Distal pancreatectomy in octogenarians: A comparative analysis of open, laparoscopic, and robotic approaches from an international multicenter cohort.

BACKGROUND: Evidence comparing surgical approaches for distal pancreatectomy in octogenarians remains limited. This study compared perioperative outcomes of open versus minimally invasive surgery and evaluated laparoscopic versus robotic techniques. METHODS: A multicenter retrospective study involving 39 international centers was conducted, including octogenarian patients who underwent distal pancreatectomy between 2012 and 2025. Open and minimally invasive approaches were compared using propensity score matching (PSM). A secondary PSM analysis compared laparoscopic and robotic procedures. Primary endpoints were severe postoperative complications (Clavien-Dindo ≥ III) and clinically relevant postoperative pancreatic fistula (CR-POPF). Secondary outcomes included operative time, blood loss, spleen preservation, conversion rate, length of stay, and 90-day mortality. RESULTS: After PSM (n = 304), minimally invasive surgery was associated with less intraoperative blood loss, lower overall morbidity burden, fewer clinically relevant post-pancreatectomy hemorrhages and respiratory complications, and shorter hospitalization compared with open surgery (median 7 vs 9 days, p = 0.009). In the minimally invasive subgroup (PSM n = 122), robotic distal pancreatectomy was associated with greater spleen preservation (36.0% vs 14.8%, p = 0.013), fewer conversions (3.3% vs 18.0%, p = 0.016), lower blood loss, and shorter hospital stay than laparoscopy (median 6 vs 8 days, p = 0.033). CONCLUSIONS: Minimally invasive distal pancreatectomy offers superior perioperative outcomes over open surgery in octogenarians. Robotic surgery provides additional advantages and may represent the optimal minimally invasive approach when performed in experienced centers.