Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA)
Authors: van Hilst Jony , de Rooij Thijs , Klompmaker Sjors , Rawashdeh Majd , Aleotti Francesca , Al-Sarireh Bilal , Alseidi Adnan , Ateeb Zeeshan , Balzano Gianpaolo , Berrevoet Frederik , Björnsson Bergthor , Boggi Ugo , Busch Olivier R. , Butturini Giovanni , Casadei Riccardo , Del Chiaro Marco , Chikhladze Sophia , Cipriani Federica , van Dam Ronald , Damoli Isacco , van Dieren Susan , Dokmak Safi , Edwin Bjørn , van Eijck Casper , Fabre Jean-Marie , Falconi Massimo , Farges Olivier , Fernández-Cruz Laureano , Forgione Antonello , Frigerio Isabella , Fuks David , Gavazzi Francesca , Gayet Brice , Giardino Alessandro , Groot Koerkamp Bas , Hackert Thilo , Hassenpflug Matthias , Kabir Irfan , Keck Tobias , Khatkov Igor , Kusar Masa , Lombardo Carlo , Marchegiani Giovanni , Marshall Ryne , Menon Krish V. , Montorsi Marco , Orville Marion , de Pastena Matteo , Pietrabissa Andrea , Poves Ignaci , Primrose John , Pugliese Raffaele , Ricci Claudio , Roberts Keith , Røsok Bård , Sahakyan Mushegh A. , Sánchez-Cabús Santiago , Sandström Per , Scovel Lauren , Solaini Leonardo , Soonawalla Zahir , Souche F. Régis , Sutcliffe Robert P. , Tiberio Guido A. , Tomazic Aleš , Troisi Roberto , Wellner Ulrich , White Steven , Wittel Uwe A. , Zerbi Alessandro , Bassi Claudio , Besselink Marc G. , Abu Hilal Mohammed 
Published: November 2017

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.