Progress is an Iterative Process.

I n this 2019 lead issue of Annals of Surgery, 2 manuscripts appear out of Europe on the topic of minimally invasive distal pancreatectomy (MIDP). The first (LEOPARD-1) is a prospective, multicenter randomized trial that compared perioperative outcomes of MIDP with standard open distal pancreatectomy (ODP), and the second (DIPLOMA) is a large, multicenter retrospective propensity score matched study that compared cancer outcomes for patients who had MIDP or ODP for pancreatic ductal adenocarcinoma (PDAC). This editorial focuses on these 2 studies, how they complement existing reports, and how they move our understanding of minimally invasive pancreatic resection (MIPR) forward. Briefly, the LEOPARD-1 trial randomized 108 patients between MIDP and ODP pancreatectomy in 14 Dutch centers and showed a 2-day reduction in time to functional recovery after MIDP. The DIPLOMA cohort study evaluated data from 1212 patients from 34 centers in 11 European countries and found a higher R0-resection rate and comparable survival after MIDP versus ODP for PDAC. Both studies are well-crafted and provide value both for surgeons performing these operations and for their patients, who are on the other side of the laparoscope. Both studies largely confirm findings in previously published, large multicenter retrospective reports. The authors and many coauthors are to be congratulated for conceiving and completing these efforts. Of all pancreatic resection types, distal pancreatectomy is best-suited for an MIS approach, as no reconstruction is necessary, and patients derive a substantial benefit from avoiding a large midline or subcostal incision. Historically, however, pancreatic resection was late to join the minimally invasive surgery (MIS) bandwagon for several reasons. First, the pancreas is situated deep in the retroperitoneum, surrounded by critical blood supply. Second, the pancreas is a finicky organ prone to considerable retaliation if poked. Third, as compared with the cholecystectomies and colectomies, the number of pancreatectomies performed is comparatively low leading to a more drawn out learning curve. The senior authors of LEOPARD-1 addressed the learning curve issue before initiating the trial. They devised a program to train surgeons in the Netherlands called LELAPS (cite) and implemented this system and a 20-case minimum for participation in the trial. The overall findings of shorter recovery time and hospital length of stay for the MIDP cohort are significant, and match the 2-day shorter hospital stay published in 2010. Of note, the rate of delayed gastric emptying was unusually high in the ODP cohort, and the B/C fistula rate was higher in the MIDP group for reasons that are unclear. Further, all open cases were performed through muscle-cutting subcostal incisions, as opposed to midline incisions, perhaps placing the ODP group at further disadvantage. Finally, it is not clear why the authors permitted 5 robotic cases to be included in this study, as we still have minimal data comparing outcomes for laparoscopic and robotic procedures. We also do not know how these results translate to other countries with higher rates of obesity and metabolic syndrome. Despite these questions, this is a solid trial that supports MIDP in the hands of surgeons who undergo dedicated training. The DIPLOMA cohort study similarly confirms results of prior multicenter studies on MIDP for PDAC, showing similar margin-negative resection rates and overall survival. One incongruity is the lower node harvest in the MIDP group, but again, this represents retrospective data. Ultimately, the DIPLOMA cohort study paves the way for the eagerly awaited, ongoing international DIPLOMA randomized controlled trial of MIDP versus ODP for PDAC, taking us to the next level of progress, proof, and understanding. On April 20, 2016, the first international state of the art conference on MIPR was held in Sao Paulo, Brazil. This well-attended conference covered the existing data on MIPR, and topics such as how to measure cost, value, quality of life, training and education, and what future research goals should look like. At this time, there were no published prospective randomized data in the field, and