Discrepancies in survival after conversion to open in minimally invasive pancreatoduodenectomy

Published:October 28, 2022DOI:


      • Minimally invasive pancreatoduodenectomy has become increasingly popular with concomitant decreases in conversion to open.
      • Conversion to open pancreatoduodenectomy is associated with a lower median overall survival than successful open operations.
      • 90-day mortality after conversion to open from minimally invasive pancreatoduodenectomy is higher at low-volume centers.
      • These data emphasize the importance of safe adoption strategies when learning minimally invasive pancreatoduodenectomy.



      The extent by which conversion to open (CTO) during minimally invasive procedures for pancreatic cancer impact survival outcomes is not fully understood.


      The 2010–2017 National Cancer Database identified 12,424 non-metastatic patients who underwent pancreatoduodenectomy for ductal adenocarcinoma. Patients were stratified into three cohorts: open (OPD), completed MIPD (cMIPD), and CTO. Subgroups were dichotomized by hospital MIPD volume.


      Across the study period, 80.6% of patients underwent OPD, 19.4% MIPD, and 24% were CTO. Median overall survival was worse after CTO (21.8 months) than for OPD (23.6 months) or cMIPD (25.2 months) (p < 0.001). Although this effect persisted for <10 MIPD/year, CTO did comparably to OPD at hospitals performing ≥10MIPD/year (CTO = 26.8 months, OPD = 27.9 months; p = 0.128). Ninety-day mortality after CTO was worse at ≤ 10 MIPD/year hospitals (9.3% vs. 2.6%).


      Short and long-term survival is impacted by CTO after MIPD, especially at lower surgical volumes, stressing careful adoption while ascending the learning curve.

      Graphical abstract


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • de Rooij T.
        • Lu M.Z.
        • Steen M.W.
        • et al.
        Minimally invasive versus open pancreatoduodenectomy: systematic review and meta-analysis of comparative cohort and registry studies.
        Ann Surg. 2016; 264 ([PMID: 26863398 DOI:): 257-267
        • Girgis M.D.
        • Zenati M.S.
        • King J.C.
        • et al.
        Oncologic outcomes after robotic pancreatic resections are not inferior to open surgery.
        Ann Surg. 2021; 274 (e262–e268. [PMID: 31663967)
        • Zureikat A.H.
        • Postlewait L.M.
        • Liu Y.
        • et al.
        A multi-institutional comparison of perioperative outcomes of robotic and open pancreaticoduodenectomy.
        Ann Surg. 2016; 264 ([PMID: 27433907 DOI:): 640-649
        • Klompmaker S.
        • Van Hilst J.
        • Wellner U.F.
        • et al.
        Outcomes after minimally-invasive versus open pancreatoduodenectomy: a pan-european propensity score matched study.
        Ann Surg. 2020; 271 ([PMID: 29864089 DOI:): 356-363
        • van Oosten A.F.
        • Ding D.
        • Habib J.R.
        • et al.
        Perioperative outcomes of robotic pancreaticoduodenectomy: a propensity-matched analysis to open and laparoscopic pancreaticoduodenectomy.
        J Gastrointest Surg: Off J Soc Surg Aliment Tract. 2021; 25 (–1804. [PMID: 33201457): 1795
        • van Hilst J.
        • de Rooij T.
        • Bosscha K.
        • et al.
        Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial.
        Lancet Gastroenterol Hepatol. 2019; 4 ([PMID: 30685489): 199-207
        • Beane J.D.
        • Pitt H.A.
        • Dolejs S.C.
        • et al.
        Assessing the impact of conversion on outcomes of minimally invasive distal pancreatectomy and pancreatoduodenectomy.
        HPB. 2018; 20 ([PMID: 29191691 DOI:): 356-363
        • Stiles Z.E.
        • Dickson Pv
        • Deneve J.L.
        • et al.
        The impact of unplanned conversion to an open procedure during minimally invasive pancreatectomy.
        J Surg Res. 2018; 227 ([PMID: 29804849 DOI:): 168-177
        • Hester C.A.
        • Nassour I.
        • Christie A.
        • et al.
        Predictors and outcomes of converted minimally invasive pancreaticoduodenectomy: a propensity score matched analysis.
        Surg Endosc. 2020; 34 ([PMID: 31016458): 544-550
        • Boffa D.J.
        • Rosen J.E.
        • Mallin K.
        • et al.
        Using the national cancer database for outcomes research: a review.
        JAMA Oncol. 2017; 3 ([PMID: 28241198 DOI:): 1722-1728
        • Asbun H.J.
        • Moekotte A.L.
        • Vissers F.L.
        • et al.
        The miami international evidence-based guidelines on minimally invasive pancreas resection.
        Ann Surg. 2020; 271 ([PMID: 31567509 DOI:): 1-14
        • Zureikat A.H.
        • Beane J.D.
        • Zenati M.S.
        • et al.
        500 minimally invasive robotic pancreatoduodenectomies: one decade of optimizing performance.
        Ann Surg. 2021; 273 ([PMID: 31851003): 966-972
        • Lof S.
        • Vissers F.L.
        • Klompmaker S.
        • et al.
        Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study.
        Br J Surg. 2021; 108 ([PMID: 33640946 DOI:): 80-87
        • Wu W.
        • He J.
        • Cameron J.L.
        • et al.
        The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy for adenocarcinoma.
        Ann Surg Oncol. 2014; 21 ([PMID: 24770680): 2873-2881
        • Labori K.J.
        • Katz M.H.
        • Tzeng C.W.
        • et al.
        Impact of early disease progression and surgical complications on adjuvant chemotherapy completion rates and survival in patients undergoing the surgery first approach for resectable pancreatic ductal adenocarcinoma - a population-based cohort study.
        Acta Oncol. 2016; 55 ([PMID: 26213211): 265-277
        • de Rooij T.
        • van Hilst J.
        • Topal B.
        • et al.
        Outcomes of a multicenter training program in laparoscopic pancreatoduodenectomy (LAELAPS-2).
        Ann Surg. 2019; 269 ([PMID: 29099400 DOI:): 344-350
      1. Zwart MJW, Nota CLM, de Rooij T, et al. Outcomes of a multicenter training program in robotic pancreatoduodenectomy (LAELAPS-3). Ann Surg (e-pub ahead of print February 2021; doi:10.1097/SLA.0000000000004783).