Surgical site infection after open versus minimally invasive left pancreatectomy: a retrospective cohort study.

BACKGROUND

Surgical site infection (SSI) remains a common complication after left pancreatectomy (LP). Whether minimally invasive (MI) approaches reduce SSI risk compared with open surgery remains debated, and pancreas-related factors may play a central role in infection development.

METHODS

This retrospective cohort study included all consecutive patients undergoing LP between 2016 and 2024 at a high-volume pancreatic unit. SSI was defined according to Centers for Disease Control and Prevention criteria. Open and MI approaches were compared. Temporal trends before and after implementation of a tailored antibiotic prophylaxis stewardship (TAPS) program were evaluated. Multivariable logistic regression, propensity score matching, and exploratory multinomial analysis assessing the relationship between clinically relevant postoperative pancreatic fistula (BC-POPF) and organ space SSI (OS-SSI) were performed.

RESULTS

A total of 969 patients underwent LP, including 590 open (61%) and 379 MI (39%) procedures. Overall SSI occurred in 20% of patients and did not differ between approaches, including after matching. On multivariable analysis, TAPS was independently associated with reduced overall SSI (OR 0.46; 95% CI 0.31-0.67) and OS-SSI (OR 0.46; 95% CI 0.31-0.68), whereas MI surgery was independently protective only against superficial SSI (SI-SSI) (OR 0.22; 95% CI 0.06-0.78). Postoperative hyperamylasemia (POH) was the strongest predictor of SSI (OR 7.09; 95% CI 4.33-11.72). Exploratory multinomial analysis showed that TAPS reduced isolated OS-SSI and combined BC-POPF + OS-SSI phenotypes, but not isolated BC-POPF, suggesting biologically interconnected but distinct postoperative phenotypes.

CONCLUSIONS

The impact of MI surgery on SSI after LP appears selective rather than universal, predominantly affecting SI-SSI. In contrast, OS-SSI appear largely driven by pancreas-specific postoperative mechanisms independent of surgical access. TAPS was associated with reduced OS-SSI, whereas POH may represent an early marker of pancreas-related infectious morbidity.