Minimally invasive pancreatoduodenectomy: is the incidence of clinically relevant postoperative pancreatic fistula comparable to that after open pancreatoduodenectomy? Olga Kantor a , Henry A. Pitt b , Mark S. Talamonti c,d , Kevin K. Roggin a , David J. Bentrem e , Richard A. Prinz c,d , and Marshall S. Baker c,d, * a Department of Surgery, University of Chicago, Chicago, IL b Department of Surgery, Temple University, Philadelphia, PA c Department of Surgery, NorthShore University HealthSystem, Evanston, IL d Pritzker School of Medicine, University of Chicago, Chicago, IL e Department of Surgery, Northwestern Medicine, Chicago, IL ARTICLE INFO Article history: Accepted 1 December 2017 A B ST R AC T Background. Studies evaluating the efficacy of minimally invasive approaches to pancreatoduodenectomy (MIS-PD) compared to open pancreatioduodenectomy (OPD) have been limited by selection bias and mixed outcomes. Methods. ACS-NSQIP 2014–2015 pancreas procedure-targeted data were used to identify patients un- dergoing PD. Intention-to-treat analysis was performed. Results. Of 7907 PD patients, 1277 (16%) underwent MIS-PD: 776 (61%) robotic or laparoscopic PD, 304 (24%) hybrid, and 197 (15%) unplanned conversions. There were no differences in demographics or comorbidities. Patients undergoing MIS-PD were less likely to have pancreatic ductal adenocarcinoma (30.9% vs 53.9%, P < 0.01) and less likely to have a dilated pancreatic duct (21.8% vs 46.7%, P < 0.01). 30- day morbidity was less for MIS-PD (63.6% vs 76.9%, P < 0.01), due to decreased delayed gastric emptying DGE) in the MIS-PD group (8.6% vs 15.5%, P < 0.01). 30-day mortality, length-of-stay, and readmissions were not significantly different. Patients undergoing MIS-PD had greater rates of CR-POPF (15.3% vs 13.0%, P = 0.03). On adjusted multivariable analysis, MIS-PD was not associated with CR-POPF (OR 1.05, 95% CI 0.87–1.26) but was associated with decreased DGE (OR 0.57, 95% CI 0.46–0.71). Conclusion. MIS-PD has comparable short-term outcomes to open PD. While CR-POPF rates are greater for MIS-PD, this increased risk appears related to case-selection bias and not inherent to the MIS- approach. (Surgery 2017;160:XXX-XXX.) © 2017 Elsevier Inc. All rights reserved. Recent prospective and retrospective studies have demonstrated that minimally invasive approaches to pancreatoduodenectomy (MIS- PD) are safe and provide short-term oncologic outcomes comparable to the gold standard of open pancreatoduodenectomy (OPD). These studies have included several large multicenter retrospective com- parisons of MIS-PD to OPD and several meta-analyses, which have demonstrated similar rates of perioperative morbidity and mortal- ity for MIS-PD compared to OPD, 1-3 similar short-term oncologic outcomes (rates of margin-negative resection and lymph node yields) in malignant periampullary tumors when comparing MIS-PD to OPD, 4-6 and similar long-term overall survival rates for pancreatic adenocarcinoma (PDAC). 7,8 While these results have been taken as promising and have driven a measurable increase in the utilization of MIS-PD for pathology in the pancreatic head, 9 they continue to be viewed with some skepticism. There are currently no randomized trials comparing these 2 operative approaches. No studies demonstrate any substantive benefit to the MIS approaches and are none are able to completely adjust for selection biases that result in patients with technically challenging pathologies being managed primarily by OPD. In many of these studies, MIS-PD broadly encompasses robotic, laparo- scopic, hybrid (robotic assisted laparoscopic), and robotic or laparoscopic procedures with open assistance. This makes perform- ing intent to treat analyses impossible. Several of the studies also identify a steep and potentially costly (although surmountable) learn- ing curve. 6,10,11 Few studies include grading of pancreas-specific outcomes. Specifically, very few studies rightly evaluate the impact Presented as an oral presentation at the 2017 Central Surgical Association Annual Meeting on August 1, 2017 in Chicago, IL. * Corresponding author. Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201. E-mail address: mba475@gmail.com (M.S. Baker). https://doi.org/10.1016/j.surg.2017.12.001 0039-6060/© 2017 Elsevier Inc. All rights reserved. Surgery ■■ (2017) ■■–■■ ARTICLE IN PRESS Please cite this article in press as: Olga Kantor, Henry A. Pitt, Mark S. Talamonti, Kevin K. Roggin, David J. Bentrem, Richard A. Prinz, and Marshall S. Baker, Minimally invasive pancreatoduodenectomy: is the incidence of clinically relevant postoperative pancreatic fistula comparable to that after open pancreatoduodenectomy?, Surgery (2017), doi: 10.1016/ j.surg.2017.12.001 Contents lists available at ScienceDirect Surgery journal homepage: www.elsevier.com/locate/ymsy