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World Journal of Gastroenterology Oct 2019Laparoscopy has been widely used in general surgical procedures, but total laparoscopic pancreaticoduodenectomy (TLPD) is still a complex and challenging surgery that is... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Laparoscopy has been widely used in general surgical procedures, but total laparoscopic pancreaticoduodenectomy (TLPD) is still a complex and challenging surgery that is only performed in a small number of patients at a few large academic medical centers. Although the safety and feasibility of TLPD have been established, few studies have compared it with open pancreaticoduodenectomy (OPD) with regard to perioperative and oncological outcomes. Therefore, we carried out a meta-analysis to evaluate whether TLPD is superior to OPD.
AIM
To compare the treatment outcomes of TLPD and OPD in order to assess the safety and feasibility of TLPD.
METHODS
We conducted a systematic search of studies comparing TLPD with OPD that were published in the PubMed, EMBASE, and Cochrane Library databases through December 31, 2018. The studies comparing TLPD and OPD with at least one of the outcomes we were interested in and with more than 10 cases in each group were included in this analysis. The Newcastle-Ottawa scale was used to assess the quality of the nonrandomized controlled trials and the Jadad scale was used to assess the randomized controlled trials. Intraoperative data, postoperative complications, and oncologic outcomes were evaluated. The meta-analysis was performed using Review Manager Software version 5.3. Random or fixed-effects meta-analyses were undertaken to measure the pooled estimates.
RESULTS
A total of 4790 articles were initially identified for our study. After screening, 4762 articles were excluded and 28 studies representing 39771 patients (3543 undergoing TLPD and 36228 undergoing OPD) were eventually included. Patients who underwent TLPD had less intraoperative blood loss [weighted mean difference (WMD) = -260.08 mL, 95% confidence interval (CI): (-336.02, -184.14) mL, < 0.00001], a lower blood transfusion rate [odds ratio (OR) = 0.51, 95%CI: 0.36-0.72, = 0.0001], a lower perioperative overall morbidity (OR = 0.82, 95%CI: 0.73-0.92, = 0.0008), a lower wound infection rate (OR = 0.48, 95%CI: 0.34-0.67, < 0.0001), a lower pneumonia rate (OR = 0.72, 95%CI: 0.60-0.85, = 0.0002), a shorter duration of intensive care unit (ICU) stay [WMD = -0.28 d, 95%CI (-2.88, -1.29) d, < 0.00001] and a shorter length of hospital stay [WMD = -3.05 d, 95%CI (-3.93, -2.17), < 0.00001], a lower rate of discharge to a new facility (OR = 0.55, 95%CI: 0.39-0.78, = 0.0008), and a lower 30-d readmission rate (OR = 0.81, 95%CI: 0.68-0.95, = 0.10) than those who underwent OPD. In addition, the TLPD group had a higher R0 rate (OR = 1.28, 95%CI: 1.13-1.44, = 0.0001) and more lymph nodes harvested (WMD = 1.32, 95%CI: 0.57-2.06, = 0.0005) than the OPD group. However, the patients who underwent TLPD experienced a significantly longer operative time (WMD = 77.92 min, 95%CI: 40.89-114.95, < 0.0001) and had a smaller tumor size than those who underwent OPD [WMD = -0.32 cm, 95%CI: (-0.58, -0.07) cm, = 0.01]. There were no significant differences between the two groups in the major morbidity, postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, bile leak, gastroenteric anastomosis fistula, intra-abdominal abscess, bowel obstruction, fluid collection, reoperation, ICU admission, or 30-d and 90-d mortality rates. For malignant tumors, the 1-, 2-, 3-, 4- and 5-year overall survival rates were not significantly different between the two groups.
CONCLUSION
This meta-analysis indicates that TLPD is safe and feasible, and may be a desirable alternative to OPD, although a longer operative time is needed and only smaller tumors can be treated.
Topics: Blood Transfusion; Clinical Trials as Topic; Disease-Free Survival; Feasibility Studies; Hospital Mortality; Humans; Laparoscopy; Neoplasm Recurrence, Local; Operative Time; Pancreas; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Tumor Burden
PubMed: 31602170
DOI: 10.3748/wjg.v25.i37.5711 -
Langenbeck's Archives of Surgery Sep 2022The learning curve of new surgical procedures has implications for the education, evaluation and subsequent adoption. There is currently no standardised surgical...
BACKGROUND
The learning curve of new surgical procedures has implications for the education, evaluation and subsequent adoption. There is currently no standardised surgical training for those willing to make their first attempts at minimally invasive pancreatic surgery. This study aims to ascertain the learning curve in minimally invasive pancreatic surgery.
METHODS
A systematic search of PubMed, Embase and Web of Science was performed up to March 2021. Studies investigating the number of cases needed to achieve author-declared competency in minimally invasive pancreatic surgery were included.
RESULTS
In total, 31 original studies fulfilled the inclusion criteria with 2682 patient outcomes being analysed. From these studies, the median learning curve for distal pancreatectomy was reported to have been achieved in 17 cases (10-30) and 23.5 cases (7-40) for laparoscopic and robotic approach respectively. The median learning curve for pancreaticoduodenectomy was reported to have been achieved at 30 cases (4-60) and 36.5 cases (20-80) for a laparoscopic and robotic approach respectively. Mean operative times and estimated blood loss improved in all four surgical procedural groups. Heterogeneity was demonstrated when factoring in the level of surgeon's experience and patient's demographic.
CONCLUSIONS
There is currently no gold standard in the evaluation of a learning curve. As a result, derivations are difficult to utilise clinically. Existing literature can serve as a guide for current trainees. More work needs to be done to standardise learning curve assessment in a patient-centred manner.
Topics: Humans; Laparoscopy; Learning Curve; Minimally Invasive Surgical Procedures; Pancreas; Pancreatectomy; Pancreaticoduodenectomy; Robotic Surgical Procedures
PubMed: 35278112
DOI: 10.1007/s00423-022-02470-3 -
HPB : the Official Journal of the... Mar 2020Hypovolemic phlebotomy (HP) is a novel intervention that involves intraoperative removal of whole blood (7-10 mL/kg) without volume replacement. The subsequent central... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Hypovolemic phlebotomy (HP) is a novel intervention that involves intraoperative removal of whole blood (7-10 mL/kg) without volume replacement. The subsequent central venous pressure (CVP) reduction is hypothesized to decrease blood loss and the need for blood transfusion. The objective was to conduct a systematic assessment of the safety and efficacy of HP on blood loss and transfusion in the liver surgery literature.
METHODS
MEDLINE, EMBASE, and Cochrane Library databases were searched. Outcomes of interest included blood loss, allogenic red blood cell transfusion, postoperative adverse events, and CVP change. A qualitative synthesis and meta-analysis were performed as appropriate.
RESULTS
Four cohort studies, one case series, and three randomized controlled trials involving 2255 patients were included. Meta-analysis of studies involving liver resections for any indication (n = 6) found no difference in transfusion (OR 0.38, p = 0.12) or incidence of adverse events with HP compared to non-use. Pooling of studies involving liver resections for an underlying pathology (n = 4) revealed HP was associated with significant reduction in transfusion (OR 0.25, p = 0.03) but no differences in blood loss (-173 mL, p = 0.17).
CONCLUSION
This review suggests HP is safe and associated with decreased transfusion in patients undergoing liver surgery. It supports further investigation.
Topics: Blood Loss, Surgical; Blood Transfusion; Hepatectomy; Humans; Hypovolemia; Phlebotomy; Treatment Outcome
PubMed: 31734240
DOI: 10.1016/j.hpb.2019.10.001 -
Annals of the Royal College of Surgeons... Nov 2020Evidence suggests that midline incisions should be closed with the small-bite technique to reduce IH formation. No recommendations exist for the closure of transverse... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Evidence suggests that midline incisions should be closed with the small-bite technique to reduce IH formation. No recommendations exist for the closure of transverse incisions used in hepatobiliary surgery. This work systematically summarises rates of IH formation and associated technical factors for these transverse incisions.
METHODS
A systematic search was undertaken. Studies describing the incidence of IH were included. Incisions were classified as transverse (two incision types) or hybrid (transverse with midline extension, comprising five incision types). The primary outcome measure was the pooled proportion of IH. Subgroup analysis based on minimum follow-up of two years and a priori definition of IH with clinical and radiological diagnosis was undertaken.
FINDINGS
Thirteen studies were identified and included 5,427 patients; 1,427 patients (26.3%) underwent surgery for benign conditions, 3,465 (63.8%) for malignancy and 535 (9.9%) for conditions that were not stated or classified as 'other'. The pooled incidence of IH was 6.0% (2.0-10.0%) at a weighted mean follow-up of 17.5 months in the transverse group, compared with 15.0% (11.0-19.0%) at a weighted mean follow-up of 42.0 months in the hybrid group ( = 0.045). Subgroup analysis did not demonstrate a statistical difference in IH formation between the hybrid versus transverse groups.
CONCLUSION
Owing to the limitations in study design and heterogeneity, there is limited evidence to guide incision choice and methods of closure in hepatopancreatobiliary surgery. There is an urgent need for a high-quality prospective cohort study to understand the techniques used and their outcomes, to inform future research.
Topics: Biliary Tract Surgical Procedures; Cholecystectomy; Digestive System Diseases; Humans; Incisional Hernia; Liver; Liver Transplantation
PubMed: 32808799
DOI: 10.1308/rcsann.2020.0163 -
Canadian Journal of Surgery. Journal... Mar 2021Portal vein arterialization (PVA) is a possible option when hepatic artery reconstruction is impossible during liver resection. The aim of this study was to review the...
BACKGROUND
Portal vein arterialization (PVA) is a possible option when hepatic artery reconstruction is impossible during liver resection. The aim of this study was to review the literature on the clinical application of PVA in hepatopancreatobiliary (HPB) surgery.
METHODS
We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched the PubMed, Embase and Web of Science databases until December 2019. Experimental (animal) studies, review articles and letters were excluded.
RESULTS
Twenty studies involving 57 patients were included. Cholangiocarcinoma was the most common indication for surgery (40 patients [74%]). An end-to-side anastomosis between a celiac trunk branch and the portal vein was the main PVA technique (35 patients [59%]). Portal hypertension was the most common longterm complication (12 patients [21%] after a mean of 4.1 mo). The median followup period was 12 (range 1-87) months. The 1-, 3- and 5-year survival rates were 64%, 27% and 20%, respectively.
CONCLUSION
Portal vein arterialization can be considered as a rescue option to improve the outcome in patients with acute liver de-arterialization when arterial reconstruction is not possible. To prevent portal hypertension and liver injuries due to thrombosis or overarterialization, vessel calibre adjustment and timely closure of the anastomosis should be considered. Further prospective experimental and clinical studies are needed to investigate the potential of this procedure in patients whose liver is suddenly de-arterialized during HPB procedures.
Topics: Bile Ducts; Digestive System Surgical Procedures; Humans; Liver; Pancreas; Portal Vein
PubMed: 33739801
DOI: 10.1503/cjs.012419 -
Pancreas Oct 2022The management of incidentally discovered pancreatic cystic lesions (PCLs) with surveillance or resection often requires shared decision-making. Patients with cirrhosis... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The management of incidentally discovered pancreatic cystic lesions (PCLs) with surveillance or resection often requires shared decision-making. Patients with cirrhosis are more likely to have PCLs discovered due to increased imaging, and those undergoing liver transplantations (LTs) may be at increased risk of carcinogenesis due to immunosuppressive medications. Our study aimed to characterize the outcomes and risk of malignant progression of PCLs in post-LT patients.
METHODS
Multiple databases were searched for studies looking at PCLs in post-LT patients from inception until February 2022. Primary outcomes were the incidence of PCLs in LT recipients and progression to malignancy. Secondary outcomes included development of worrisome features, outcomes of surgical resection for progression, and change in size.
RESULTS
A total of 12 studies with 17,862 patients with 1411 PCLs were included. The pooled proportion of new PCL development in post-LT patients was 68% (95% confidence interval [CI], 42-86; I2 = 94%) over the follow-up of 3.7 (standard deviation, 1.5) years. The pooled progression of malignancy and worrisome features was 1% (95% CI, 0-2; I2 = 0%) and 4% (95% CI, 1-11; I2 = 89%), respectively.
CONCLUSIONS
Compared with nontransplant patients, incidental PCLs do not carry a higher risk of malignancy.
Topics: Humans; Pancreatic Cyst; Liver Transplantation; Pancreas; Pancreatic Neoplasms; Diagnostic Imaging
PubMed: 37078940
DOI: 10.1097/MPA.0000000000002155 -
Antioxidants (Basel, Switzerland) May 2024The limited supply and rising demand for kidney transplantation has led to the use of allografts more susceptible to ischemic reperfusion injury (IRI) and oxidative... (Review)
Review
The limited supply and rising demand for kidney transplantation has led to the use of allografts more susceptible to ischemic reperfusion injury (IRI) and oxidative stress to expand the donor pool. Organ preservation and procurement techniques, such as machine perfusion (MP) and normothermic regional perfusion (NRP), have been developed to preserve allograft function, though their long-term outcomes have been more challenging to investigate. We performed a systematic review and meta-analysis to examine the benefits of MP and NRP compared to traditional preservation techniques. PubMed (MEDLINE), Embase, Cochrane, and Scopus databases were queried, and of 13,794 articles identified, 54 manuscripts were included ( = 41 MP; = 13 NRP). MP decreased the rates of 12-month graft failure (OR 0.67; 95%CI 0.55, 0.80) and other perioperative outcomes such as delayed graft function (OR 0.65; 95%CI 0.54, 0.79), primary nonfunction (OR 0.63; 95%CI 0.44, 0.90), and hospital length of stay (15.5 days vs. 18.4 days) compared to static cold storage. NRP reduced the rates of acute rejection (OR 0.48; 95%CI 0.35, 0.67) compared to in situ perfusion. Overall, MP and NRP are effective techniques to mitigate IRI and play an important role in safely expanding the donor pool to satisfy the increasing demands of kidney transplantation.
PubMed: 38929081
DOI: 10.3390/antiox13060642 -
BJS Open May 2022
Topics: Colorectal Neoplasms; Humans; Liver Neoplasms; Review Literature as Topic
PubMed: 35598157
DOI: 10.1093/bjsopen/zrac051