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

Abstract

The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91–1.61 and RR = 0.78; 95%CrI 0.54–1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82–1.43 and RR = 0.87; 95%CrI 0.64–1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80–1.46 and RR = 0.93; 95%CrI 0.65–1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients’ outcomes.

Robot-assisted pancreatoduodenectomy with the da Vinci Xi: can the costs of advanced technology be offset by clinical advantages? A case-matched cost analysis versus open approach

“…Hence, in accordance with other data already reported in literature, the most relevant consequence of the better post-operative course after RPD positively impacting on costs was the significantly shorter LoS [4,26,27,33,34]. Indeed, despite the minimal differences in clinical outcomes between the two groups, the stay of the open group was meaningful 6 days longer, likewise or even better to data reported by some authors in series showing no differences in term of overall post-operative complications between OPD and RPD [35,36].…”

“…Nevertheless, in the last years, RAS has been increasingly diffused for different surgical procedures, including pancreatic surgery, mostly for distal pancreatectomy but also for PD. Considering the clinical outcomes, RPD represents a remarkable application of minimally invasive surgical technology, and some studies have shown favorable results if compared to the open approach [25][26][27]. Hence, the technical advantages of robotic systems should theoretically allow the expansion of the adoption of minimally invasive approach in the field of pancreatic surgery [28].…”

“…This is probably due to the well-known advantages of the minimally invasive approach, which is associated to a reduced tissue trauma, postoperative pain, pulmonary impairment, and systemic stress response [2,27,37]. In this regard, the main specific advantage of the robotic system is probably to allow to perform complex procedures such as PD without conversion to open surgery, and therefore to gain the benefits of the minimally invasive approach in all cases of the Xi-RPD-group [26]. Moreover, also the lower incidence of overall complication of the Xi-RPD-group, although not significantly different, may have partially contributed to the shorter LoS, in accordance with data reported in literature [27,34].…”

Equivalency of short-term perioperative outcomes after open, laparoscopic, and robotic ileal pouch anal anastomosis. Does procedure complexity override operative approach?

“…However, all of these studies were institutional series with small sample sizes. Corresponding findings have also been seen in other complex operations such as major hepatic resections [ 13 , 14 ], pancreatoduodenectomies [ 15 ], and esophagectomies, [ 16 ] where minimally invasive approaches, including robotic and laparoscopic surgery, were found to have similar perioperative outcomes compared to traditional open surgery.…”

Total Laparoscopic Pancreaticoduodenectomy with Left Posterior Superior Mesenteric Artery First-Approach and Plexus-Preserving Circumferential Lymphadenectomy: A Surgical Case Report (With Video)

“…And with the development of technology and minimally invasive tendency in medicine, minimally invasive pancreaticoduodenectomy, especially total laparoscopic pancreaticoduodenectomy (tLPD) is not out of this way. Recent systematic reviews showed that LPD was superior against open PD in aspects of inoperative blood transfusion, wound and pulmonary infection, and shorter hospital stays; and there are no differences of relevant postoperative pancreatic stula (POPF), severe complications, postoperative mortality, retrieved lymph nodes (LNs), and R0-resection rate [3,4]. However, to achieve the safety and effectiveness, they also recommended that LPD should be proceed by surgeons with expertise and through learning curve in high-volume centers [3,4].…”