TOPLINE:

In a randomized trial of patients with left-sided resectable pancreatic cancer, minimally invasive pancreatectomy showed comparable overall survival and disease-free survival to open surgery, confirming its long-term oncologic safety.

METHODOLOGY:

• Left pancreatectomy with splenectomy is the standard of care for patients with resectable cancer in the body and tail of the pancreas. Minimally invasive approaches shorten postoperative recovery time, and initial findings from the DIPLOMA trial confirmed the noninferiority of minimally invasive vs open surgery in terms of the R0 resection rate. However, the long-term oncologic safety has been uncertain.
• DIPLOMA was a multicenter, randomized noninferiority trial involving 258 patients with upfront resectable pancreatic ductal adenocarcinoma of the body or tail of the pancreas. Patients were randomly assigned to undergo either minimally invasive (n = 131) or open left pancreatectomy (n = 127).
• Surgical techniques were standardized: The open approach used a radical antegrade modular pancreatosplenectomy, whereas the minimally invasive approach employed a radical “no-touch” left pancreatosplenectomy. The minimally invasive arm included both laparoscopic and robot‑assisted procedures.
• The primary outcome was overall survival by intention to treat, and secondary outcomes included disease-free survival, adjuvant therapy administration rates, time to adjuvant therapy initiation, and recurrence rates. The median follow-up was 38 months.

TAKEAWAY:

• Median overall survival was comparable between the groups — 32 months with minimally invasive and 34 months with open surgery (hazard ratio [HR], 1.02; P = .92). Patients in both groups also had similar 1-year (79% vs 73%) and 3-year (46% vs 50%) survival rates.
• Both surgical approaches resulted in similar disease-free survival: a median 21 months with minimally invasive vs 17 months with open surgery (HR, 0.96; P = .81).
• Overall, 70% of patients undergoing minimally invasive surgery and 72% of those undergoing open surgery received adjuvant therapy. There was no difference between the groups in median time to therapy initiation (59 vs 56 days; P = .92).
• Post hoc analyses showed that the effect of surgical approach on overall survival was consistent across patient subgroups with regard to BMI, tumor size, tumor location, multivisceral involvement, or receipt of neoadjuvant therapy.

IN PRACTICE:

“The present analysis provides strong certainty about the oncological safety of minimally invasive left pancreatectomy vs open left pancreatectomy in patients with upfront resectable left-sided pancreatic cancer,” the study authors concluded. A commentary published with the study concurred. “These findings are especially relevant as surgeons navigate the tension between embracing innovation and preserving long-term outcomes,” wrote Adrian Diaz, MD, MPH, of the University of Chicago, Chicago, and Melissa E. Hogg, MD, of Endeavor-NorthShore University Health System, Evanston, Illinois. “When performed with sound oncologic principles, surgical approach should not determine survival.”

SOURCE:

The study, led by Caro Bruna, MD, University of Amsterdam, Department of Surgery, Amsterdam, Netherlands, was published online in JAMA Surgery.

LIMITATIONS:

The trial was underpowered to assess differences in overall and disease-free survival between the two surgery groups because doing so would require a sample size exceeding 1000 patients. Only 27% of procedures in the minimally invasive arm were robotic, an important distinction as the field moves increasingly toward robotic approaches.

DISCLOSURES:

The trial was supported by grants from Medtronic Covidien AG and Johnson & Johnson Medical Limited. Bruna reported receiving grants from Medtronic and Johnson & Johnson during the conduct of the study and grants from the Intuitive Foundation and the Dutch Cancer Foundation outside the submitted work. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.