Comparison of Long‐Term Oncologic and Perioperative Outcomes of Minimally Invasive and Open Pancreatoduodenectomy for Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma: Exploring Type 0 Resection as a Potential Indication for MIPD

BACKGROUND: The safety and efficacy of minimally invasive pancreatoduodenectomy (MIPD) for pancreatic ductal adenocarcinoma (PDAC) remain controversial. This study evaluated the surgical and oncological outcomes of MIPD versus open pancreatoduodenectomy (OPD) after overcoming the MIPD learning curve. METHODS: Between April 2014 and July 2022, 357 patients underwent pancreatoduodenectomy for resectable (RPC) or borderline resectable (BRPC) PDAC. After excluding early-phase MIPD cases, 112 patients underwent MIPD and 245 underwent OPD. Propensity score matching was performed. Subgroup analysis assessed outcomes in patients undergoing PD without vascular resection (type 0). RESULTS: MIPD was associated with longer operation time (p = 0.002), but similar estimated blood loss and intraoperative transfusion volumes. Rates of clinically relevant postoperative fistula and delayed gastric emptying were comparable. Disease-free survival (DFS) and overall survival (OS) did not differ significantly between MIPD and OPD groups (p = 0.670 and p = 0.179, respectively). In type 0 resections, OS was equivalent, but DFS was significantly better in the MIPD group. CONCLUSIONS: MIPD is a safe and feasible option for RPC and BRPC PDAC, with oncologic outcomes comparable to OPD. Type 0 tumors, not requiring vascular resection, may represent an optimal indication for MIPD.