Minimally invasive vs. open-extended distal pancreatectomy with multi-organ resection: postoperative and oncological outcomes for left-sided pancreatic ductal adenocarcinoma

Abstract

Background Minimally invasive extended distal pancreatectomy (MIEDP) is often challenging for pancreatic ductal adenocarcinoma (PDAC) due to its aggressive invasion into adjacent organs or major blood vessels. This study aimed to compare the surgical and oncological outcomes of MIEDP and open-extended distal pancreatectomy (OEDP) for left-sided PDAC. Methods A retrospective data review was conducted for 798 patients with left-sided PDAC who underwent distal pancreatectomy between 2009 and 2020. Among these, 388 patients were included in the analysis who underwent extended distal pancreatectomy, as defined in the Miami International evidence-based guidelines. Results Of those 388 included patients, 217 underwent MIEDP and 171 OEDP. No significant differences were observed in the clinicopathological characteristics or 90-day mortality rates between the groups. Moreover, severe complications (CDC III or higher) were similar between groups (MIEDP: 11.1%; OEDP: 17.6%; P = 0.052). MIEDP was associated with a shorter time to adjuvant chemotherapy initiation relative to OEDP (5.9 vs. 6.6 weeks; P = 0.061). Multivariable analysis revealed that combined vessel resection was a significant factor for severe complications (OR: 3.642, 95% CI: 2.025-6.549; P < 0.001). The five-year survival rates were comparable (MIEDP: 25.5%; OEDP: 18.1%; P = 0.132). However, poorer survival was associated with pathological invasion of adjacent organs (HR: 1.479, 95% CI: 1.133-1.930; P = 0.004), postoperative complications, R0 resection, poor differentiation, lymphovascular invasion, perineural invasion, and failure to complete adjuvant chemotherapy. Conclusions MIEDP is feasible and safe in selected left-sided PDAC with suspected multiorgan invasion and shows oncologic outcomes comparable to OEDP, with faster recovery signals. Prognosis appears driven more by pathological invasion than by surgical approach or extent of concomitant resection.