Validating the ISGPS Complexity Score for Minimally Invasive Pancreatoduodenectomy: Annals of Surgery | July 2026

Introduction:

Minimally invasive pancreaticoduodenectomy (MIPD) is increasingly being adopted, but its technical complexity raises concerns regarding patient safety and surgical outcomes. To improve case selection and match procedural difficulty with surgeon expertise, the International Study Group for Pancreatic Surgery (ISGPS) recently developed a complexity grading system. This multicenter registry study externally validated the ISGPS grading system in real-world practice.

Why was this study needed?

. MIPD has a steep learning curve and variable outcomes across centers.

. Objective tools are needed to match case complexity with surgical expertise.

. The newly proposed ISGPS complexity grading system required external validation.

. Better patient selection could improve safety and reduce postoperative complications.

Results:

Using data from the international IGOMIPS registry, 426 minimally invasive pancreaticoduodenectomies were analyzed. The study demonstrated a progressive increase in severe postoperative complications with increasing ISGPS complexity grade, confirming the grading system's ability to discriminate surgical risk. A pancreatic duct diameter ≤3 mm emerged as the strongest independent predictor of major postoperative complications. Outcomes for low-complexity procedures were consistent across surgeons and centers, whereas more complex operations achieved better results in highly experienced centers. Less experienced centers also showed higher rates of intraoperative deviation from the planned procedure, including unplanned conversion to total pancreatectomy, highlighting the challenges of undertaking complex MIPD without sufficient expertise.

Clinical Impact:

These findings validate the ISGPS complexity grading system as a practical tool for patient selection, surgical planning, and referral. Aligning procedural complexity with surgeon and institutional experience may improve outcomes, support structured training pathways, and facilitate safer implementation of minimally invasive pancreatic surgery.

Bottom Line:

The ISGPS complexity grading system reliably predicts outcomes after minimally invasive pancreaticoduodenectomy and supports matching case complexity with surgeon and center expertise to enhance patient safety and surgical outcomes.