Postpancreatectomy Mortality (PPM) Following Minimally Invasive Pancreatic Surgery Is Mainly Driven by Pancreatectomy-Specific Complications: Application of the ISGPS Classification Through Root-Cause Analysis on a Nationwide Cohort

BACKGROUND: Postpancreatectomy mortality (PPM) remains relatively unexplored after minimally invasive pancreatic surgery (MIPS). The International Study Group for Pancreatic Surgery (ISGPS) recently proposed a consensus definition and classification of PPM based on root-cause analysis. We aimed to assess the applicability of this classification and characterize mechanisms of PPM following MIPS. METHODS: This study retrospectively analyzed consecutive patients undergoing MIPS enrolled in the Italian IGoMIPS registry (October 2019-July 2025). All PPM events were reviewed and attributed specific PPM types using structured root-cause analysis according to ISGPS criteria. Multivariable logistic regression identified predictors of PPM, and PPM type distributions were compared across procedures. RESULTS: Out of 3590 patients, the PPM rate was 2.7%. Specifically, PPM occurred in 5.9% following minimally invasive pancreatoduodenectomy (MIPD), 0.8% following left pancreatectomy (MILP), and 4.8% following total pancreatectomy (MITP), while no PPM events occurred after parenchyma-sparing resections. Increased age and American Society of Anesthesiology Physical Status (ASA-PS) ≥3 independently predicted PPM. Root-cause analysis showed that most PPM followed cascades of multiple pancreatectomy-specific complications, predominantly postoperative pancreatic fistula (POPF) and postpancreatectomy hemorrhage (PPH). PPM 2 accounted for approximately two-thirds of deaths, particularly after MIPD and MITP, whereas PPM 1 and PPM 3 accounted for 13.3% and 15.3%, respectively. CONCLUSIONS: Mortality after MIPS predominantly occurs after a cascade of pancreatectomy-specific complications rather than technical failure or isolated medical events. Centers performing MIPS should invest in strategies to mitigate POPF and PPH and minimize failure to rescue once they occur.