Feasibility and safety of minimally invasive distal pancreatosplenectomy in resectable and borderline resectable pancreatic cancer following neoadjuvant chemotherapy

Abstract

BackgroundThe role of minimally invasive surgery (MIS) in advanced pancreatic ductal adenocarcinoma (PDAC) remains controversial, particularly after neoadjuvant chemotherapy. Most previous studies have excluded such patients, and evidence supporting MIS in this context is limited. We evaluated the safety, technical feasibility, and oncologic outcomes of minimally invasive distal pancreatectomy (MIDP) following neoadjuvant chemotherapy in patients with advanced pancreatic cancer.MethodsWe retrospectively reviewed 105 patients who underwent distal pancreatectomy with splenectomy for advanced PDAC following neoadjuvant chemotherapy at a single institution between January 2005 and August 2024. Patients were categorized into open (ODP, n = 37) and minimally invasive (MIDP, n = 68) groups. Perioperative outcomes, pathologic features, and long-term survival were compared before and after propensity score matching. Subgroup and multivariable analyses were performed.ResultsMIDP was associated with significantly lower estimated blood loss compared with ODP (166.8 vs. 269.7 mL, p = 0.020), and no patient in the MIDP group required intraoperative transfusion. Other perioperative outcomes, including operation time, postoperative morbidity, and length of hospital stay, were comparable between groups. R0 resection rates, lymph node yield, and pathologic staging did not differ significantly. Long-term disease-free and overall survival were similar between groups, including in patients who received FOLFIRINOX-based neoadjuvant and adjuvant chemotherapy. After propensity score matching, survival outcomes remained comparable. Multivariable analysis identified estimated blood loss and N2 nodal status as independent predictors of recurrence, while N2 nodal status was the only independent predictor of overall survival. The surgical approach was not associated with oncologic outcomes.ConclusionsMinimally invasive distal pancreatectomy is a safe and oncologically sound option for selected patients with advanced PDAC after neoadjuvant chemotherapy. With careful patient selection, MIS may be effectively applied even in technically challenging cases.