Total Laparoscopic Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma. Oncologic Advantages Over Open Approaches?

In the last decade, the laparoscopic approach for pancreatic pathology has been introduced with encouraging results in terms of hospital stay, less postoperative pain and less blood loss, according with case series reports of laparoscopic pancreaticoduodenectomy in the literature, however, the inclusion of malignant pathology is limited. The value of a fast patient recovery after surgery will play a key role favor to complete an adjuvant chemotherapy regimen and in consequence have the chance to increase the overall survival time. The group of the Mayo Clinic (Rochester, USA), directed by Michel Kendrick has published an original article in Annals of Surgery (October 2014), showing the results of their prospective comparative cohort of patients with pancreatic adenocarcinoma who underwent a total laparoscopic approach, but the authors concluded that longer follow up is needed. In the discussion section, the pancreatoduodenectomy (TLPD) versus open classical approach (OP) was compared, in terms of oncologic results. In this report the researchers define as their primary oncologic outcomes; the time between start of chemotherapy and progression-free survival. They analyzed a total of 322 patients, (108 pts in TLPD group and 214 in OPD group), of these, 88% were available for complete data about their adjuvant treatment. Their results showed benefits for TLPD in terms of  less median time  between surgery and initiation of adjuvant chemotherapy (p=0.01), also the patients delayed more than 90 days were less in TLPD groups respect to OPD groups (5% vs 12%, p=0.04). Interesting results were obtained when a multivariate analysis was performed, showing that a delay of chemotherapy beyond 90 days or not receiving it, was a factor related with poor overall survival. (p < 0.001) Although the time of follow up was short (16.5 months for TLPD and 15.1 months in OPD group), the progression-free survival was longer in the TLPD group comparing to OPD groups (P=0.03). However overall survival was similar in both groups. This study shows, thus, similar results in terms of oncologic aspects between TLPD and OPD, authors  talk about the limitations of their study, and the article concludes with an interesting discussion panel with worldwide experts surgeons in pancreatic cancer. Fully recommended.