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Ann Surg. 2017 Nov 2. doi: 10.1097/SLA.0000000000002561. [Epub ahead of print]

Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA): A Pan-European Propensity Score Matched Study.

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*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.



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).


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.


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.


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).


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.

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