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Page 4 of 15 Shannon et al. Mini-invasive Surg 2023;7:32 https://dx.doi.org/10.20517/2574-1225.2023.83

complication rates, post-operative pancreatic fistulas grade B/C, or 90-day mortality between open and
[28]
minimally invasive approaches .
A follow-up study using the LEOPARD trial cohort evaluated long-term quality of life, cosmetic
[29]
satisfaction, and overall major complications beyond one year . After a median follow-up of 44 months for
84 patients, there was no significant difference between minimally invasive and open DP groups in the
primary outcomes of quality of life, major complications, readmission, and incisional hernia. However,
patients were more content with their cosmesis in the minimally invasive group.

The LAPOP trial followed the LEOPARD trial and was an unblinded single-center superiority study
conducted between 2015 and 2019 in which patients were randomized to laparoscopic (n = 29) or open DP
(n = 29). The primary outcome was the length of post-operative hospital stay, and secondary outcomes
included time to functional recovery, operative time, and perioperative complication rates. Median post-
operative hospital LOS (5 vs. 6 days in open; P = 0.002) and time to functional recovery (4 vs. 6 days; P
= 0.007) were significantly shorter in the laparoscopic DP group compared to the open group. No
difference was seen in operative time or complication rates between the two groups .
[30]
The LEOPARD and LAPOP trials represent the only two published randomized prospective trials to date,
evaluating outcomes between minimally invasive and open techniques for DP. It is important to note that
these trials included both benign and malignant indications for pancreatectomy and, therefore, did not
compare oncologic outcomes between the two surgical approaches . An individual patient data meta-
[31]
analysis from the International Minimally invasive Pancreatic Resection Trialist Group (IMIPRT)
compared outcomes in all patients from the LEOPARD and LAPOP trials . The authors found similar
[32]
rates of major complications between minimally invasive and open approaches (adjusted odds ratio 0.54;
P = 0.148), although there was a trend toward higher pancreatic fistula in the minimally invasive group.
They concluded that in properly trained hands, minimally invasive DP may be the preferred approach. The
findings of the LEOPARD trial were further validated by an assessment of the National Quality
Improvement Program of the American College of Surgeons (ACS-NSQIP), which showed an 11% risk
reduction in composite major morbidity after minimally invasive DP compared to an open approach .
[33]
In addition to these two seminal trials, much has been published on minimally invasive DP compared to an
open approach. A 2020 study randomized 60 patients to laparoscopic or open DP and found shorter LOS
[30]
and time to recovery and less bleeding with laparoscopy . There was no difference in complications,
including pancreatic fistula. Another randomized controlled trial from 2023 showed improved quality of life
[34]
in patients undergoing laparoscopic DP at two years post-operatively . A European consortium performed
a propensity score-matched study comparing oncologic outcomes for patients who underwent minimally-
invasive vs. open DP between 2007 and 2015 . Overall survival, perioperative complications, and 90-day
[35]
mortality were similar between groups; however, R0 resection was significantly higher in the minimally
invasive group. Interestingly, despite the equivalent survival and oncologic outcomes, the number of lymph
nodes harvested was lower in the minimally invasive group. Other retrospective, propensity-matched
studies and meta-analyses have shown similar results [36-43] . However, one propensity-matched study from a
Korean group showed improved overall and disease-free survival for minimally invasive DP compared to
an open approach . Additionally, in contrast to the majority of the literature, an assessment of the ACS-
[44]
NSQIP database found higher rates of post-operative pancreatic fistula in the minimally invasive group,
similar to the IMIPRT group study mentioned above . This was validated by a randomized controlled trial
[45]
by van der Heijde et al., which showed higher rates of post-operative pancreatic fistula in the minimally
invasive DP . Further studies are needed to clarify these conflicting results regarding the impact of a
[46]