A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: It's time to randomize

doi:10.1016/j.surg.2014.06.081

Surgery

Volume 157, Issue 1, January 2015, Pages 45-55

https://doi.org/10.1016/j.surg.2014.06.081 Get rights and content

Background

Laparoscopic distal pancreatectomy is regarded as a feasible and safe surgical alternative to open distal pancreatectomy for lesions of the pancreatic tail and body. The aim of the present systematic review was to provide recommendations for clinical practice and research on the basis of surgical morbidity, such as pancreas fistula, delayed gastric empting, safety, and clinical significance of laparoscopic versus open distal pancreatectomy for malignant and nonmalignant diseases of the pancreas.

Methods

A systematic literature search (MEDLINE) was performed to identify all types of studies comparing laparoscopic distal pancreatectomy and open distal pancreatectomy. Random effects meta-analyses were calculated after critical appraisal of the included studies and presented as odds ratios or mean differences each with corresponding 95% confidence intervals.

Results

A total of 4,148 citations were retrieved initially; available data of 29 observational studies (3,701 patients overall) were included in the meta-analyses. Five systematic reviews on the same topic were found and critically appraised. Meta-analyses showed superiority of laparoscopic distal pancreatectomy in terms of blood loss, time to first oral intake, and hospital stay. All other parameters of operative morbidity and safety showed no difference. Data on oncologic radicality and effectiveness are limited.

Conclusion

Laparoscopic distal pancreatectomy seems to be a safe and effective alternative to open distal pancreatectomy. No more nonrandomized trials are needed within this context. A large, randomized trial is warranted and should focus on oncologic effectiveness, defined end points, and cost-effectiveness.

Section snippets

Methods

The reporting of this systematic review is in accordance with the PRISMA Statement²³ and the Downs and Black checklists for systematic reviews of nonrandomized studies.²⁴

Overview of existing systematic reviews

Five systematic reviews with meta-analysis were found and summarised (Table I). The largest, published by Sui et al in 2012,¹⁹ included 19 observational studies (1,935 patients). Overall, these systematic reviews reported superiority of LDP over ODP with regard to operation time,19, 21 blood loss,¹⁹ duration of hospital stay,18, 19, 20, 21 and overall morbidity.18, 19, 20 Mortality showed no difference in all available systematic reviews. Oncologic outcomes were assessed sparsely in these

Summary of findings and findings in context

In comparison with ODP as the historic gold standard for operative resection of lesions in the body and tail of the pancreas, LDP seems to be a safe and effective alternative in terms of operation time, blood loss, and perioperative mortality and morbidity, such as pancreatic fistula formation, fluid collections, postoperative bleeding, and wound infection. Moreover, duration of hospital stay and time to first oral intake was significantly decreased in the LDP group. Data on oncologic

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Cited by (214)

Meta-analysis of laparoscopic spleen-preserving distal pancreatectomy versus laparoscopic distal pancreatectomy with splenectomy: An insight into confounding by indication
2024, Surgeon
To evaluate comparative outcomes of laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic distal pancreatectomy with splenectomy (LDPS).
A systematic search of multiple electronic data sources and bibliographic reference lists were conducted. Comparative studies reporting outcomes of LSPDP and LDPS were considered followed by evaluation of the associated risk of bias according to ROBINS-I tool. Perioperative complications, clinically important postoperative pancreatic fistula (POPF), infectious complications, blood loss, conversion to open, operative time and duration of hospital stay were the investigated outcome parameters.
Nineteen studies were identified enrolling 3739 patients of whom 1860 patients underwent LSPDP and the remaining 1879 patients had LDPS. The patients in the LSPDP and LDPS groups were of comparable age (p = 0.73), gender (p = 0.59), and BMI (p = 0.07). However, the patient in the LDPS group had larger tumour size (p = 0.0004) and more malignant lesions (p = 0.02). LSPDP was associated with significantly lower POPF (OR:0.65, p = 0.02), blood loss (MD:-28.30, p = 0.001), and conversion to open (OR:0.48, p < 0.0001) compared to LDPS. Moreover, it was associated with significantly shorter procedure time (MD: −22.06, p = 0.0009) and length of hospital stay (MD: −0.75, p = 0.005). However, no significant differences were identified in overall perioperative (OR:0.89, p = 0.25) or infectious (OR:0.67, p = 0.05) complications between two groups.
LSPDP seems to be associated with lower POPF, bleeding and conversion to open compared to LDPS in patients with small-sized benign tumours. Moreover, it may be quicker and reduce hospital stay. Nevertheless, such advantages are of doubtful merit about large-sized or malignant tumours. The available evidence is subject to confounding by indication.
External validation of fistula risk scores for postoperative pancreatic fistula after distal pancreatectomy
2023, Surgery (United States)
Fistula risk scores such as distal fistula risk scores and DISPAIR have been recently developed to assess the risk of clinically relevant postoperative pancreatic fistula after distal pancreatectomy. This study aimed to validate these models externally using a large-scale Chinese cohort.
The study enrolled adult patients who underwent distal pancreatectomy at a high-volume single center between January 2011 and December 2021. The clinically relevant postoperative pancreatic fistula was defined as grade B/C, according to the 2016 International Study Group of Pancreatic Surgery. Model performance was evaluated using the area under the curve.
Among 653 eligible patients, 126 (19.3%) suffered from clinically relevant postoperative pancreatic fistulas. Independent predictors for clinically relevant postoperative pancreatic fistulas included body mass index, diabetes mellitus, pancreatic thickness at both neck and transection sites, main pancreatic duct diameter, and soft pancreas. Clinically relevant postoperative pancreatic fistula risk increased with increasing score severity. All 3 prediction models showed acceptable discrimination, with area under the curve values of preoperative distal fistula risk score at 0.723 (95% confidence interval 0.687–0.757), intraoperative distal fistula risk score at 0.737 (95% confidence interval 0.701–0.770), and DISPAIR at 0.721 (95% confidence interval 0.685–0.755). No significant differences were found among them.
Distal fistula risk scores and DISPAIR are useful tools for predicting clinically relevant postoperative pancreatic fistula after distal pancreatectomy, highlighting their importance in guiding surgical approach decisions and mitigating strategies against this complication in clinical practice.
Nationwide analysis of unplanned conversion during minimally invasive distal pancreatectomy for pancreatic adenocarcinoma
2023, HPB
Utilization of minimally-invasive distal pancreatectomy (MIDP) for pancreatic adenocarcinoma has increased. While unplanned conversion to an open procedure during MIDP is associated with inferior short-term outcomes, the long-term consequences of conversion have not been adequately examined.
Patients with pancreatic adenocarcinoma undergoing MIDP were selected from the National Cancer Database (2010-2015) and subdivided based on the occurrence of unplanned conversion. Post-operative outcomes and overall survival (OS) were examined. Conversion was additionally compared to a matched group of planned open resections.
Among 592 patients undergoing attempted MIDP, unplanned conversion occurred in 23.1%. Despite increased 90-day mortality among patients experiencing conversion, there was no difference in median OS between groups (25.0 vs 27.8 months, p = 0.095). For patients undergoing conversion, post-operative outcomes and long-term survival were similar when compared to a propensity-matched group of patients undergoing planned open resection. On multivariable analysis, treatment at an academic facility (OR 0.63) and a robotic approach (OR 0.50) were both significantly associated with completed MIDP.
Despite inferior post-operative outcomes compared to successful MIDP, unplanned conversion did not result in significantly reduced long term survival. MIDP can be attempted selectively but treatment at experienced centers via a robotic approach should be considered.
Comparison of Spleen-Preservation Versus Splenectomy in Minimally Invasive Distal Pancreatectomy
2023, Journal of Gastrointestinal Surgery
Spleen-preservation during minimally invasive distal pancreatectomy (MIDP) can be technically challenging and remains controversial. Our primary aim was to compare MIDP and splenectomy with spleen-preserving MIDP. Secondarily, we compared two spleen-preserving techniques.
Adults undergoing MIDP (2007–2021) were retrospectively included in this single-center study. Intraoperative and postoperative outcomes between spleen-preservation and splenectomy and between the two spleen-preserving techniques were compared using the Mann–Whitney U test for continuous data, and Fisher’s exact test for categorical data.
Of the 293 patients who underwent MIDP, preservation of the spleen was intended in 208 (71%) patients. Spleen-preservation was achieved in 174 patients (84%) via the Warshaw technique (130; 75%) or vessel-preservation (44; 25%). The spleen-preserving group had shorter length of stay (3 vs 4 days, p < 0.01), fewer conversions to open (1 vs 12, p < 0.01) and less blood loss (p < 0.01) compared to the splenectomy group. Operative (OR) times were comparable (229 vs 214 min, p = 0.67). Except for the operative time, which was longer for the Warshaw technique (245 vs 183 min, p = 0.01), no other differences between the two spleen-preserving techniques were found. At a median follow-up of 43 (IQR 18–79) months after spleen-preservation, only 2 (1.1%) patients had required splenectomy (1 partial splenectomy for infarct/abscess after Warshaw, 1 for variceal bleeding after vessel-preserving).
Spleen-preservation is not associated with increased risk of blood loss, longer hospital stay, conversion, nor lengthy OR times. Late splenectomy is very rarely required. Given the immune consequences of splenectomy, spleen-preservation should be strongly considered in MIDP.
The role of minimally invasive surgery in resectable distal pancreatic adenocarcinoma
2023, HPB
In distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), we hypothesize that minimally invasive DP (MIDP) carries short-term benefits over ODP (ODP) in the absence of postoperative pancreatic fistula (POPF).
NSQIP database was queried to select patients who underwent DP for PDAC with available report on POPF. The population was divided into No-POPF vs. POPF groups. In each group, propensity-score matching was applied to compare 30-day outcomes of ODP vs. MIDP.
There were 2,824 patients; 2,332 (82%) had No-POPF and 492 (21%) had POPF. In No-POPF patients, 921 pairs were matched between ODP and MIDP. MIDP patients had slightly longer operations (227 vs. 205 minutes; p < 0.001), but lower rates of surgical site complications (1% vs. 2.9%; p = 0.002), postoperative transfusion (7.1% vs. 11.0%; p = 0.003), overall morbidity (21.1% vs. 26.3%; p = 0.009), and one-day shorter median length of stay (LOS) (5 vs. 6 days; p = 0.001).
In the POPF group, 172 pairs were matched. There was no difference in morbidity, mortality, reoperation, LOS, and home discharge. Similar conclusions were drawn in the intention-to-treat and per-protocol analyses.
POPF is common following DP for PDAC. In the absence of POPF, MIDP is associated with fewer postoperative morbidities and shorter LOS.
Outcomes of patients with pancreatic cancer undergoing minimally invasive distal pancreatectomy
2023, Surgery (United States)

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^∗: Both authors contributed equally to this work.

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Liver/PancreasA systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: It's time to randomize

Background

Methods

Results

Conclusion

Section snippets

Methods

Overview of existing systematic reviews

Summary of findings and findings in context

J Gastrointest Surg

J Gastrointest Surg

J Gastrointest Surg

J Gastrointest Surg

Adv Surg

J Gastrointest Surg

Asian J Surg

HPB (Oxford)

Control Clin Trials

Asian J Surg

J Am Coll Surg

Surgery

HPB (Oxford)

J Gastrointest Surg

J Gastrointest Surg

J Gastrointest Surg

HPB (Oxford)

Hepatobiliary Pancreat Dis Int

Lancet

Surgery

Laparoscopic distal pancreatectomy for neuroendocrine tumors of the pancreas

Hepatogastroenterology

Laparoscopic cholecystectomy is the current “gold standard” for the treatment of gallstone disease

Ann Surg

Laparoscopic adrenalectomy: new gold standard

World J Surg

Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution

Arch Surg

Laparoscopic surgery combined with preservation of the spleen for distal pancreatic tumors

Surg Endosc

Technical aspects of left-sided pancreatic resection for cancer

Dig Surg

Update on laparoscopic pancreatectomy in 2010

Minerva Chir

Laparoscopic and open distal pancreatectomy: a comparison of outcomes

Am Surg

Laparoscopic vs open distal pancreatectomy: a single-institution comparative study

Arch Surg

Liver/Pancreas
A systematic review and meta-analysis of laparoscopic versus open distal pancreatectomy for benign and malignant lesions of the pancreas: It's time to randomize