Minimally invasive surgery for pancreatic cancer - are we there yet? - a narrative review

Abstract

Objective: The aim of this review article is to evaluate the current status of minimally invasive pancreatic resections (MIPR) for pancreatic ductal adenocarcinoma (PDAC), in light of the present evidence. Background: Published data, largely in the form of retrospective studies and a few prospective/ randomized controlled trials have confirmed feasibility, safety, and equivalent short-term outcomes of MIPR in experienced hands. Hence, several recent evidence-based international consensus guidelines have stated MIPR to be at par with the open approach, when these surgeries are performed at high-volume centers. However, longer operative duration, high conversion rates, inferior oncological outcomes, and increased mortality reported in low-volume centers, especially during minimally invasive pancreaticoduodenectomy remains a matter of concern, questioning its broad applicability. Hence, distal pancreatic resections are adopted more widely with a minimally invasive approach as compared to pancreatic head resections. Also, MIPR for PDAC in particular, remains controversial due to lack of high quality data evaluating longterm outcomes of MIPR for PDAC alone. Considering the ongoing impact of neoadjuvant treatment on pancreatic cancer surgery and the corresponding increase in vascular resections and arterial divestment procedures, applicability of MIPR in this setting remains questionable. Methods: Medline, PubMed, Embase, Cochrane Library, and various international evidence-based guidelines were searched for the current status of minimally invasive resections for pancreatic cancer (PDAC). Conclusions: The available evidence establishes the feasibility and safety of MIPR, however for PDAC the widespread application remains controversial owing to a dearth of literature evaluating the longterm outcomes. Apart from the outcomes, establishing the exact indications, appropriate patient selection, enhanced cost, and learning curve issues need further studies.