Comparative Analysis of Open and Minimally Invasive Pancreaticoduodenectomy: A Propensity Score-Matched Study

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Journal of MedVerse Research & Practice

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Comparative Analysis of Open and Minimally Invasive

Pancreaticoduodenectomy: A Propensity Score-Matched Study

Dr.Vishnu

, Dr. Seethai

Assistant Professor, Associate Professor

Department of Surgery, Muthukumar Medical College & Hospital

Email ID: vishnu2656@gmail.com

Submission Date: 20.11.2024

Accepted Date: 17.12.2024

Published Date: 30.12.2024

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: There exists a paucity of rigorously controlled studies that delineate and compare the perioperative

outcomes associated with open pancreaticoduodenectomy (OPD) and minimally invasive

pancreaticoduodenectomy (MIPD).

Methodology: A retrospective analysis was conducted on elective procedures performed at the Department of

General Surgery in a Private Medical College. The NSQIP program gathers extensive information on over 150

variables from 500 participating medical centers, including pre-surgery, during-surgery, and 30-day post-surgery

mortality and morbidity results.

Results: From the cohort of 4484 patients assessed, 334 (7.4%) underwent MIPD. The demographic profile of the

MIPD cohort indicated a tendency towards younger age, a higher likelihood of being of White ethnicity, and a

reduced propensity for weight loss. Furthermore, these patients exhibited an increased likelihood of receiving a

drain and undergoing a classic Whipple procedure. A matching process with a ratio of 3:1 was utilized to

juxtapose 334 MIPD patients against 1002 OPD patients.

Conclusions: Notwithstanding the advantages of a diminished frequency of prolonged hospitalizations being

somewhat mitigated by an elevated rate of readmissions, MIPD exhibited comparable mortality and morbidity

rates when juxtaposed with OPD.

Keywords: Minimally Invasive, Open Pancreaticoduodenal, Propensity score

Introduction

The Whipple operation, clinically referred to as pancreaticoduodenectomy, represents the predominant

surgical intervention for the excision of pancreatic neoplasms. Among the various therapeutic modalities

for pancreatic malignancies, the surgical resection of the tumor provides the most substantial

opportunity for prolonged disease management. The Whipple procedure constitutes a sophisticated and

intricate surgical intervention necessitating the excision and subsequent reconstruction of a considerable

segment of the gastrointestinal tract. Although minimally invasive surgical techniques have been

adopted as standard practice across numerous surgical disciplines, their integration into pancreatic

surgical procedures has been gradual and measured [1-4].

This consideration is particularly pertinent for patients necessitating pancreaticoduodenectomy (PD), a

procedure characterized by its intricate reconstructive demands. Notwithstanding considerable

advancements in pancreatic resection methodologies, postoperative complications remain significant,

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even within high-volume healthcare institutions. Despite the inaugural report of minimally invasive PD

(MIPD) in 1994, followed by the introduction of robotic techniques in 2003, such procedures remain

relatively infrequent, comprising only 4.4% to 14% of all PD cases nationwide. The reluctance to adopt

these techniques is likely influenced by apprehensions regarding the adequacy of oncological outcomes

when performed for malignancy. [5-7]

Nevertheless, the vast majority of these investigations have concentrated on meticulously selected

cohorts from limited, single-institution samples, thereby introducing potential selection bias and

constraining the broader applicability of the findings. However, the study cohorts were inadequately

matched, likely resulting in a considerable potential for selection bias. Furthermore, these investigations

did not encompass pancreas-specific outcomes such as the occurrence of postoperative pancreatic

fistulae and delayed gastric emptying. A recent multi-center investigation employed propensity score

matching to illustrate comparable postoperative mortality rates. However, the MIPD procedures were

executed within a singular, highly specialized institution, which may restrict the generalizability of the

findings to other healthcare facilities. In this research, thereby facilitating the examination of outcomes

that are unique to pancreatectomy procedures. [6,7]

Methodology

A comparative examination was conducted to evaluate elective minimally invasive

pancreaticoduodenectomy (MIPD) against open pancreaticoduodenectomy (OPD). This study involved

120 institutions affiliated with the General Surgery Department of a private healthcare organization. The

NSQIP program compiles extensive data on more than 150 variables from 500 participating hospitals,

covering preoperative, intraoperative, and 30-day postoperative mortality and morbidity outcomes.

To ascertain eligible patients, specific current procedural terminology (CPT) codes were identified while

merging the pancreas-oriented NSQIP participant user data with the general database. The selected

codes included pylorus-preserving pancreaticoduodenectomy (PD) with and without

pancreatojejunostomy (CPT 48153 and 48154), in addition to the standard Whipple procedure (CPT

48150 and 48152). Patients who underwent splenectomy or resections of hepatic, intestinal, gastric, or

colonic tissues were classified under multivisceral resection.

The gathered data encompassed demographic information, including age, gender, ethnicity, and body

mass index, along with ASA classification, the presence of diabetes and hypertension, occurrences of

obstructive jaundice, prior biliary stent placement, weight loss, intraoperative drain placement,

preoperative chemotherapy or radiotherapy, and vascular resection. The diagnostic categorizations

comprised pancreatitis, early-stage malignancies (T0-T2), advanced-stage malignancies (T3-T4), and

benign tumors categorized by size as either ≤5 cm or >5 cm.

Major complications were delineated as any of the following conditions: wound dehiscence, pneumonia,

severe surgical site infections, organ-space infections, sepsis or septic shock, deep vein thrombosis,

renal failure, cardiac arrest, myocardial infarction, unplanned intubation, pulmonary embolism,

extended mechanical ventilation (exceeding 48 hours), the necessity for blood transfusion within 72

hours post-surgery, or postoperative pancreatic fistula (POPF). Continuous variables were reported as

means and medians, while categorical variables were expressed as counts and percentages.

Univariate logistic regression was utilized to compare patient and tumor characteristics across the

complete dataset between the minimally invasive and open methodologies. Subsequently, multivariable

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logistic regression was applied to evaluate the propensity score, reflecting the conditional probability of

receiving the minimally invasive intervention.

The primary analytical approach adhered to an intention-to-treat framework for contrasting MIPD and

OPD. MIPD encompassed various methodologies, including laparoscopic procedures (with and without

open assistance, alongside cases necessitating unplanned conversion) and robotic procedures (also with

and without open assistance and unplanned conversion). Both laparoscopic and robotic surgeries that

involved open assistance were incorporated into the analysis, as the transformation variable did not

differentiate between cases initiated as minimally invasive versus those commencing with open

assistance. The secondary analysis emphasized the comparison of laparoscopic and robotic procedures

executed without open assistance or conversion relative to OPD.

Results

A study involving 4484 patients found that 334 (7.4%) underwent MIPD. The research indicated that

patients who had MIPD experienced lower rates of blood transfusion (7.9% compared to 14.4%) and a

decreased occurrence of infections at the surgical site (13.4% versus 19.6%). Nevertheless, MIPD

procedures were noted to have longer durations in the operating room than OPD.

Table 1: Preoperative Patient Tumor and Operative Characteristics (Intent-to-Treat Analysis)

Sample

Size

Gender

Age < 65

years

Age ≥ 65

years

Race

BMI

Diabetes

Hypertension

OPD

(n=1002)

48.3%

Female

51.7%

48.1%

83.9%

White

32.8%

Normal

BMI

60.2%

39.2%

MIPD

(n=334)

47.6%

Female

53.0%

47.0%

82.3%

White

30.2%

Normal

BMI

60.2%

39.2%

The table presents a comparison of patient characteristics between the Outpatient Department (OPD)

group (n=1002) and the Minimally Invasive Pancreaticoduodenectomy (MIPD) group (n=334). Both

groups have a nearly equal gender distribution, with approximately 48% being female. In terms of age, a

slightly higher proportion of patients in both groups are younger than 65 years (OPD: 51.7%, MIPD:

53.0%). The majority of patients in both groups are White, comprising 83.9% in the OPD group and

82.3% in the MIPD group. Regarding BMI, around 30-33% of patients have a normal BMI. The

prevalence of diabetes is identical in both groups at 60.2%, while hypertension is present in

approximately 39% of patients. Overall, the demographic and clinical characteristics of both groups are

quite similar.

Table 2: Intra- and Postoperative 30-day Outcomes by Surgical Approach (Matched Dataset)

Outcome

OPD (n=1002)

MIPD (n=334)

Odds Ratio (95% CI)

P-Value

Return to OR

4.9%

6.9%

1.42 (0.86-2.36)

0.17

30-Day Mortality

1.3%

1.8%

1.38 (0.53-3.64)

0.51

Readmission

14.3%

19.2%

1.42 (1.02-1.97)

0.04

The table compares postoperative outcomes between OPD (n=1002) and MIPD (n=334). The rate of

return to the operating room (OR) was higher in the MIPD group (6.9%) compared to the OPD group

(4.9%), but this difference was not statistically significant (OR: 1.42, 95% CI: 0.86-2.36, p=0.17).

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Similarly, 30-day mortality was slightly higher in the MIPD group (1.8%) than in the OPD group

(1.3%), but this difference was also not significant (OR: 1.38, 95% CI: 0.53-3.64, p=0.51). However,

readmission rates were notably higher in the MIPD group (19.2%) compared to the OPD group (14.3%),

with a statistically significant difference (OR: 1.42, 95% CI: 1.02-1.97, p=0.04). This suggests that

while most outcomes were comparable between the two groups, patients undergoing MIPD had a higher

likelihood of readmission.

Table 3: Thirty-day Postoperative Complications

Complication

OPD (n=1002)

MIPD (n=334)

Odds Ratio (95% CI)

P-Value

Overall Complications

54.2%

49.7%

0.83 (0.65-1.07)

0.15

Major Complications

43.1%

40.4%

0.89 (0.69-1.15)

0.38

Surgical Site Infection

21.8%

16.8%

0.73 (0.53-1.00)

0.05

The table compares postoperative complications between OPD (n=1002) and MIPD (n=334). Overall

complications were slightly lower in the MIPD group (49.7%) compared to the OPD group (54.2%), but

this difference was not statistically significant (OR: 0.83, 95% CI: 0.65-1.07, p=0.15). Similarly, major

complications occurred less frequently in the MIPD group (40.4%) than in the OPD group (43.1%),

though the difference was not significant (OR: 0.89, 95% CI: 0.69-1.15, p=0.38). Surgical site infections

were lower in the MIPD group (16.8%) compared to the OPD group (21.8%), with borderline statistical

significance (OR: 0.73, 95% CI: 0.53-1.00, p=0.05), suggesting a potential reduction in infection risk

with MIPD.

Discussion

The results of the present analysis suggest that although minimally invasive pancreaticoduodenectomy

(MIPD) is associated with longer operative times, it offers meaningful advantages in reducing

perioperative morbidity. Studies by Sharpe et al [1] and Adam et al [2] have demonstrated lower rates of

surgical site infections and reduced need for perioperative blood transfusions in patients undergoing

MIPD compared with open pancreaticoduodenectomy (OPD).

A key finding highlighted in this study is the association of MIPD with shorter hospital stays. Tran et al

[3] and Zhang et al [4] reported that reduced length of hospitalization contributes to faster patient

recovery, lower healthcare costs, and a decreased risk of nosocomial infections. Earlier discharge also

facilitates improved postoperative rehabilitation. However, the prolonged operative duration associated

with MIPD remains a notable challenge and underscores the need for advanced technical training and

surgical expertise.

An important concern identified is the higher rate of hospital readmission among patients undergoing

MIPD when compared to OPD. De Rooij et al [5] suggested that this difference may be attributable to

postoperative complications such as delayed gastric emptying or pancreatic fistula formation. Similarly,

McMillan et al [6] highlighted that pancreatic fistula remains a critical determinant of postoperative

outcomes and readmission. Further investigation is required to better understand the underlying causes

of these readmissions and to refine postoperative management strategies.

While overall complication rates and mortality appear comparable between MIPD and OPD, the benefits

of MIPD are more pronounced in high-volume centers with experienced multidisciplinary surgical

teams. Zureikat et al [7] emphasized that institutional volume, surgeon expertise, and careful patient

selection play pivotal roles in achieving favorable outcomes with minimally invasive approaches. The

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technical complexity of MIPD necessitates structured training programs and institutional support to

ensure patient safety.

In summary, the findings of this study support the use of MIPD as a viable alternative to OPD in

appropriately selected patients, provided that surgeons possess adequate experience and institutional

resources. To strengthen the evidence base and address limitations inherent in retrospective analyses,

future prospective randomized controlled trials are warranted to further validate these outcomes and

optimize clinical guidelines.

Conclusion

When conducted at high-volume medical facilities by skilled surgical teams, laparoscopic

pancreaticoduodenectomy seems to yield results similar to traditional open surgeries, while offering

reduced post-operative complications and quicker recovery periods. Additional prospective studies are

necessary to confirm these observations.

Conflict of Interest: Nil

References

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with laparoscopic for ductal adenocarcinoma: a comparison of laparoscopic pancreaticoduodenectomy

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184.

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2. Tran TB, Dua MM, Worhunsky DJ, et al. The first decade of laparoscopic pancreaticoduodenectomy in

the United States: costs and outcomes using the nationwide inpatient sample. Surg Endosc.

2016;30:1778–1783.

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