Abstract and Introduction
Objective: The aim of this review article is to evaluate the current status of minimally invasive pancreatic resections (MIPR) for pancreatic ductal adenocarcinoma (PDAC), in light of the present evidence.
Background: Published data, largely in the form of retrospective studies and a few prospective/randomized controlled trials have confirmed feasibility, safety, and equivalent short-term outcomes of MIPR in experienced hands. Hence, several recent evidence-based international consensus guidelines have stated MIPR to be at par with the open approach, when these surgeries are performed at high-volume centers. However, longer operative duration, high conversion rates, inferior oncological outcomes, and increased mortality reported in low-volume centers, especially during minimally invasive pancreaticoduodenectomy remains a matter of concern, questioning its broad applicability. Hence, distal pancreatic resections are adopted more widely with a minimally invasive approach as compared to pancreatic head resections. Also, MIPR for PDAC in particular, remains controversial due to lack of high quality data evaluating long-term outcomes of MIPR for PDAC alone. Considering the ongoing impact of neoadjuvant treatment on pancreatic cancer surgery and the corresponding increase in vascular resections and arterial divestment procedures, applicability of MIPR in this setting remains questionable.
Methods: Medline, PubMed, Embase, Cochrane Library, and various international evidence-based guidelines were searched for the current status of minimally invasive resections for pancreatic cancer (PDAC).
Conclusions: The available evidence establishes the feasibility and safety of MIPR, however for PDAC the widespread application remains controversial owing to a dearth of literature evaluating the long-term outcomes. Apart from the outcomes, establishing the exact indications, appropriate patient selection, enhanced cost, and learning curve issues need further studies.
Minimally invasive surgery (MIS) has gradually evolved, especially in the past two decades; and now is an integral part of management for almost all digestive diseases. In gastrointestinal (GI) cancers, MIS has shown equivalent results to the open approach for early gastric and colorectal cancers.[1–3] Technological advances and the development of specific skill sets required for this approach by dedicated surgical teams led to rapid development in laparoscopic and robotic surgery for GI cancers.
The minimally invasive approach did not gain much popularity for pancreatic surgery for a long time since its first introduction in the early 1990s.[4,5] Probable reasons being the anatomic disadvantages, i.e., retroperitoneal location of the organ, its intimate relations with major blood vessels and, the soft, friable, unforgiving nature of the gland. However, much progress has been made in the past decade and today MIS is widely accepted for managing benign pancreatic lesions or tumors with low malignant potential, especially in the distal pancreas.
MIPR has the potential to provide unreplaceable advantages to patients undergoing surgery for pancreatic cancer in terms of early recovery, fewer complications, reduced hospital stay, and cosmetically pleasing wounds. Several retrospective studies and a few randomized trials have demonstrated the safety and feasibility of minimally invasive pancreatic resections (MIPR), i.e., minimally invasive pancreaticoduodenectomy (MIPD), and minimally invasive distal pancreatectomy (MIDP). Although these studies reported favorable outcomes of certain parameters with MIS (lower blood loss, morbidity, and shorter hospital stay); the longer operative duration, high conversion rates, inferior oncological outcomes, and increased mortality reported in low-volume centers remain a matter of concern. Hospital volumes have a strong impact on postoperative outcomes for major pancreatic resections, even with the conventional open approach. With MIPR, the surgical complexity increases further, and hence it is recommended that such procedures are performed at specialized centers with a high volume of pancreatic surgery. Furthermore, the mid-term and long-term outcomes of MIPR for pancreatic ductal adenocarcinoma (PDAC) along with the issues of the indications and learning curve are controversial and need further assessment.
Also, as neoadjuvant therapy (NAT) is being more utilized for resectable and borderline resectable pancreatic ductal adenocarcinoma (PDAC), prospective evaluation of MIPR for PDAC after NAT remains the job at the fore.
In the present article, we intend to provide an overview of the progress made so far and the current position of MIPR for PDAC. We present the following article in accordance with the Narrative Review reporting checklist (available at https://cco.amegroups.com/article/view/10.21037/cco-21-131/rc).
Chin Clin Oncol. 2022;11(1):3 © 2022 AME Publishing Company