Laparoscopic Pancreatoduodenectomy Feasible in Experienced Hands but With Marginal Benefit

NEW YORK (Reuters Health) – Laparoscopic pancreatoduodenectomy (LPD) has only marginal clinical benefit over open pancreatoduodenectomy (OPD), even when performed by experienced surgeons, according to a large multicenter study from China.

The benefit and safety of LPD for the treatment of pancreatic or periampullary tumors remain controversial. Studies have shown that the learning curve plays an important role in LPD. Until now, however, there were no randomized studies on LPD performed by surgeons who surmounted the steep learning curve of at least 104 procedures, the study team explains in The Lancet Gastroenterology and Hepatology.

In their paper, Dr. Min Wang of Huazhong University of Science and Technology, in Wuhan, and colleagues report results of a modified intention-to-treat analysis of 297 patients in the LPD group and 297 patients in the OPD group with a premalignant or malignant indication for pancreatoduodenectomy.

LPD was associated with a significantly shorter postoperative length of hospital stay (primary endpoint, 15 days vs. 16 days). The reduced length of stay was statistically significant, but the benefit was clinically marginal, the investigators note.

In addition, there were no significant differences between LPD and OP in 90-day mortality, postoperative complications, and pathological and oncological outcomes.

Dr. Wang and colleagues say the results of this randomized controlled trial indicate that LPD is a “feasible and safe procedure when performed by experienced surgeons at high-volume specialized institutions.”

“Although these experienced surgeons had passed the learning curve for successful LPD, the smaller observed benefit in terms of length of stay compared with the expected advantage also raises questions regarding the potential indications and patient populations who will benefit from this minimally invasive, albeit challenging, surgery,” they add.

“Strict monitoring from surgical societies is urgently needed to ensure that all surgeons have completed the learning curve before independently doing LPD operations to ensure patient safety,” they advise.

The authors of a linked comment say the study “contributes an important piece to the puzzle of whether LPD for pancreatic cancer, albeit feasible at high-volume centers, is an innovation that hospital organizations and health-care systems should invest in.”

“The most probable answer is that the marginal benefits of LPD do not warrant the obstacles of an extensive learning curve, safety concerns, and economic and infrastructure hurdles associated with the procedure,” write Dr. Martin Schneider and Dr. Markus Buchler of the University of Heidelberg, in Germany.

“Such an answer would confirm a basic principle in surgery: success does not depend on technical feasibility but on adapting technical advances to true medical needs and, most importantly, to the benefit of the individual patient,” they add.

SOURCE: https://bit.ly/3y56nYa and https://bit.ly/33F9B6x Lancet Gastroenterology and Hepatology, online April 26, 2021.

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