“Minimally Invasive Versus Open Pancreaticoduodenectomy for Cancer. Practice Patterns and Short-term Outcomes Among 7061 Patients”

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To the Editor:
We congratulate the authors for giving us an insight into the national practice patterns and utilization of minimally invasive pancreaticoduodenectomy for cancer from a large United States National Cancer Database.1 Minimally invasive pancreaticoduodenectomy was first described by Gagner and Pomp2 in 1994, and there has been a recent surge of interest as described by the authors. Pancreaticoduodenectomy is a complex procedure and advantage of laparoscopic approach used to be closely scrutinized.
We would like to discuss certain aspects of this article. The authors have excluded distal cholangiocarcinoma and ampullary and duodenal adenocarcinoma from analysis where most of the laparoscopic procedures would be applicable. Table 1 compares the patient cohort between the 2 groups but seems to have nonspecific variables such as annual income, insurance status, and metro/urban/rural that seem to have no effect on the overall outcome of the study. Because the authors discuss the 30-day mortality, it would have been more appropriate if variables such as presence of gastric outlet obstruction, body mass index, jaundice, and eastern cooperative oncology group status were included and compared.
There are no data regarding the intraoperative details as to the duration of surgery or the amount of blood loss needing transfusion and the number of pancreaticoduodenectomies needing venous resection and reconstruction. Similarly, when we are assessing “short-term outcomes” as specified in the title, we would want to know the immediate postoperative outcomes and complications such as pancreatic fistula, postpancreatectomy hemorrhage, pseudoaneurysm, delayed gastric emptying, and re-explorations, which would have an important bearing on hospital stay and 30-day mortality. Some studies have even described a shorter time to initiation of adjuvant therapy as a short-term outcome with minimally invasive pancreaticoduodenectomy.3 While describing the 30-day mortality, we would also be interested to know what were the causes of mortality and were there any specific complications that occurred more frequently with minimally invasive pancreaticoduodenectomy. Probably, similar hospital stay in both the groups is a surrogate marker for similar postoperative complications.
In spite of the aforementioned text, we would still want to hold the results of the study as a landmark outcome in the ongoing debate on minimally invasive versus open pancreaticoduodenectomy. The authors have included even the low-volume centers performing minimally invasive pancreaticoduodenectomy in the article, which gives it a wider generalizability. Minimally invasive pancreaticoduodenectomy has been claimed to be superior to open pancreaticoduodenectomy by various authors.4,5 We often forget the fact that these results are from centers with expertise to perform such complicated surgical procedures in well-chosen cases. With the surge of interest, surgeons all around the world are trying to perform minimally invasive pancreaticoduodenectomy, the results of which have never been presented.
We thank the authors for updating us with their findings about increased 30-day mortality in minimally invasive group compared with open group, which certainly needs further analysis. This is a result that would make many reflect back and wonder “is it worth it”? We wholly reciprocate the authors that there should be guidelines for the competency of surgeons before this epidemic becomes a pandemic. The indications where this may be undertaken needs to be defined.
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