A systematic review and network meta-analysis of different surgical approaches for pancreaticoduodenectomy

Abstract

Background: Minimally invasive pancreaticoduodenectomy (MIPD) is a demanding surgical procedure, thus explaining its slow expansion and limited popularity amongst Hepato-Pancreatico-Biliary (HPB) surgeons. However, three main advantages of robotic assisted pancreaticoduodenectomy (PD) including improved dexterity, 3D vision less surgical fatigue, may overcome some of the hurdles and ultimately lead to a wider adoption. This systematic review and network meta-analysis aims to evaluate the current literature on open and MIPD. Methods: A systematic literature search was conducted for studies reporting robotic, laparoscopic and open surgery for PD. Network meta-analysis of intraoperative (operating time, blood loss, transfusion rate), postoperative (overall and major complications, pancreatic fistula, delayed gastric emptying, length of hospital stay) and oncological outcomes (R0 resection, lymphadenectomy) were performed. Results: Sixty-one studies including 62,529 patients were included in the network meta-analysis, of which 3% (n = 2131) were totally robotic (TR) and 10% (n = 6514) were totally laparoscopic (TL). There were no significant differences between surgical techniques for major complications, overall and grade B/C fistula, biliary leak, mortality and R0 resections. Transfusion rates were significantly lower in TR compared to TL and open. Operative time for TR was longer compared with open and TL. Both TL and TR were associated with significantly lower rates of wound infections, pulmonary complications, shorter length of stay and higher lymph nodes examined when compared to open. TR was associated with significantly lower conversion rates than TL. Conclusion: In summary, this network meta-analysis highlights the variability in techniques within MIPD and compares other variations to the conventional open PD. Current evidence appears to demonstrate MIPD, both laparoscopic and robotic techniques are associated with improved rates of surgical site infections, pulmonary complications, and a shorter hospital stay, with no compromise in oncological outcomes for cancer resections.

Systematic review and updated network meta-analysis comparing open, laparoscopic, and robotic pancreaticoduodenectomy

“…Previous studies have showed that LapPD and RobPD seem to be equally safe and were associated with reduced morbidity, shorter hospital length of stay, and non-inferior oncologic outcomes when compared to OpenPD [9][10][11][12][13][14]. The purpose of this network meta-analysis is to provide an updated evidence comparing short-term surgical and oncologic outcomes within pure OpenPD, LapPD, and RobPD.…”

Current Status of Laparoscopic and Robotic Pancreatic Surgery and Its Adoption in Singapore

“…Despite the theoretical and potential advantages that robotic surgery offers, its widespread use is limited by its high cost that has curtailed accessibility to the robotic platform. 8 Globally, only a few centres 4,15,31 have reported their experiences with RPS. The high cost of acquiring and maintaining this platform has meant that few surgeons from around the world have regular access to this technology for training purposes.…”

“…11 Compared to the open approach, LPS is reported to provide the added benefits of smaller incisions with better cosmetic results, lower level of postoperative pain and estimated blood loss, shorter hospital stay and recovery time with equivalent morbidity and overall mortality rate. [12][13][14][15][16][17][18] It is, however, important to emphasise that most of the evidence that supported the use of LPS is limited to retrospective case-control studies, [12][13][14][15][16][17][18] and only 4 randomised controlled trials (RCT) had been performed to date. [19][20][21][22] Despite the clinical advantages offered by LPS, the major obstacle to its widespread adoption is the technically demanding nature of the procedure and its steep learning curve.…”

Prognostic Biomarkers for Pancreatic Ductal Adenocarcinoma: An Umbrella Review

“…To raise the rate of survival in PDAC patients, more financial costs have been made around the world ( 7 , 8 ). Currently, surgical treatment is still the only radical therapy for PDAC ( 9 , 10 ). Although adjuvant chemotherapy may prolong the survival of PDAC patients, the prognosis of PDAC patients remains poor due to the lack of early diagnostic methods and accurate recurrence and prognostic biomarkers ( 11 – 13 ).…”