LAUSR

OBJECTIVE To assess the nationwide long-term uptake and outcomes of minimally invasive distal pancreatectomy (MIDP) after a nationwide training program and randomized trial. BACKGROUND Two randomized trials demonstrated the superiority of MIDP over open distal pancreatectomy (ODP) in terms of functional recovery and hospital stay. Data on implementation of MIDP on a nationwide level are lacking. METHODS 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). In the late implementation period, 5/16 centers performed >75% of procedures as MIDP. 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 d, 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 the use of MIDP between centers and, especially, robotic MIDP.