Nationwide Use and Outcome of Minimally Invasive Distal Pancreatectomy in IDEAL Stage IV Following a Training Program and Randomized Trial

Purpose: To assess the nationwide long‐term uptake and outcomes of minimally invasive distal pancreatectomy (MIDP) after a nationwide training program and randomized trial. Method: Nationwide audit‐based study including consecutive patients after MIDP and ODP in 16 centers in the Dutch Pancreatic Cancer Audit (2014‐2021). The cohort was divided into three periods: early implementation, during the LEOPARD randomized trial, and late implementation. Primary endpoints were MIDP implementation rate and textbook outcome. Results: Overall, 1496 patients were included with 848 MIDP (56.5%) and 648 ODP (43.5%). From the early to the late implementation period, the use of MIDP increased from 48.6% to 63.0% and of robotic MIDP from 5.5% to 29.7% (p<0.001). The overall use of MIDP (45% to 75%) and robotic MIDP (1% to 84%) varied widely between centers (p<0.001). After MIDP, in‐hospital mortality and textbook outcome remained stable over time. In the late implementation period, ODP was more often performed in ASA score III‐IV (24.9% vs 35.7%, p=0.001), pancreatic cancer (24.2% vs 45.9%, p<0.001), vascular involvement (4.6% vs 21.9%, p<0.001), and multivisceral involvement (10.5% vs 25.3%, p<0.001). After MIDP, shorter hospital stay (median 7 vs 8 days, p<0.001) and less blood loss (median 150 vs 500 mL, p<0.001), but more grade B/C postoperative pancreatic fistula (24.4% vs 17.2%, p=0.008) occurred as compared to ODP. Conclusion: A sustained nationwide implementation of MIDP after a successful training program and randomized trial was obtained with satisfactory outcomes. Future studies should assess the considerable variation in MIDP use between centers and, especially, robotic MIDP.