Minimally invasive distal pancreatectomy: International collaboration to improve surgical treatment of left-sided pancreatic neoplasms

In this thesis, international collaborative efforts have been made to investigate the feasibility, safety, and outcomes of minimally invasive distal pancreatectomy. The minimally invasive approach towards distal pancreatectomy is increasingly integrated into standard surgical treatment for left-sided benign and pre-malignant neoplasms. Spleen-preserving minimally invasive distal pancreatectomy has shown superior outcomes compared to an open approach in terms of technical outcomes such as splenic preservation rates and long-term sequalae of esophageal varices. Both Warshaw and Kimura techniques can be performed minimally invasive with low rates of splenic infarction requiring reinterventions. On the longer term, quality of life is comparable between minimally invasive and open distal pancreatectomy. The role of a minimally invasive approach to resectable pancreatic cancer has been debated because of the expectation of inferior oncological outcomes in the absence of randomized trials. This thesis reports a randomized trial performed in 35 centers from 12 countries, which showed that the minimally invasive approach is non-inferior to open distal pancreatectomy in this patient group and may be considered a safe alternative to an open approach. Considering the arguably high-complex nature of distal pancreatectomy, a step-wise approach is crucial for the implementation of such procedure. In the Netherlands, a safe and sustained implementation was observed after the completion of a nationwide training program and randomized trial. Approximately two-thirds of patients are currently operated on using a minimally invasive approach. For the further nationwide and worldwide implementation, dedicated training curricula and registration of outcomes in (inter)national registries is advised.