{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T14:08:33Z","timestamp":1786975713653,"version":"build-2736575974"},"reference-count":24,"publisher":"American Medical Association (AMA)","issue":"7","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Surg"],"published-print":{"date-parts":[[2026,7,1]]},"abstract":"\n Importance<\/jats:title>\n Minimally invasive pancreatoduodenectomy (MIPD) aims to improve postoperative recovery compared with open pancreatoduodenectomy (OPD). However, it is unclear whether the benefits of MIPD extend beyond the initial hospital stay.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To assess postoperative recovery after hospital discharge\u2014using activity tracking\u2014in patients with upfront resectable neoplasm in the pancreatic head or periampullary region, comparing MIPD with OPD.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n The patient-blinded DIPLOMA-2 randomized clinical trial was conducted between 2022 and 2023. This was an international, multicenter trial in 14 high-volume centers in 6 European countries. Included in the analysis were patients with suspected or proven upfront resectable neoplasm (ie, without vascular contact) in the pancreatic head or periampullary region. Study data were analyzed from January 2024 to January 2025.<\/jats:p>\n <\/jats:sec>\n \n Interventions<\/jats:title>\n Patients were randomly assigned to undergo MIPD or OPD (2:1 ratio). Patients wore an activity tracker (Fitbit Inspire 2 [Google]) from 2 weeks before surgery until 90 days thereafter. The tracker monitored step count, active minutes, and heart rate variability (HRV), wherein high HRV reflects parasympathetic activity and thus physiological relaxation and recovery.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n Postoperative physical activity in the first 90 postoperative days.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n A total of 288 patients (mean [SD] age, 68.3 [9.9] years; 168 male [58.3%]) were included in this analysis. Activity tracker data were available from 236 of 288 patients (82%; 155 in the MIPD and 81 in the OPD groups). On postoperative day 30, patients in the MIPD group averaged 659 more steps daily (95% CI, 79-1240 steps;\n P<\/jats:italic>\n \u2009=\u2009.03), had 22 more active minutes daily (95% CI, 3-40 minutes;\n P<\/jats:italic>\n \u2009=\u2009.03), and had a 9-millisecond higher HRV (95% CI, 2-15 milliseconds;\n P<\/jats:italic>\n \u2009=\u2009.006), compared with the OPD group. On postoperative day 90, step count and active minutes were comparable between groups, but HRV remained higher in the MIPD group. Patients after MIPD had a significantly higher step count between postoperative day 16 and 39 and more active minutes between day 14 and 37.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this randomized clinical trial, activity tracking up to 90 days revealed increased physical activity up to 5 weeks after MIPD and less physiological stress up to 3 months, as compared with OPD. Future studies should confirm whether these relatively modest benefits persist in other settings, such as lower-volume centers.<\/jats:p>\n <\/jats:sec>\n \n Trial Registration<\/jats:title>\n \n ISRCTN.org Identifier:\n ISRCTN27483786<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamasurg.2026.1503","type":"journal-article","created":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T15:30:25Z","timestamp":1779291025000},"page":"682","source":"Crossref","is-referenced-by-count":4,"title":["Activity and Physiological Stress Within 90 Days After Minimally Invasive and Open Pancreatoduodenectomy"],"prefix":"10.1001","volume":"161","author":[{"given":"Caro L.","family":"Bruna","sequence":"first","affiliation":[{"name":"Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands"},{"name":"Cancer Center Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anouk M. L. H.","family":"Emmen","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands"},{"name":"Cancer Center Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nine","family":"de Graaf","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands"},{"name":"Cancer Center Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marco","family":"Ramera","sequence":"additional","affiliation":[{"name":"Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy"},{"name":"Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jony","family":"van Hilst","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands"},{"name":"Cancer Center Amsterdam, the Netherlands"},{"name":"Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bergthor","family":"Bj\u00f6rnsson","sequence":"additional","affiliation":[{"name":"Department of Surgery in Link\u00f6ping and Department of Biomedical and Clinical Sciences, Link\u00f6ping University, Link\u00f6ping, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ugo","family":"Boggi","sequence":"additional","affiliation":[{"name":"Department of Surgery, Universit\u00e1 di Pisa, Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olivier R.","family":"Busch","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands"},{"name":"Cancer Center Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Freek","family":"Daams","sequence":"additional","affiliation":[{"name":"Cancer Center Amsterdam, the Netherlands"},{"name":"Amsterdam UMC, Location Vrije Universiteit, Department of Surgery, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mathieu","family":"D\u2019Hondt","sequence":"additional","affiliation":[{"name":"Department of Digestive and Hepatobiliary\/Pancreatic Surgery, Groeninge Hospital Kortrijk, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Ferrari","sequence":"additional","affiliation":[{"name":"Department of Surgery, Niguarda Ca\u2019Granda Hospital, Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastiaan","family":"Festen","sequence":"additional","affiliation":[{"name":"Cancer Center Amsterdam, the Netherlands"},{"name":"Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Geert","family":"Kazemier","sequence":"additional","affiliation":[{"name":"Cancer Center Amsterdam, the Netherlands"},{"name":"Amsterdam UMC, Location Vrije Universiteit, Department of Surgery, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martina","family":"Guerra","sequence":"additional","affiliation":[{"name":"Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ignace H.","family":"de Hingh","sequence":"additional","affiliation":[{"name":"Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benedetto","family":"Ielpo","sequence":"additional","affiliation":[{"name":"Department of Surgery, Hospital Del Mar, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tobias","family":"Keck","sequence":"additional","affiliation":[{"name":"Department of Surgery, UKSH Campus L\u00fcbeck, L\u00fcbeck, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bas Groot","family":"Koerkamp","sequence":"additional","affiliation":[{"name":"Erasmus MC Cancer Institute, Department of Surgery, University Medical Center Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C. A. Puck","family":"Klok","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daan J.","family":"Lips","sequence":"additional","affiliation":[{"name":"Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Misha D. P.","family":"Luyer","sequence":"additional","affiliation":[{"name":"Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J. Sven D.","family":"Mieog","sequence":"additional","affiliation":[{"name":"Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Morelli","sequence":"additional","affiliation":[{"name":"General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Quintus","family":"Molenaar","sequence":"additional","affiliation":[{"name":"Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands"},{"name":"Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roeland F.","family":"de Wilde","sequence":"additional","affiliation":[{"name":"Erasmus MC Cancer Institute, Department of Surgery, University Medical Center Rotterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahsoem","family":"Ali","sequence":"additional","affiliation":[{"name":"Cancer Center Amsterdam, the Netherlands"},{"name":"Amsterdam UMC, Location Vrije Universiteit, Department of Surgery, Amsterdam, the Netherlands"},{"name":"Amsterdam UMC, Location Vrije Universiteit, Department of Epidemiology and Data Science, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clarissa","family":"Ferrari","sequence":"additional","affiliation":[{"name":"Research and Clinical Trials Unit, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johannes","family":"Berkhof","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Location Vrije Universiteit, Department of Epidemiology and Data Science, Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrick","family":"Maisonneuve","sequence":"additional","affiliation":[{"name":"Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marc G.","family":"Besselink","sequence":"additional","affiliation":[{"name":"Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands"},{"name":"Cancer Center Amsterdam, the Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad","family":"Abu Hilal","sequence":"additional","affiliation":[{"name":"Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom"},{"name":"Department of Surgery, School of Medicine, University of Jordan, Amman, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anette","family":"J\u00f6nsson","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Ginesini","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Celine","family":"De Meyere","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michele","family":"Mazzola","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ulrich F","family":"Wellner","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annalisa","family":"Comandatore","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hjalmar","family":"Van Santvoort","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bert A","family":"Bonsing","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daphne HM","family":"Droogh","sequence":"additional","affiliation":[{"name":"for the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"5","key":"soi260024r1","doi-asserted-by":"publisher","first-page":"966","DOI":"10.1097\/SLA.0000000000003550","article-title":"500 Minimally invasive robotic pancreatoduodenectomies: 1 decade of optimizing performance.","volume":"273","author":"Zureikat","year":"2021","journal-title":"Ann Surg"},{"key":"soi260024r2","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1016\/j.yasu.2014.05.011","article-title":"The utility of the robot in pancreatic resections.","volume":"48","author":"Zureikat","year":"2014","journal-title":"Adv Surg"},{"issue":"6","key":"soi260024r3","doi-asserted-by":"publisher","first-page":"438","DOI":"10.1016\/S2468-1253(21)00054-6","article-title":"Laparoscopic vs open pancreatoduodenectomy for pancreatic or periampullary tumors: a multicenter, open-label, randomized controlled trial.","volume":"6","author":"Wang","year":"2021","journal-title":"Lancet Gastroenterol Hepatol"},{"issue":"5","key":"soi260024r4","doi-asserted-by":"publisher","first-page":"428","DOI":"10.1016\/S2468-1253(24)00005-0","article-title":"Effect of robotic vs open pancreaticoduodenectomy on postoperative length of hospital stay and complications for pancreatic head or periampullary tumors: a multicenter, open-label randomized controlled trial.","volume":"9","author":"Liu","year":"2024","journal-title":"Lancet Gastroenterol Hepatol"},{"issue":"3","key":"soi260024r5","doi-asserted-by":"publisher","first-page":"256","DOI":"10.1093\/bjs\/znab436","article-title":"Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis.","volume":"109","author":"Kuemmerli","year":"2022","journal-title":"Br J Surg"},{"issue":"1","key":"soi260024r6","doi-asserted-by":"publisher","first-page":"665","DOI":"10.1186\/s13063-023-07657-7","article-title":"Minimally invasive vs open pancreatoduodenectomy for pancreatic and periampullary neoplasm (DIPLOMA-2): study protocol for an international multicenter patient-blinded randomized controlled trial.","volume":"24","author":"de Graaf","year":"2023","journal-title":"Trials"},{"issue":"1","key":"soi260024r7","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1097\/SLA.0000000000002979","article-title":"Minimally Invasive vs Open Distal Pancreatectomy (LEOPARD): a multicenter patient-blinded randomized controlled trial.","volume":"269","author":"de Rooij","year":"2019","journal-title":"Ann Surg"},{"issue":"5","key":"soi260024r8","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1002\/bjs.10438","article-title":"Randomized clinical trial of open vs laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery program (ORANGE II study).","volume":"104","author":"Wong-Lun-Hing","year":"2017","journal-title":"Br J Surg"},{"issue":"2","key":"soi260024r9","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1016\/j.pan.2015.01.002","article-title":"Implementation of enhanced recovery program for laparoscopic distal pancreatectomy: feasibility, safety and cost analysis.","volume":"15","author":"Richardson","year":"2015","journal-title":"Pancreatology"},{"issue":"1","key":"soi260024r10","doi-asserted-by":"publisher","first-page":"58","DOI":"10.1016\/j.pan.2012.11.312","article-title":"Implementation of enhanced recovery program after pancreatoduodenectomy: a single-center UK pilot study.","volume":"13","author":"Abu Hilal","year":"2013","journal-title":"Pancreatology"},{"key":"soi260024r11","doi-asserted-by":"publisher","first-page":"159","DOI":"10.1186\/s12966-015-0314-1","article-title":"Systematic review of the validity and reliability of consumer-wearable activity trackers.","volume":"12","author":"Evenson","year":"2015","journal-title":"Int J Behav Nutr Phys Act"},{"key":"soi260024r12","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1200\/CCI.17.00152","article-title":"Feasibility of wearable physical activity monitors in patients with cancer.","volume":"2","author":"Gupta","year":"2018","journal-title":"JCO Clin Cancer Inform"},{"issue":"12","key":"soi260024r13","doi-asserted-by":"publisher","DOI":"10.1056\/EVIDoa2500045","article-title":"Minimally invasive vs open pancreatoduodenectomy for resectable neoplasms.","volume":"4","author":"de Graaf","year":"2025","journal-title":"NEJM Evid"},{"key":"soi260024r14","doi-asserted-by":"publisher","first-page":"c332","DOI":"10.1136\/bmj.c332","article-title":"CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials.","volume":"340","author":"Schulz","year":"2010","journal-title":"BMJ"},{"key":"soi260024r17","doi-asserted-by":"publisher","DOI":"10.1016\/j.lanepe.2024.100864","article-title":"Robotic versus open partial pancreatoduodenectomy (EUROPA): a randomized controlled stage 2b trial.","volume":"39","author":"Klotz","year":"2024","journal-title":"Lancet Reg Health Eur"},{"issue":"6","key":"soi260024r18","doi-asserted-by":"publisher","first-page":"882","DOI":"10.1016\/j.hlc.2020.09.936","article-title":"The effect of minimally invasive surgery and sternotomy on physical activity and quality of life.","volume":"30","author":"Moscarelli","year":"2021","journal-title":"Heart Lung Circ"},{"issue":"1","key":"soi260024r19","doi-asserted-by":"publisher","first-page":"404","DOI":"10.1186\/s12885-025-13778-w","article-title":"Preoperative heart rate variability as a predictor of postoperative pneumonia and lung function recovery in surgical lung cancer patients: a prospective observed study.","volume":"25","author":"Lai","year":"2025","journal-title":"BMC Cancer"},{"issue":"1","key":"soi260024r20","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1056\/NEJMoa2502760","article-title":"Structured exercise after adjuvant chemotherapy for colon cancer.","volume":"393","author":"Courneya","year":"2025","journal-title":"N Engl J Med"},{"key":"soi260024r21","doi-asserted-by":"publisher","DOI":"10.2196\/42815","article-title":"Fitbit data to assess functional capacity in patients before elective surgery: pilot prospective observational study.","volume":"25","author":"Angelucci","year":"2023","journal-title":"J Med Internet Res"},{"issue":"1","key":"soi260024r22","doi-asserted-by":"publisher","first-page":"288","DOI":"10.1186\/s12891-019-2663-4","article-title":"The role of wearable devices and objective gait analysis for the assessment and monitoring of patients with lumbar spinal stenosis: systematic review.","volume":"20","author":"Chakravorty","year":"2019","journal-title":"BMC Musculoskelet Disord"},{"issue":"5","key":"soi260024r23","doi-asserted-by":"publisher","first-page":"496","DOI":"10.1016\/j.jsams.2013.10.241","article-title":"Validation of the Fitbit One activity monitor device during treadmill walking.","volume":"17","author":"Takacs","year":"2014","journal-title":"J Sci Med Sport"},{"key":"soi260024r24","doi-asserted-by":"publisher","first-page":"138","DOI":"10.1016\/j.ijcard.2015.03.038","article-title":"Fitbit: an accurate and reliable device for wireless physical activity tracking.","volume":"185","author":"Diaz","year":"2015","journal-title":"Int J Cardiol"},{"key":"soi260024r15","unstructured":"Fitabase. Home page. Accessed January 26, 2024. https:\/\/www.fitabase.com"},{"key":"soi260024r16","unstructured":"Castor Electronic Data Capture. Home page. Accessed January 26, 2024. https:\/\/www.castoredc.com"}],"container-title":["JAMA Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/articlepdf\/2849213\/jamasurgery_bruna_2026_oi_260024_1782745011.75486.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T15:00:43Z","timestamp":1783522843000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/fullarticle\/2849213"}},"subtitle":["A Predefined Analysis of the DIPLOMA-2 Randomized Clinical Trial"],"short-title":[],"issued":{"date-parts":[[2026,7,1]]},"references-count":24,"journal-issue":{"issue":"7","published-print":{"date-parts":[[2026,7,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamasurg.2026.1503","relation":{},"ISSN":["2168-6254"],"issn-type":[{"value":"2168-6254","type":"print"}],"subject":[],"published":{"date-parts":[[2026,7,1]]}}}