A review of the current evidence for the role of minimally invasive pancreatic surgery following neo-adjuvant chemotherapy

Objective

Surgical resection of pancreatic cancer remains the only potentially curative treatment for pancreatic ductal adenocarcinoma. The robotic platform has been introduced to surgical practice and recent large studies from national registries have demonstrated similar or improved peri-operative outcomes compared to the standard open approach. Neo-adjuvant chemotherapy is increasingly being offered to patients with borderline resectable/locally advanced disease but this has led to more challenging resections. Numbers of patients undergoing minimally invasive resection following neo-adjuvant chemotherapy remain low. The aim of this review is to assess the current evidence for the peri-operative safety and long-term oncological outcomes associated with minimally invasive pancreatic resection following neo-adjuvant chemotherapy.

Methods

Medline, Embase and Cochrane Central Register for Clinical Trials were searched up until 31st October 2021. The search terms include “minimally invasive”, “robotic”, “laparoscopic”, “pancreatectomy”, “pancreatic resection”, “whipple's pancreaticoduodenectomy”, “distal pancreatectomy”, “chemotherapy”, “neo-adjuvant chemotherapy”, “radiotherapy”, “neo-adjuvant chemoradiotherapy”, “induction therapy”, and “conversion surgery”. All studies including patients undergoing pancreatic resections were included. Studies which did not clearly state the approach to resection (minimally invasive or open) were excluded.

Results

Seventy-eight studies were identified of which 8 compared open and minimally invasive resection following neo-adjuvant chemotherapy. There was insufficient data to perform a meta-analysis. Robotic surgery was associated with lower blood loss and shorter length of hospital stay. Three-year overall survival rates were similar between patients who underwent robotic or open resection however the robotic approach was associated with higher lymph node yield and a lower R1 resection rate.

Conclusion

Currently the evidence for minimally invasive surgery following neo-adjuvant chemotherapy is limited. Long-term oncological outcomes are similar to patients undergoing open resection and there is some evidence to suggest superior peri-operative outcomes. As numbers are limited, future studies analysing national and international databases on minimally invasive pancreatic resection are required to provide sufficient evidence to support the use of minimally invasive pancreatic resection following neo-adjuvant chemotherapy in high-risk groups.