Minimally invasive pancreatic surgery: Introduction, development, and outcome assessment

The research presented in this thesis provides insight in the dissemination and outcomes of minimally invasive pancreatic resections on a national and international level. A worldwide survey regarding minimally invasive pancreatic resection showed that participants value minimally invasive pancreatic resection as a useful development, especially for distal pancreatectomy. In the Netherlands minimally invasive distal pancreatectomy was introduced with a specific nationwide training program (LAELAPS). Following, a multicenter, patient-blinded, randomized controlled trial was performed (LEOPARD) and found a 2-day reduction in time to functional recovery after the minimally invasive approach. Cost-effectiveness analysis showed that minimally invasive distal pancreatectomy has a probability of 0.653 of being more cost-effective than open. The oncological safety of minimally invasive distal pancreatectomy remains uncertain and further (randomized) studies are needed. Following the successful introduction of minimally invasive distal pancreatectomy interest increased in also performing minimally invasive pancreatoduodenectomy in the Netherlands. A second nationwide training program (LAELAPS-2) was performed with successful outcomes. Following, a second multicenter, patient-blinded, randomized controlled trial (LEOPARD-2) was performed. This trial was preliminary terminated due to a 90-day, complication-related mortality of five patients in the laparoscopic pancreatoduodenectomy group versus one in the open pancreatoduodenectomy group. The primary outcome, time to functional recovery, was at this time comparable after both procedures. The LEOPARD-2 trial therefore raised concerns on the safety of laparoscopic pancreatoduodenectomy without showing evidence for a benefit in terms of time to functional recovery, in medium-high volume centers, even when performed by trained surgeons. In conclusion, minimally invasive pancreatic surgery has come a long way regarding the introduction, development, and assessment of minimally invasive pancreatic surgery. Hopefully, this thesis stimulates surgeons worldwide to consider carefully whether they are equipped to perform minimally invasive pancreatic surgery and stimulates to participate in large multicenter studies and registries