001).

The minimally invasive cohort also had significantly more operations for cancer and fewer for pancreatitis (p=0.001).

When the results were adjusted for demographics, comorbidities, hospital teaching status, and indications, MIDP was associated with a 1.22-day decrease in hospital length of stay (p=0.046), a 25% decrease in the overall complication rate (p=0.04), fewer bleeding complications (p=0.02), and fewer postoperative infections (p=0.03).

There were no differences in rates of splenectomy or in-hospital mortality.

The authors acknowledge some limitations of the study due to shortcomings of the NIS database, such as a lack of information about the incidence of postoperative pancreatic fistula formation and the nature and extent of the cancer diagnoses. Some issues with coding inherent to all administrative databases were also mentioned.

The lack of specific oncologic data in the NIS prevented the authors from performing a comparative subset analysis of patients with malignancies. "However," Dr. Sicklick said, "an earlier multicenter study reported equivalent oncologic outcomes between LDP and ODP for patients with malignancies. In particular, there were no differences in margin positive rates, lymph node yield, or overall survival."

He noted that it was also a retrospective analysis.

Dr. Sicklick said his group currently does about 75% of their distal pancreatectomies using minimally invasive techniques. "We typically will perform open resections for patients with locally advanced or borderline resectable disease, as well as when the tumors involve the neck of the pancreas."

"Our group prefers to approach all diseases of the distal pancreas with MIDP and perform >90% of cases with this technique including those with cancer," said Dr. Stauffer, citing the same contraindications as Dr. Sicklick.

For future studies of cancer outcomes, Dr. Sicklick suggests that "cross-referencing databases such as NIS and SEER would be one way to follow these patients over the long term." He believes that as time goes on and surgeons become more comfortable with MIDP, the selection bias will diminish. Comparing comparable tumor stages over time would be an ideal method to compare oncologic outcomes following both MIDP and ODP.

Dr. Stauffer said, "There will always be selection bias with the use of retrospective studies which can only be overcome with the use of randomized prospective studies." But he believes that nearly every surgeon who performs MIDP would be unwilling to participate in this type of study after observing the improved outcomes for patients.


JAMA Surgery 2014.


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