Response to the Letter to the Editor: Minimally Invasive Versus Open Pancreaticoduodenectomy for Cancer Is Associated With Increased 30-day Mortality

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We appreciate the interest that the authors had in our recent article on short-term outcomes from minimally invasive versus open pancreaticoduodenectomy for cancer.1 As highlighted in the “Methods” section, patients with distal cholangiocarcinoma and ampullary or duodenal cancers were not included in the study because of the unavailability of specific data. Although these tumors are common, the vast majority of minimally invasive pancreaticoduodenectomies performed in the United States are for pancreatic adenocarcinoma.2,3 For example, the largest published institutional series of laparoscopic pancreaticoduodenectomies from the United States included 108 patients, all of whom underwent the procedure for pancreatic ductal adenocarcinoma.2
Our study was based on data from the National Cancer Data Base, which is one of the largest cancer registries in the world, capturing more than 70% of all new cancer diagnoses in the United States. Although the National Cancer Data Base is representative and provides robust short-term outcomes such as 30-day mortality, it lacks data on intraoperative variables and pancreatectomy-related complications. Therefore, information with regard to important surgical variables such as estimated blood loss, operative time, presence of jaundice, delayed gastric emptying, pancreatic fistula formation, or cause of postoperative mortality was not available for analysis. This limitation was highlighted in the “Discussion” section of the article. We agree with the authors that these surgical outcomes need to be examined in future studies to gain better insight into the observed increased 30-day mortality. Variables such as patient's annual income, insurance status, and metro/urban/rural setting of care can indeed have effects on patients’ outcomes; they represent proxies for identifying possible vulnerable populations who might not have adequate access to care or support systems for recovery.
Although specific causes of 30-day mortality were unknown, it is crucial to report the increased 30-day mortality associated with minimally invasive pancreaticoduodenectomy, given the surging interest in disseminating this relatively new technique. Our study emphasizes the complexity of minimally invasive pancreaticoduodenectomy and suggests that there might be a need to better define the necessary skills set required for its safe implementation.
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