Highlight
The recent multicenter randomized DIPLOMA trial establishes that minimally invasive left pancreatectomy for patients with resectable pancreatic ductal adenocarcinoma in the body and tail yields equivalent overall survival and disease-free survival compared to open surgery. Both approaches deliver similar rates of adjuvant therapy administration and timing, reinforcing the long-term oncologic safety of minimally invasive approaches when adhering to rigorous surgical principles.
Study Background
Pancreatic ductal adenocarcinoma (PDAC), particularly when located in the body and tail of the pancreas, presents a significant surgical challenge with high morbidity and mortality. The standard curative approach for resectable tumors in these regions is left pancreatectomy combined with splenectomy. While open surgery remains the traditional method, minimally invasive surgery (MIS), including laparoscopic and robotic approaches, has been gaining traction due to benefits such as reduced postoperative pain, shorter hospitalization, and quicker recovery.
Although early evidence, including the preliminary results from the DIPLOMA trial, suggested that MIS could achieve comparable R0 resection rates to open surgery for pancreatic cancer, concerns lingered regarding its long-term oncologic safety. Given the aggressiveness of pancreatic cancer and the critical importance of surgical quality, confirming survival equivalence over extended follow-up is essential before broadly endorsing MIS as a standard option.
Study Design
The DIPLOMA trial was a multicenter, randomized noninferiority study involving 258 patients diagnosed with upfront resectable PDAC in the body or tail of the pancreas. Participants were randomized to undergo either minimally invasive left pancreatectomy (n=131) or open left pancreatectomy (n=127).
The surgical techniques were standardized to ensure oncologic rigor: the open surgery arm utilized a radical antegrade modular pancreatosplenectomy, and the minimally invasive arm employed a radical “no-touch” technique. The minimally invasive group included both laparoscopic and robot-assisted surgeries, reflecting contemporary surgical practice.
The primary endpoint was overall survival analyzed on an intention-to-treat basis. Secondary endpoints included disease-free survival, rates and timing of adjuvant therapy initiation, and cancer recurrence patterns. The median follow-up duration was 38 months, providing robust longitudinal data.
Key Findings
The study demonstrated no significant difference in median overall survival between the groups: 32 months for minimally invasive surgery versus 34 months for open surgery (hazard ratio [HR], 1.02; P = .92). Survival rates at 1 and 3 years were also similar—79% vs 73% at 1 year and 46% vs 50% at 3 years for minimally invasive and open surgery, respectively.
Disease-free survival showed comparable results with median durations of 21 months for the minimally invasive group and 17 months for open surgery (HR, 0.96; P = .81).
Importantly, adjuvant chemotherapy administration rates were nearly identical (70% in minimally invasive surgery vs 72% in open surgery), with no difference in median time to initiation (59 vs 56 days). This underscores that the surgical approach did not delay essential postoperative oncologic treatment.
Post hoc subgroup analyses revealed the consistency of these survival outcomes across important clinical variables, including patient body mass index, tumor size and location, multivisceral involvement, and receipt of neoadjuvant therapy. These findings support the generalizability of the results to a broad patient population eligible for upfront surgery.
Expert Commentary
The DIPLOMA investigators conclude that minimally invasive left pancreatectomy is oncologically safe for patients with resectable left-sided pancreatic cancer when conducted with strict oncologic principles. This consensus is echoed in an accompanying editorial by Drs. Adrian Diaz and Melissa E. Hogg, who highlight the balance surgeons must strike between adopting innovative techniques and safeguarding long-term outcomes.
The availability of minimally invasive platforms, including robotic surgery, offers enhanced visualization and precision, which, combined with meticulous surgical technique, can achieve results on par with traditional open procedures. However, these findings also emphasize that surgical expertise and adherence to established cancer resection standards remain paramount regardless of approach.
While the DIPLOMA trial offers high-level evidence, questions remain about patient selection criteria, feasibility in less experienced centers, and applicability in tumors requiring complex multivisceral resections beyond the scope of this trial.
Conclusion
The DIPLOMA trial robustly supports the long-term oncologic safety of minimally invasive left pancreatectomy for resectable pancreatic ductal adenocarcinoma in the body and tail of the pancreas. Comparable overall and disease-free survival, as well as similar delivery of adjuvant chemotherapy, confirm that when performed using standardized radical techniques, minimally invasive surgery is a viable alternative to open surgery.
This evidence should reassure surgeons and patients considering minimally invasive options and may encourage broader implementation where surgical expertise is available. Future research should explore optimization of patient selection, expansion to complex cases, and integration within multimodal treatment protocols to further improve outcomes in pancreatic cancer.
References
Bruna CL, van Hilst J, Korrel M, et al; European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS). Minimally Invasive vs Open Left Pancreatectomy for Resectable Pancreatic Cancer: Long-Term Results of the Randomized DIPLOMA Trial. JAMA Surg. 2025 Oct 8. doi:10.1001/jamasurg.2025.4054. Epub ahead of print. PMID: 41060640.
