Original Article |

Comparative Effectiveness of Minimally Invasive and Open Distal Pancreatectomy for Ductal Adenocarcinoma

Deepa Magge, MD; William Gooding, MS; Haroon Choudry, MD; Jennifer Steve, BA; Jennifer Steel, PhD; Amer Zureikat, MD; Alyssa Krasinskas, MD; Mustapha Daouadi, MD; Kenneth K. W. Lee, MD; Steven J. Hughes, MD; Herbert J. Zeh, MD; A. James Moser, MD
JAMA Surg. 2013;148(6):525-531. doi:10.1001/jamasurg.2013.1673.
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Importance Multicenter studies indicate that outcomes of open (ODP) and minimally invasive distal pancreatectomy (MIDP) are equivalent for benign lesions. However, data for pancreatic carcinoma are limited.

Objective To compare outcomes of ODP and MIDP for early-stage pancreatic ductal carcinoma to determine relative safety and oncologic efficacy.

Design Retrospective analysis of 62 consecutive patients undergoing ODP or MIDP for pancreatic ductal carcinoma by intention to treat with propensity scoring to correct for selection bias.

Setting A high-volume university center for pancreatic surgery.

Participants Sixty-two patients at a single institution.

Interventions Patients underwent ODP or MIDP.

Main Outcome Measures Perioperative mortality, morbidity, readmission, postoperative complications, disease progression, and overall survival.

Results Thirty-four patients underwent ODP, and 28 underwent MIDP with 5 conversions to ODP. No significant differences in age, body mass index, performance status, tumor size, or radiographic stage were identified. High rates of margin-negative resection (ODP, 88%; MIDP, 86%) and median lymph node clearance (ODP, 12; MIDP, 11) were achieved in both groups with equal rates and severity of postoperative complications (ODP, 50%; MIDP, 39%) and pancreatic fistula (ODP, 29%; MIDP, 21%). Despite conversions, intended MIDP was associated with reduced blood loss (P = .006) and length of stay (P = .04). Conversion was associated with a poor histologic grade and positive nodes. Median overall survival for the entire cohort was 19 (95% CI, 14-47) months. Minimally invasive distal pancreatectomy was performed increasingly in later study years and for patients with a higher Charlson–Age Comorbidity Index. Overall survival after ODP or intended MIDP was equivalent after adjusting for comorbidity and year of surgery (relative hazard, 1.11 [95% CI, 0.47-2.62]).

Conclusions and Relevance We detected no evidence that MIDP was inferior to ODP based on postoperative outcomes or overall survival. This conclusion was verified by propensity score analysis with adjustment for factors affecting selection of operative technique.

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Figure 1. Propensity analysis based on a logistic regression model logarithm of the odds ratio (log OR) for attempting minimally invasive distal pancreatectomy (MIDP) at the University of Pittsburgh Medical Center (UPMC). A, Accrual to open distal pancreatectomy (ODP) and MIDP by study year. B, Propensity to perform MIDP relative to year 1 (2002) adjusted to a Charlson–Age Comorbidity Index (CCI) of 2. The OR for MIDP increased progressively from 2002 (year 1) to 2010 (year 9). C, Log OR for attempting MIDP at UPMC as a function of the CCI adjusted to year 2007. The OR for attempting MIDP increased across the range of CCIs from 0 to 9, indicating that patients with more medical comorbidities were more likely to undergo MIDP with time relative to ODP. Whiskers represent 95% confidence intervals.

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Figure 2. Median overall survival for all patients undergoing distal pancreatectomy and adjuvant therapy for pancreatic ductal carcinoma. Dotted lines indicate 95% confidence intervals.

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Figure 3. Propensity score–adjusted overall survival analysis after open (ODP) and minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal carcinoma (relative hazard, 1.11 [95% CI, 0.47-2.62]; P = .80).

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Figure 4. Cumulative hazard ratio of death from pancreatic ductal carcinoma (PDC) as a function of time after surgical resection. The hazard ratio for PDC-related death is highest in the first 8 months and falls rapidly after 24 months despite the provision of adjuvant chemotherapy to 53 study patients (86%). Diagonal line represents a line of constant hazard, or unity.




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