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Introduction
Laparoscopic pancreaticoduodenectomy (Lap PD) has been shown to have similar outcomes as the conventional open approach (Open PD), in selected patients. The cancer-specific outcomes in patients with periampullary malignancy have not been reported in sufficient numbers to allow conclusions. We report an unselected series of 53 patients who underwent Lap PD for periampullary malignancy and compare these to matched patients who underwent Open PD at our institution.
Methods
From February 2009 to October 2010, 109 pancreaticoduodenectomies were performed for periampullary malignancy. With approval from the institutional IRB, 53 patients underwent a total laparoscopic approach, without the use of hand-port or incision other than for specimen extraction. Exclusion criteria Lap PD included tumors > 4cm or vascular invasion determined by preoperative three phase CT scan. During the study period, 6 patients did not meet criteria established for Lap PD and are excluded from the analysis. Propensity score matching was used to examine the institutional database, and select patients for the control group based on Age, Sex, Ca 19-9 and key preoperative comorbidities. The institution practices a uniform approach to adjuvant chemotherapy for patients resected with intent to cure, with a goal benchmark of beginning of therapy 6 weeks following surgery. Perioperative outcomes were tracked for 90 days following surgery.
Results
Rates of pancreatic fistula, delayed gastric emptying and mortality were not different between patients who underwent Lap or Open PD. Estimated blood loss was less in the Lap PD group, and operative time was longer in the Lap PD group. Percentage of patients undergoing a margin negative resection was equivalent amongst the groups, and mean tumor size and percentage of regional lymph node metastasis were also not different. Significant differences were noted regarding the likelihood of beginning adjuvant therapy at 6 weeks. 87 % of patients in the Lap PD group achieved this benchmark, and only 53% in the open PD group. Lastly, patients undergoing open PD were more likely to be debilitated after surgery than those who underwent the minimally invasive approach.
Conclusions
This study is the first to compare a contemporary cohort of patients undergoing Lap PD and Open PD for cancer. Lap PD in this study was associated with less blood loss, longer operative time, equal rates of complications, and improved likelihood receiving adjuvant therapy in a timely manner following surgery. The benefits of minimal access surgery regarding faster recovery may allow patients with periampullary malignancy to receive timely adjuvant chemotherapy.
Perioperative and Cancer Specific Outcomes for Laparoscoic and Open Pancreaticoduodenectomy.

	Laparoscopic n = 53	Open n = 53	p Value
Estimated Blood Loss, ml.	369( 50 -1400)	964 (250 -1600)	<0.05
Operative Time, minutes	387 (245-689)	248 (157-512)	<0.05
Grade B/C Pancreatic Fistula *	11/53 (20)	13/53 (25)	NS
Delayed Gastric Emptying	2/53 (4)	1/53 (2)	NS
Mortality, No. (%)	2/53 (4)	1/53 (2)	NS
Tumor Size, mean mm.	3.2 (0.5 -4.0)	3.5 (1.0 -4.0)	NS
Margin Negative, R o resection No. (%)	45/53 (85)	41/53 (77)	NS
Regional Lymph Node Metastasis, No. ( %()	39/53 (75)	38/53 (72)	NS
% of patients beginning adjuvant therapy at 6 weeks	46/53 (87)	28/53 (53)	<0.05
Karnofsky Performance Status < 70 at 6 weeks.	1/53 (2)	18/53 (34)	<0.05

* Bassi et al, 2005.
Karnovsky performance status <70 - patient unable to work or cary on normal activites of daily living without assistance.