Critical appraisal of the adoption of minimally-invasive pancreatoduodenectomies at a single institution: initial experience with the first 120 consecutive cases

Abstract Background: We analysed the evolution and outcomes of minimally-invasive pancreatoduodenectomy (MIPD) during our initial adoption of this approach. We also compared the outcomes between the different approaches used to perform the pancreatic anastomoses. Methods: A retrospective review of consecutive patients who underwent MIPD between 2013 to 2022 was performed. Comparison of pancreato-enteric anastomotic outcomes were performed using one-to-one propensity matched analysis. Results: 120 patients underwent MIPD including 14 (11.7%) total pancreatectomies (TP) and 17 (14.2%) with concomitant vascular reconstructions. The number of patients who had laparoscopic (L) or robotic (R) PD were 77 (64.2%) and 43 (35.8%) respectively. There were 32 (26.7%) patients with post-operative pancreatic fistulas (POPF), of which 28 (23.3%) were grade B and 4 (3.3%) were grade C. There were no 30-day mortalities. Comparisons between open and minimally invasive pancreatojejunostomy (PJ) showed a higher likelihood of intra-operative blood loss (500mls vs 275mls, p<0.001) and intra-operative blood transfusion (12(40%) vs 3(10%), p=0.015). Patients who had robotic PJ reconstruction demonstrated fewer pseudoaneurysms (1(4%) vs 7(28%), p=0.049) and lesser intra-operative blood loss (250mls vs 300mls, p = 0.023) when compared to laparoscopic PJ reconstruction, but tended to be associated with a longer operation time (665min vs 550min, p<0.001). Comparison with international benchmark outcomes for open PD demonstrated that except for a higher-Grade B POPF rate; the postoperative morbidity, major morbidity, Grade C POPF and in-hospital mortality rates of MIPD were within international benchmark cutoffs. Conclusion: Our initial experience demonstrated that MIPD can be safely adopted. Robotic reconstruction may reduce the risk of pseudoaneurysm compared to laparoscopy.