Chinese Expert Consensus on Laparoscopic or Robot-Assisted Radical Pancreatic Cancer Resection (2022 Edition)

Authors: Minimally Invasive Diagnosis and Treatment Group of Pancreatic Cancer Professional Committee of Chinese Anti-Cancer Association, Pancreatic Surgery Group of Chinese Society of Surgery

Article source: Chinese Journal of Surgery, 2023, 61(3)

summary

Although there is still controversy about the efficacy and safety of minimally invasive radical resection for pancreatic cancer, most of the existing research results suggest that minimally invasive radical resection has broad application prospects. Referring to the opinions of Chinese experts and the results of worldwide studies, this consensus aims to explore the related issues of minimally invasive radical pancreatectomy for pancreatic cancer, so as to improve the perioperative safety and oncological effect of laparoscopic and robotic-assisted radical pancreatectomy. The 15 recommendations cover five topics: oncological outcomes and patient safety for laparoscopic and robotic pancreaticoduodenectomy, left pancreatectomy for pancreatic cancer, learning curve, safety of neoadjuvant therapy, and vasculature in minimally invasive radical pancreatic cancer resection, with the level of evidence and strength of recommendations assessed against the assessment, development and evaluation methods of the recommendation grade. This consensus provides a reference and guidance for surgeons to choose minimally invasive radical resection for the treatment of pancreatic cancer. Although this consensus is not sufficient to answer all the questions of laparoscopic and robot-assisted radical pancreatic cancer surgery, it represents the current consensus on the application of these technologies in the treatment of pancreatic cancer in Chinese mainland.

Although pancreatic surgery has a history of more than 100 years, it is still considered the most challenging procedure in abdominal surgery due to its high morbidity and mortality rate. Since the world's first laparoscopic pancreaticoduodenectomy (LPD) was reported in 1994 [1], laparoscopic or robotic-assisted techniques have been explored in pancreatic surgery. In the past decade, all kinds of minimally invasive pancreatic surgeries have been carried out, mainly laparoscopic or robot-assisted, and the technology has become mature, and the safety of the operation has been significantly improved. Theoretically, laparoscopic or robotic-assisted surgery can perform the same type of pancreatic surgery as open surgery, and even better than open surgery in terms of function-preserving pancreatic surgery, but there is still controversy in the surgical treatment of pancreatic malignancy. At present, the focus of controversy in the application of laparoscopic or robotic-assisted surgery in the curative treatment of pancreatic cancer mainly focuses on the oncological evaluation of treatment effect and surgical safety, and most of the published clinical studies are retrospective, and most of them focus on minimally invasive surgical techniques themselves. In view of the oncological characteristics of pancreatic cancer with high malignancy, wide invasion and poor prognosis, as well as the clinical practice that radical tumor resection is more difficult than conventional surgery, it is necessary to discuss the related issues of laparoscopic or robotic-assisted surgery in the treatment of pancreatic cancer in order to ensure the perioperative safety and radical tumor effect of radical pancreatic cancer surgery. This consensus was formulated by the Minimally Invasive Diagnosis and Treatment Group of the Pancreatic Cancer Professional Committee of the Chinese Anti-Cancer Association and the Pancreatic Surgery Group of the Surgical Branch of the Chinese Medical Association to organize relevant experts in pancreatic surgery in China, with reference to the research progress and guideline consensus in this field at home and abroad, and combined with expert experience. The quality of the evidence and the strength of the recommendations were evaluated according to the grading of recommendations, assessment, development, evaluation (GRADE) (Table 1). The quality of the evidence was classified as 'high', 'moderate', 'low', and 'very low', with a strong recommendation rating of 'strong' and 'fair' [2]. Although this consensus is not enough to answer all the problems faced in the treatment of pancreatic cancer through laparoscopic and robotic-assisted surgery, it represents the current consensus on the application of laparoscopic and robotic minimally invasive techniques in the diagnosis and treatment of pancreatic cancer in Chinese mainland.

1. Perioperative safety of LPD in the treatment of pancreatic head cancer

Although the total operative time for LPD was slightly longer than that of open pancreatoduodenectomy (OPD) [3, 4, 5, 6], meta-analyses of patients with pancreatic head cancer showed that LPD was superior to OPD in terms of length of hospital stay and intraoperative blood loss, but there was no statistically significant difference in postoperative complications such as pancreatic fistula, postoperative hemorrhage, and perioperative mortality [6, 7, 8]. Cai et al. [9] explored the perioperative safety of LPD in patients over 70 years of age with pancreatic head cancer, and found that the enrolled older adults had worse nutritional status and more comorbidities than younger adults, but there was no statistically significant difference in the perioperative safety of LPD with young people. Chapman et al. [10] analyzed the 90-day mortality rate of LPD and OPD in patients with pancreatic head cancer over 75 years of age in the National Cancer Database (NCDB), and found that the mortality rate of elderly patients with LPD was lower than that of OPD.

Recommendation 1: The intraoperative blood loss and hospital stay of LPD in the treatment of pancreatic head cancer are better than OPD. At this stage, it is recommended that LPD be performed in patients with pancreatic head cancer in units with mature technical conditions (level of evidence: moderate; Recommended intensity: strong).

2. Radical tumor curative effect and long-term survival of LPD in the treatment of pancreatic head cancer

With the gradual improvement of the safety of LPD, its radical curability for pancreatic head cancer has become the focus of attention. In two analyses of patients with pancreatic head cancer, LPD was superior to OPD in terms of R0 resection rate and number of lymph nodes obtained [7, 8]. However, another study did not find a difference in the rate of R0 resection and the number of lymph nodes obtained in the treatment of pancreatic head cancer with LPD and OPD [11]. In terms of the timing of initiation of postoperative adjuvant chemotherapy, some investigators found that patients with pancreatic head cancer were able to receive adjuvant chemotherapy earlier after LPD [6,12], while another study failed to find a difference in postoperative adjuvant chemotherapy time between LPD and OPD [11]. However, there was no statistically significant difference in the proportion of postoperative adjuvant chemotherapy between the two surgical modalities [11, 12]. Peng et al. [12] showed that the disease-free survival of LPD was longer than that of OPD. The results of Chen et al. [11] suggest that the 3-, 4-, and 5-year survival rate of LPD in the treatment of pancreatic head cancer is better than that of OPD. However, there is also a non-statistically significant difference in overall survival (OS) [5, 6, 7, 8,12]. Chapman et al. [10] performed a propensity score match (PSM) between the basic status of pancreatic head cancer patients over 75 years of age who were treated with LPD or OPD in NCDB and tumor-related characteristic factors, and found that although there was no significant difference in survival between the two groups, there was a trend of prolonged survival in the LPD group.

Recommendation 2: For appropriately screened patients with pancreatic head cancer, LPD is not inferior to OPD in terms of R0 resection rate, number of lymph nodes obtained, and long-term survival rate. In technologically mature settings, LPD surgery was associated with similar oncological radical outcomes as OPD surgery (level of evidence: moderate; Recommended Intensity: Average).

三、机器人胰十二指肠切除术（robotic pancreatoduodenectomy，RPD）治疗胰头癌的围手术期安全性

Compared with traditional laparoscopic equipment, the robot has a three-dimensional imaging system and a flexible robotic wrist, which can theoretically improve the accuracy and smoothness of surgery. At present, the results of prospective randomized controlled studies or meta-analyses comparing RPD with OPD in the treatment of pancreatic head cancer are rare. Vining et al. [13] performed a PSM analysis of pancreatic head cancer data from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) and showed that the incidence of postoperative bleeding in the RPD group was lower than that in the OPD group, but there was no statistically significant difference in postoperative pancreatic fistula. Similar results were reached in two other single-center, small-sample PSM studies [14, 15].

Recommendation 3: RPD has certain advantages over OPD in the treatment of pancreatic head cancer in terms of perioperative safety, and experienced units can perform relevant surgeries (level of evidence: low; Recommended Intensity: Average).

4. Radical tumor curative effect and long-term survival of RPD in the treatment of pancreatic head cancer

At present, there are few prospective studies and meta-analyses of the oncological effects of RPD in the treatment of pancreatic head cancer. Nassour et al. [16] analyzed the data in NCDB and found that the RPD group was superior to the OPD group in terms of the number of lymph nodes obtained and the rate of postoperative adjuvant chemotherapy, and there was no statistically significant difference in R0 resection rate and postoperative survival. Similar conclusions were reached in two single-center PSM analyses [14, 15]. It has also been suggested that patients with pancreatic head cancer who receive RPD are more likely to receive adjuvant chemotherapy earlier after surgery than OPD [17].

Recommendation 4: RPD is non-inferior to OPD in terms of near-term and long-term efficacy in radical tumor resection. In technically mature settings, RPD in appropriately screened patients with pancreatic head cancer can achieve a similar oncologic radical outcome as OPD (level of evidence: low; Recommended Intensity: Average).

5. Comparison of the perioperative safety of RPD and LPD in the treatment of pancreatic head cancer

In 2000, the robotic surgery system was approved by the U.S. Food and Drug Administration for clinical use, and minimally invasive surgery has seen a situation where robots and laparoscopic surgery go hand in hand. Compared with laparoscopic equipment, robotic surgery has the disadvantages of fixed surgical field and expensive equipment, but it has the advantage that the mechanical wrist can be rotated freely at 540°, which makes some complex resection and reconstruction steps easier and reduces the workload of the surgeon [18].

At present, there are few literature comparing the perioperative safety of LPD and RPD in the treatment of pancreatic head cancer. Stiles et al. [19] analyzed the data of 350 cases of minimally invasive pancreatoto-duodenectomy (MIPD) in the ACS-NSQIP database, and the overall conversion laparotomy rate was 24.6%, which was lower than that of LPD. The results of Kamarajah et al. [20] showed that RPD reduced the rate of conversion to laparotomy and blood transfusion compared with LPD without considering the type of pathology, and there was no difference between the two in terms of other perioperative safety indicators. However, among the 6 retrospective literatures included, two single-center reports only about 20 RPD and LPD cases, and the remaining 4 were from the database of American industry associations. Therefore, the results of this study only represent safety data in the early stages of the MIPD learning curve. Whether the comparison results of the perioperative safety of LPD and RPD will change after the learning curve of minimally invasive surgery has been completely passed remains to be further verified.

Recommendation 5: The surgical difficulty of LPD or RPD for pancreatic head cancer is much higher than that for ampullary or pancreatic benign tumors, and more difficult surgical procedures may be faced during the operation. Early in the learning curve of pancreatic head cancer surgery, RPD may have some advantages over LPD in terms of perioperative clinical safety. For surgeons who are still in the early stages of the learning curve, units with the capacity can give preference to RPD for the treatment of pancreatic head cancer (level of evidence: low; Recommended Intensity: Average).

6. Comparison of tumor curability and long-term survival of RPD and LPD in the treatment of pancreatic head cancer

At present, only Nassour et al. [21] compared the radical tumor resection effect and long-term survival of RPD and LPD by analyzing the data of pancreatic head cancer in NCDB. There were no significant differences in R0 resection rate, number of lymph nodes dissected, postoperative adjuvant chemotherapy rate, OS, and 1, 2, and 3-year survival rates.

Recommendation 6: Robotic and laparoscopic treatment of pancreatic head cancer has a similar effect on radical tumor resection. For pancreatic head cancer cases to be treated with MIPD, each unit can choose RPD or LPD for the treatment of pancreatic head cancer according to their own learning curve stage and their own experience (level of evidence: low; Recommended Intensity: Average).

七、腹腔镜胰体尾切除术（laparoscopic distal pancreatectomy，LDP）的围手术期安全性

No prospective randomised controlled studies were identified comparing the perioperative safety of LDP with open distal pancreatectomy (ODP). LDP has been shown to be longer than ODP in terms of operative duration, but superior to ODP in terms of length of hospital stay and intraoperative blood loss, but there are no statistically significant differences in overall perioperative complication rates, pancreatic fistula rates, and perioperative mortality rates [22, 23, 24]. A retrospective review of data from large samples of pancreatic caudal carcinoma in NCDB also suggests that LDP is superior to ODP in terms of length of hospital stay, but there is no statistically significant difference in the 90-day mortality rate [25, 26]. Sulpice et al. [27], after analyzing data from the French Health Database, found that LDP had an advantage over ODP in terms of length of hospital stay, but LDP had a lower 90-day case fatality rate than ODP, and suggested that this difference may be related to case selection bias.

The rate of LDP conversion to laparotomy reported by a single center varied greatly (0%~26%) [28, 29, 30, 31]. Raoof et al. [26] summarized that the conversion rate of 605 cases of pancreatic caudal carcinoma receiving LDP in NCDB from 2010 to 2013 was as high as 27%. Differences in the rate of switching laparotomy between studies may be related to the different stages of the learning curve in each center. Switching laparotomy prolongs the duration of surgery and increases the morbidity rate, but does not increase perioperative mortality [19].

2003年Strasberg等［32］介绍了根治性顺行模块化胰脾切除术（radical antegrade modular pancreato- splenectomy，RAMPS）治疗胰体尾癌的临床资料。 有研究结果显示，RAMPS的围手术期安全性与ODP相近［33］。 腹腔镜RAMPS（laparoscopic RAMPS，L-RAMPS）与开腹RAMPS（open RAMPS，O-RAMPS）相比，两者在住院时间、术中出血量及临床相关胰瘘方面差异无统计学意义［34, 35］。

Recommendation 7: LDP has certain advantages over ODP in perioperative rehabilitation. The perioperative safety profile of L-RAMPS is also the same as that of open surgery. Technically mature centres may conduct LDP (level of evidence: moderate; Recommended intensity: strong).

8. Radical tumor curative effect and long-term survival of LDP

There was no statistically significant difference between LDP and ODP in terms of R0 resection rate [22, 23, 24] and number of lymph nodes dissected [22,24]. Kantor et al. [25] found similar conclusions in a large-sample retrospective study of pancreatic tail-of-pancreatic carcinoma cases in NCDB. The results of the DIPLOMA study in Europe showed that the R0 resection rate of minimally invasive distal pancreatectomy (MIDP) was higher than that of the ODP group [36], but because they were all non-randomized controlled studies, it was difficult to avoid bias caused by preoperative evaluation even after PSM of tumor diameter, tumor site and adjacent organ invasion. There was also no statistically significant difference between L-RAMPS and O-RAMPS in the short-term radical tumor resection [34, 35].

The results of the long-term survival study showed that there was no significant difference in the chemotherapy completion rate [22], postoperative recurrence rate [23], and overall survival [22] in patients with pancreatic caudal carcinoma who received LDP or ODP. Retrospective studies of large samples of pancreatic cuff carcinoma in NCDB [25, 26] and the DIPLOMA study in Europe [36] suggest that there was no statistically significant difference in survival between LDP and ODP. Sulpice et al. [27] analyzed the data of pancreatic caudal cancer cases in the French Health Database and found that the OS of LDP was longer than that of ODP, but there was no significant difference in 1-, 3-, and 5-year survival rates. Only one review compared the survival of patients with pancreatic crest cancer with L-RAMPS and O-RAMPS, and the difference was not statistically significant [34].

Recommendation 8: The available evidence suggests that LDP is not statistically significant different from ODP in terms of R0 resection rate, number of lymph node dissections, and survival rate. LDP may be performed in experienced units based on selection of appropriate cases (level of evidence: moderate; Recommended intensity: strong).

九、机器人胰体尾切除术（robotic distal pancreatectomy，RDP）的围手术期安全性

At present, there are few studies on RDP and ODP. Nassour et al. [16] included data from 332 and 2 386 patients with pancreatic tail cancer treated with RDP and ODP, respectively, and showed that RDP was superior to ODP in terms of length of hospital stay and 90-day mortality. Because the study was retrospective and the NCDB did not provide data on perioperative complications, it was difficult to rule out differences in perioperative mortality due to selection bias. In the DIPLOM study, a large European study comparing MIDP and ODP, it was found that MIDP was superior to ODP in terms of intraoperative blood loss and length of hospital stay, with no significant difference in the 90-day mortality rate between the two groups [36]. Watson et al. [37] conducted a PSM study of patients with pancreatic caudal cancer who received MIDP or ODP in NCDB and reached similar conclusions.

Recommendation 9: The available evidence suggests that RDP in appropriately selected cases has some perioperative safety advantages over OPD. RDP for pancreatic corpotailal carcinoma can be performed in experienced units (level of evidence: low; Recommended intensity: strong).

10. The radical tumor curative effect and long-term survival of RDP

Nassour et al. [16] performed a retrospective analysis of the data of pancreatic caudal carcinoma in a large sample of NCDB, suggesting that RDP was superior to ODP in the number of lymph nodes dissected and the rate of postoperative adjuvant chemotherapy, but there was no significant difference in the rate of R0 resection. However, other single-center studies have found no difference in the number of lymph nodes dissected and the R0 resection rate [38, 39, 40]. Nassour et al. [16] analyzed the data in NCDB and found that RDP was superior to ODP in OS, but there was no statistically significant difference in 1-, 3-, and 5-year survival. However, the single-center report by Magistri et al. [40] did not find a difference in OS between the two.

Recommendation 10: For appropriately selected patients with pancreatic tail cancer, the oncological radical effect and long-term survival of RDP and ODP are comparable. Experienced units may select appropriate patients with pancreatic crest carcinoma to undergo RDP (level of evidence: low; Recommended intensity: strong).

11. Comparison of the perioperative safety of RDP and LDP

Raoof et al. [41] and Watson et al. [37] conducted a retrospective analysis of the case data of pancreatic corpo-caudal carcinoma in NCDB and found that the conversion laparotomy rate of RDP was lower than that of LDP, but there was no significant difference between the length of hospital stay and the 90-day mortality rate. Single-center retrospective analysis suggests that RDP may be performed slightly longer than LDP, but there is no statistically significant difference in intraoperative blood loss and postoperative pancreatic fistula incidence [42, 43].

Recommendation 11: The results of the existing studies suggest that the rate of conversion to laparotomy in RDP is lower than that in LDP. The choice between laparoscopic versus robotic procedures can be individualized based on the surgeon's experience and stage of the learning curve (level of evidence: low; Recommended Intensity: Average).

12. Radical tumor curative effect and long-term survival of RDP and LDP

Raoof et al. [41] conducted a retrospective analysis of pancreatic caudal carcinoma case data in NCDB and found that there were no significant differences between RDP and LDP in terms of R0 resection rate, number of lymph nodes obtained, duration of postoperative adjuvant chemotherapy, and rate of adjuvant chemotherapy. Watson et al. [37] analyzed the case data of pancreatic caudal carcinoma in NCDB, and the results were similar to those of Raoof et al. [41], except that RDP was superior to LDP in the number of lymph nodes obtained. Other single-center studies have reached similar conclusions [39,42, 43, 44, 45, 46]. In terms of long-term survival, with the exception of Watson et al. [37], which reported that RDP was superior to LDP, no other report found a statistically significant difference in OS and 1-, 2-, and 3-year survival [41, 42, 43,45, 46].

Recommendation 12: The radical tumor resection effect and long-term survival of RDP and LDP in the treatment of pancreatic circulus carcinoma are comparable, and minimally invasive surgery can be selected to carry out radical pancreatectomy for pancreatic circulocarcinoma according to the experience of the surgeon (level of evidence: low, recommended strength: fair).

13. The learning curve of minimally invasive techniques in pancreatic cancer surgery

There is not much literature on the MIDP learning curve. Lof et al. [47] showed that the incidence of serious postoperative complications decreased significantly after the completion of 30 cases of LDP, and the proportion of patients with pancreatic cancer and the proportion of patients with T3 and T4 stages during surgery gradually increased with the accumulation of experience and the learning curve. Shakir et al. [48] concluded that after the completion of 40 cases of RDP, there was a significant decrease in operative time and readmission rates. Napoli et al. [49] used a significant reduction in operation time as a marker of learning curve and found that the completion of 10 cases of RDP significantly reduced the operation time. In the study of Lee et al. [39], the learning curves of RDP and LDP were studied with the decrease in operation time and conversion laparotomy rate as the mark, and found that the operation time decreased significantly after the completion of 60 LDPs, but there was no significant difference in the conversion laparotomy rate, while there was no significant difference in the first 20 patients and the last 17 patients in the RDP group, suggesting that the learning curve of RDP was shorter.

Most researchers believe that the learning curve of LPD is 30~40 cases [50, 51, 52, 53]. Nagakawa et al. [52] concluded that 30 cases of LPD could enter a stable phase after completion, and the time of specimen resection and intraoperative blood loss were significantly reduced. Intraperitoneal fat accumulation, chronic pancreatitis, and lymph node dissection all increase specimen resection time and blood loss before entering a stable phase. Because patients with pancreatic cancer require lymph node dissection and are often accompanied by localized chronic inflammation, LPD in patients with pancreatic cancer should only be performed after the learning curve has been completed [53]. The learning curve has a significant impact on the perioperative safety of LPD. In the multicenter prospective randomized controlled study (LEOPARD-2) in the Netherlands, the 90-day mortality rate in the LPD group was much higher than that in the laparotomy group, which was discontinued by the ethics committee because the participants in the study only needed to have more than 20 cases of LPD experience, which was well below the learning curve of about 40 cases [54]. Some investigators have found that after the completion of 39 cases of LPD, the proportion of pancreatic head cancer and T3 and T4 tumors increased significantly, and the difficulty of surgery increased, resulting in no significant difference in the incidence of postoperative complications compared with 39 cases after the learning curve [53]. The results of a multi-center retrospective study in China show that the LPD learning curve is divided into two stages; The first phase, consistent with the rest of the literature, was approximately 40 cases, and then the complication rate did not decrease significantly as the difficulty of case selection increased, until 104 cases did not fully pass the learning curve [50]. The learning curve of RPD is shorter than that of LPD because the operation of the robotic system is more in line with the habit of laparotomy, but the learning curve of RPD reported in most of the literature is 30~40 cases [55, 56, 57, 58]. With the increasing maturity of laparoscopic and robotic-assisted radical pancreatic cancer surgery, the learning curve for second- and third-generation surgeons is expected to shorten under the guidance of first-generation surgeons performing this procedure [59].

Performing laparoscopic or robotic-assisted pancreatic cancer surgery inevitably carries the risk of switching to laparotomy. Results from a multicenter study in Europe suggest that risk factors for laparotomy in MIPD include a maximum tumor diameter of >4 cm, age > 75 years, laparoscopic-assisted surgery, and a low-volume medical center [60]. Pancreatic cancer in mid-MIDP < 1 cm from the root of the splenic vessels is a risk factor for laparotomy [47]. Patients should be carefully selected before the learning curve is passed, and cases with risk factors for conversion to laparotomy should be avoided.

Recommendation 13: Attempts at AJCC stage T3 or above or cases of pancreatic cancer with risk factors for switching laparotomy in vascular invasion should be avoided as much as possible until the learning curve is passed (level of evidence: low, strength of recommendation: strong).

14. Safety of minimally invasive surgery for pancreatic cancer after neoadjuvant therapy

Neoadjuvant therapy has become the treatment of choice for patients with borderline resectable and locally advanced pancreatic cancer. Neoadjuvant therapy has been shown to improve the rate of R0 resection, reduce lymph node metastasis, reduce nerve and vascular invasion, and prolong tumor-free survival [61]. However, the inflammatory response and tissue fibrosis associated with neoadjuvant therapy also make surgery more difficult and increase the incidence of surgery-related complications [13]. In the DIPLOMA study, neoadjuvant therapy for MIDP was 3 percent versus 10 percent in the ODP arm, suggesting that surgeons still prefer open surgery for neoadjuvant cases [36]. Nassour et al. [62] retrospectively analyzed the short- and long-term efficacy of patients with neoadjuvant chemotherapy for pancreatic cancer in NCDB who received RPD and OPD, respectively, and found that patients with RPD had a shorter hospital stay, a higher number of lymph nodes dissected, and a higher proportion of postoperative adjuvant chemotherapy, but the perioperative mortality rate and long-term survival rate were similar to those of the two.

Recommendation 14: Neoadjuvant therapy for pancreatic cancer is not a contraindication to minimally invasive pancreatic surgery. Clinicians with extensive experience in minimally invasive pancreatic surgery may choose to perform this type of minimally invasive surgery (level of evidence: low, strength recommended: fair).

15. Safety of minimally invasive surgery for pancreatic cancer with vasoresection

With the continuous improvement of surgical technology, the proportion of pancreatic cancer patients undergoing combined vascular resection has increased significantly. In the DIPLOMA study, vascularization was 6 percent in the MIDP group and 11 percent in the ODP group [36]. Minimally invasive radical pancreatic cancer surgery combined with vasculature is technically difficult and risky, and is related to the rate of conversion to laparotomy [13]. With the accumulation of experience in minimally invasive radical pancreatic cancer surgery, the complication rate of related surgeries may gradually decrease. As one of the earliest centers in the world to develop LPD, Kendrick's group reported no statistically significant difference in perioperative safety between the two groups in the controlled study of combined vascularized LPD versus OPD, but a higher proportion of complex vascular reconstruction in the OPD group than in the LPD group [63]. In 2018, Kuesters et al. [3] reported single-center data for pancreatic cancer surgery, and the proportion of combined vasorectomy in the LPD group was 40.3%, and the proportion of combined vasoresection in the LPD group was 42.8%, and there was no difference between the LPD group and the OPD group in terms of hospital stay and perioperative mortality rate except that the operation time was longer than that of the OPD group.

Recommendation 15: Minimally invasive radical pancreatic cancer surgery with combined vasculature is technically difficult and risky, and is recommended to be performed in a large pancreatic center with skilled minimally invasive pancreatic techniques (level of evidence: low, strength of recommendation: fair).

This consensus aims to provide reference and guidance for laparoscopic and robot-assisted surgery in the treatment of pancreatic cancer. In view of the complexity of the biological behavior of pancreatic cancer, laparoscopic, robot-assisted or laparotomy should be individualized according to the specific condition of the patient, combined with the equipment and conditions of the unit and the relevant experience of the surgical team. At the same time, patients and their families should be fully informed of the possible benefits and risks of laparoscopic or robot-assisted surgery before surgery, and the final surgical plan should be agreed upon under the premise of obtaining informed consent from patients and families. In view of the low level of evidence-based medical evidence available on laparoscopic and robotic-assisted surgery for pancreatic cancer, pancreatic centers are encouraged to collaborate on relevant prospective randomized controlled studies to provide stronger evidence-based medical evidence support for the development of relevant surgical techniques.

List of members of the Consensus Writing and Validation Committee: Zhao Yupei (Peking Union Medical College Hospital) Deputy Team Leader: Yu Xianjun (Fudan University Cancer Hospital), Wang Wei (Fudan University Cancer Hospital), Mu Yiping (Zhejiang Provincial People's Hospital) Team members (in alphabetical order of surname): Bai Xueli (The First Affiliated Hospital of Zhejiang University School of Medicine), Chen Rufu (Guangdong Provincial People's Hospital), Cheng Wei (Hunan Provincial People's Hospital), Deng Xiaxing (Ruijin Hospital Affiliated to Shanghai Jiao Tong University), Fu Deliang (Huashan Hospital, Fudan University), Hong Defei (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine), Huang Heguang (Union Hospital, Fujian Medical University), Jiang Kuirong (The First Affiliated Hospital of Nanjing Medical University), Jiang Chongyi (East China Hospital, Fudan University), Jin Gang (The First Affiliated Hospital of Naval Medical University), Li Jiangtao (The Second Affiliated Hospital of Zhejiang University School of Medicine), Li Jingdong (The Affiliated Hospital of North Sichuan Medical College), Li Shengping (Sun Yat-sen University Cancer Hospital), Chen Liu (Cancer Hospital Affiliated to Fudan University), Jianhua Liu (The Second Hospital of Hebei Medical University), Jun Liu (Shandong Provincial Hospital), Rong Liu (The First Medical Center of the General Hospital of the People's Liberation Army), Yahui Liu (The First Hospital of Jilin University), Bing Peng (West China Hospital, Sichuan University), Renyi Qin (Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology), Chenghao Shao (The Second Affiliated Hospital of Naval Medical University), Zhijian Tan (Guangdong Provincial Hospital of Traditional Chinese Medicine), Liguo Tian (Editorial Department of Chinese Journal of Practical Surgery), Huaizhi Wang (Chongqing Hospital, University of Chinese Academy of Sciences), Lei Wang (Qilu Hospital, Shandong University), Wenming Wu (Peking Union Medical College Hospital), Heshui Wu (Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology), Zheng Tong (The First Affiliated Hospital of Xi'an Jiaotong University), Xiaowu Xu (Cancer Hospital of Fudan University), Xiaoyu Yin (The First Affiliated Hospital of Sun Yat-sen University), Xiao Yu (Third Xiangya Hospital, Central South University), Yufeng Yuan (Zhongnan Hospital of Wuhan University), Yinmo Yang (First Hospital of Peking University), Zhu Chunfu (Changzhou Second People's Hospital), Zhang Taiping (Peking Union Medical College Hospital) Writing Expert: Jiang Chongyi

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