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World Journal of Surgery Aug 2013In the past decade, Enhanced Recovery after Surgery (ERAS) protocols have been implemented in several fields of surgery. With these protocols, a faster recovery and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In the past decade, Enhanced Recovery after Surgery (ERAS) protocols have been implemented in several fields of surgery. With these protocols, a faster recovery and shorter hospital stay can be accomplished without an increase in morbidity or mortality. The purpose of this study was to review systematically the evidence for implementation of an ERAS protocol in pancreatic resections, with particular emphasis on pancreaticoduodenectomies (PDs).
METHODS
A systematic search was performed in Medline, Embase, Pubmed, CINAHL, and the Cochrane library for papers describing an ERAS program in adult patients undergoing elective pancreatic surgery published between January 1966 and December 2012. The primary outcome measure was postoperative length of stay. Secondary outcome measures were time to recovery of normal function, overall postoperative complication rates, readmissions, and mortality. Subsequently, a meta-analysis of outcome measures focusing on PD was conducted. This systematic review and meta-analysis was performed according to the PRISMA statement.
RESULTS
The literature search produced 248 potentially relevant papers. Of these, eight papers met the predefined inclusion criteria: five case-control studies, two retrospective studies, and one prospective study, describing a total of 1,558 patients. Only three of the studies reported data on discharge criteria and assessed time to recovery and return to normal function. Implementation of an ERAS protocol led in four of five comparative studies to a significant decrease in length of stay (reduction of 2-6 days in different studies). Meta-analysis of four studies focusing on PDs showed that there was a significant difference in complication rates in favor of the ERAS group (absolute risk difference 8.2 %, 95 % confidence interval (CI) 2.0-14.4, p = 0.008). Introduction of an ERAS protocol did not result in an increase in mortality or readmissions. Delayed gastric emptying and incidence of pancreatic fistula did not differ significantly between groups. All studies reporting on hospital costs showed a decrease after implementation of ERAS.
CONCLUSIONS
This systematic review suggests that using an ERAS protocol in pancreatic resections may help to shorten hospital length of stay without compromising morbidity and mortality. This seemed to apply to distal pancreatectomy, total pancreatectomy, and PD. Meta-analysis was performed for those studies focusing on PD and showed that there were no differences in readmission or mortality. Morbidity rates were significantly lower for patients managed according ERAS principles.
Topics: Humans; Outcome Assessment, Health Care; Pancreatectomy; Pancreaticoduodenectomy; Recovery of Function
PubMed: 23568250
DOI: 10.1007/s00268-013-2044-3 -
International Journal of Surgery... May 2018Laparoscopic pancreatic surgery (LPS) has been widely used in the treatment of benign and low-grade pancreatic diseases. It is necessary to expand the current knowledge... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Laparoscopic pancreatic surgery (LPS) has been widely used in the treatment of benign and low-grade pancreatic diseases. It is necessary to expand the current knowledge on the feasibility and safety of LPS for pancreatic ductal adenocarcinoma (PDAC) by systematic reviewing the published studies and analyzing them by meta-analysis.
METHODS
Original articles compared LPS with open pancreatic surgery (OPS) for PDAC, published from January 1994 to August 2017 were searched in medical databases. Postoperative pancreatic fistula (POPF), morbidity, mortality, operation time, blood loss, transfusion, hospital stay, retrieved lymph nodes (RLNs), and survival outcomes were compared.
RESULTS
Fourteen studies with a total of 13174 patients (1705 in LPS and 11469 in OPS) were included for the meta-analysis. LPS showed less morbidity (RR = 0.78, 95%CI: 0.66-0.92, P < .01), blood loss (WMD = -298.05 ml, 95% CI, -482.98∼-113.12 ml; P < .01), shorter hospital stay (WMD = -2.86, 95%CI, -3.85∼-1.87; P < .01), more RLNs (WMD = 1.47, 95%CI: 0.15-2.78; P = .03) and comparable POPF (RR = 1.12, 95%CI: 0.82-1.53, P = .50), operation time (WMD = 22.23 min; 95%CI: -19.56-64.01, P = .30), and 5-year overall survival (HR = 0.92, 95%CI: 0.80-1.06; P = .23) compared to OPS.
CONCLUSION
LPS can be performed safely in carefully selected patients with PADC and would improve the surgical outcomes. Considering the limitation of study design, the conclusions should be interpret cautiously and warrant to be confirmed by randomized controlled studies.
Topics: Blood Loss, Surgical; Blood Transfusion; Carcinoma, Pancreatic Ductal; Humans; Laparoscopy; Length of Stay; Operative Time; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications; Treatment Outcome
PubMed: 29337177
DOI: 10.1016/j.ijsu.2017.12.032 -
The British Journal of Surgery Dec 2019Surgeons have traditionally been reluctant to perform total pancreatectomy because of concerns for brittle diabetes and poor quality of life (QoL). Several recent...
BACKGROUND
Surgeons have traditionally been reluctant to perform total pancreatectomy because of concerns for brittle diabetes and poor quality of life (QoL). Several recent studies have suggested that outcomes following total pancreatectomy have improved, but a systematic review is lacking.
METHODS
A systematic review was undertaken of studies reporting on outcomes after total pancreatectomy for all indications, except chronic pancreatitis. PubMed, EMBASE (Ovid), and Cochrane Library were searched (2005-2018). Endpoints included functional outcome and QoL.
RESULTS
A total of 21 studies, including 1536 patients, fulfilled the eligibility criteria. During a median follow-up of 20·8 (range 1·5-96·0) months, 18·6 per cent (45 of 242 patients) were readmitted for endocrine-related morbidity, with associated mortality in 1·6 per cent (6 of 365 patients). No diabetes-related mortality was reported in studies including only patients treated after 2005. Symptoms related to exocrine insufficiency were reported by 43·5 per cent (143 of 329 patients) during a median follow-up of 15·9 (1·5-96·0) months. Overall QoL, reported by 102 patients with a median follow-up of 28·6 (6·0-66·0) months, using the EORTC QLQ-C30 questionnaire, showed a moderately reduced summary score of 76 per cent, compared with a general population score of 86 per cent (P = 0·004).
CONCLUSION
Overall QoL after total pancreatectomy is affected adversely, in particular by the considerable impact of diarrhoea that requires better treatment. There is also room for improvement in the management of diabetes after total pancreatectomy, particularly with regards to prevention of diabetes-related morbidity.
Topics: Humans; Pancreatectomy; Pancreatic Neoplasms; Postoperative Period; Quality of Life; Recovery of Function
PubMed: 31502658
DOI: 10.1002/bjs.11296 -
Annals of Surgery May 2015The true rate of new-onset diabetes (NODM) after distal pancreatectomy (DP) is not known. This systematic review was carried out to obtain exact percentages regarding... (Review)
Review
OBJECTIVE
The true rate of new-onset diabetes (NODM) after distal pancreatectomy (DP) is not known. This systematic review was carried out to obtain exact percentages regarding the incidence of NODM after DP for different indications.
BACKGROUND
Distal pancreatectomy is the standard procedure for removal of benign or (potentially) malignant lesions from the pancreatic body or tail and increasingly used for removal of often benign lesions. It is associated with low mortality rates, though postoperative diabetes remains a serious problem.
METHODS
Embase, PubMed, Medline, Web of Science, the Cochrane Library, and Google Scholar were searched for articles reporting incidence of NODM after DP. Methodological quality of the included studies was assessed by means of the Newcastle-Ottawa scale for cohort studies and the Moga scale for case series. Mean weighted overall percentages of NODM after DP for different indications were calculated with 95% confidence intervals (CI) and corresponding P values.
RESULTS
Twenty-six studies were included, comprising 1.731 patients undergoing DP. The average cumulative incidence of NODM after DP performed for chronic pancreatitis was 39% and for benign or (potentially) malignant lesions it was 14%. Comparing the proportions of these 2 groups showed a significant difference (95% CI: 0.351-0.434 and 0.110-0.172, respectively, P < 0.000). The average percentage of insulin-dependent diabetes among patients with NODM after DP was 77%.
CONCLUSIONS
This review is the largest of its kind to assess the cumulative incidence of NODM after DP and shows that NODM is a frequently occurring complication, with incidence depending on the preexisting disease and follow-up time. Because NODM can affect quality of life, patients undergoing DP should be preoperatively provided with this information as specific as possible.
Topics: Diabetes Mellitus; Diabetes Mellitus, Type 1; Humans; Incidence; Pancreatectomy; Pancreatic Diseases; Pancreatic Neoplasms; Pancreatitis, Chronic; Time Factors
PubMed: 24983994
DOI: 10.1097/SLA.0000000000000819 -
Journal of Hepato-biliary-pancreatic... Jan 2022Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other... (Review)
Review
BACKGROUND
Minimally invasive distal pancreatectomy (MIDP) was initially performed for benign tumors, but recently its indications have steadily broadened to encompass other conditions including pancreatic malignancies. Thorough anatomical knowledge is mandatory for precise surgery in the era of minimally invasive surgery. However, expert consensus regarding anatomical landmarks to facilitate the safe performance of MIDP is still lacking.
METHODS
A systematic literature search was performed using keywords to identify articles regarding the vascular anatomy and surgical approaches/techniques for MIDP.
RESULTS
All of the systematic reviews revealed that MIDP was not associated with an increase in postoperative complications. Moreover, most showed that MIDP resulted in less blood loss than open surgery. Regarding surgical approaches for MIDP, a standardized stepwise procedure improved surgical outcomes, including blood loss, operative time, and major complications. There are two approaches to the splenic vessels, superior and inferior; however, no study has ever directly compared them with respect to clinical outcomes. The morphology of the splenic artery affects the difficulty of approaching the artery's root. To select an appropriate dissecting layer when performing posterior resection, thorough knowledge of the anatomy of the fascia, left renal vein/artery, and left adrenal gland is needed.
CONCLUSIONS
In MIDP, a standardized approach and precise knowledge of anatomy facilitates safe surgery and has the advantage of a shorter learning curve. Anatomical features and landmarks are particularly important in cases of radical MIDP and splenic vessel preserving MIDP.
Topics: Humans; Laparoscopy; Minimally Invasive Surgical Procedures; Pancreatectomy; Pancreatic Neoplasms; Treatment Outcome
PubMed: 33527758
DOI: 10.1002/jhbp.902 -
Minerva Chirurgica Oct 2016Metastases to the pancreas from other primary tumors are increasingly recognized in clinical practice, but the real role of surgery remains unclear. This study was... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Metastases to the pancreas from other primary tumors are increasingly recognized in clinical practice, but the real role of surgery remains unclear. This study was designated to evaluate by a meta-analytic approach the results of surgical treatment for the most common malignancies metastasizing to the pancreas.
EVIDENCE ACQUISITION
MEDLINE, PubMED, Scopus and Web of Sciences were searched from January 2000 to December 2015. Studies reporting postoperative complications, postoperative mortality, disease-free and overall survival of patients undergoing resection for secondary tumours of the pancreas, were included.
EVIDENCE SYNTHESIS
Fourteen publication with 281 patients met the inclusion criteria and were subjected to the analysis. Operative morbidity and mortality were 34% and 1.3% respectively. Pancreatic resection for renal cell cancer showed better survival compared to other non-renal cell cancer (ratio of mean 1.83; 95% CI: 1.42-2.36, I2=74.52%, P<0.001). Disease-free interval was longer for metastatic renal cell carcinoma patients (mean difference 6.36, 95% CI: 3.803-8.912 years, I2=76:54%, P<0.001). A meta-regression was used to correlate the two endpoints and showed that a longer DFI is associated to a longer survival.
CONCLUSIONS
Pancreatic resection for metastasis should be reserved to patients in good health conditions, with isolated disease from renal cell cancer. For other types of tumor, surgery should be performed only in individual basis. There is a need of studies evaluating the role of chemotherapy in the neoadjuvant setting or the best sequential use of multimodality treatment (targeted therapy, radiotherapy, surgery, etc.).
Topics: Carcinoma, Renal Cell; Humans; Kidney Neoplasms; Pancreatectomy; Pancreatic Neoplasms; Survival Analysis; Treatment Outcome
PubMed: 27412234
DOI: No ID Found -
European Journal of Surgical Oncology :... Apr 2014Tumours rarely metastasise to the pancreas. While surgical resection of such metastases is believed to confer a survival benefit, there is limited data to support such... (Review)
Review
AIM
Tumours rarely metastasise to the pancreas. While surgical resection of such metastases is believed to confer a survival benefit, there is limited data to support such management. We present a systematic review of case series of pancreatic metastasectomy and analysis of survival outcomes.
METHODS
A literature search was performed using the PubMed and Cochrane databases and the reference lists of relevant articles, searching for sizeable case series of pancreatic metastasectomy with curative intent. Data extracted included basic demographics, histological primary tumour, presentation, operative management, complications and survival, while the MINORS index was used to assess study quality.
RESULTS
18 studies were found which met our inclusion criteria, involving 399 patients. Renal cell carcinoma (RCC) was the commonest malignancy metastasising to the pancreas, responsible for 62.6% of cases, followed by sarcoma (7.2%) and colorectal carcinoma (6.2%). While survival data was not uniformly reported, the median survival post-metastasectomy was 50.2 months, with a one-year survival of 86.81% and five-year survival of 50.02%. Median survival for RCC was 71.7 months with 70.4% five-year survival. Median survival was similar in patients with synchronous and metachronous pancreatic metastases, but patients with additional extrapancreatic metastases had a significantly shorter survival than patients with isolated pancreatic metastases (26 versus 45 months). Study quality was poor, with a median MINORS score of 10/16.
CONCLUSIONS
Within the limitations of a review of non-randomised case series, it would appear that pancreatic metastasectomy confers a survival benefit in selected patients. Better evidence is required, but may prove difficult to acquire.
Topics: Carcinoma; Carcinoma, Renal Cell; Colorectal Neoplasms; Humans; Kidney Neoplasms; Metastasectomy; Pancreatectomy; Pancreatic Neoplasms; Sarcoma; Survival Analysis; Treatment Outcome
PubMed: 24462547
DOI: 10.1016/j.ejso.2013.12.022 -
Updates in Surgery Jan 2023Robotic surgery has become a promising surgical method in minimally invasive pancreatic surgery due to its three-dimensional visualization, tremor filtration, motion... (Meta-Analysis)
Meta-Analysis
Robotic surgery has become a promising surgical method in minimally invasive pancreatic surgery due to its three-dimensional visualization, tremor filtration, motion scaling, and better ergonomics. Numerous studies have explored the benefits of RDP over LDP in terms of perioperative safety and feasibility, but no consensus has been achieved yet. This article aimed to evaluate the benefits and drawbacks of RDP and LDP for perioperative outcomes. By June 2022, all studies comparing RDP to LDP in the PubMed, the Embase, and the Cochrane Library database were systematically reviewed. According to the heterogeneity, fix or random-effects models were used for the meta-analysis of perioperative outcomes. Odds ratio (OR), weighted mean differences (WMD), and 95% confidence intervals (CI) were calculated. A sensitivity analysis was performed to explore potential sources of high heterogeneity and a trim and fill analysis was used to evaluate the impact of publication bias on the pooled results. Thirty-four studies met the inclusion criteria. RDP provides greater benefit than LDP for higher spleen preservation (OR 3.52 95% CI 2.62-4.73, p < 0.0001) and Kimura method (OR 1.93, 95% CI 1.42-2.62, p < 0.0001) in benign and low-grade malignant tumors. RDP is associated with lower conversion to laparotomy (OR 0.41, 95% CI 0.33-0.52, p < 0.00001), and shorter postoperative hospital stay (WMD - 0.57, 95% CI - 0.92 to - 0.21, p = 0.002), but it is more costly. In terms of postoperative complications, there was no difference between RDP and LDP except for 30-day mortality (RDP versus LDP, 0.1% versus 1.0%, p = 0.03). With the exception of its high cost, RDP appears to outperform LDP on perioperative outcomes and is technologically feasible and safe. High-quality prospective randomized controlled trials are advised for further confirmation as the quality of the evidence now is not high.
Topics: Humans; Robotic Surgical Procedures; Pancreatectomy; Prospective Studies; Treatment Outcome; Length of Stay; Operative Time; Pancreatic Neoplasms; Laparoscopy
PubMed: 36378464
DOI: 10.1007/s13304-022-01413-3 -
International Journal of Surgery... Mar 2024Partial pancreatectomy, commonly used for chronic pancreatitis, or pancreatic lesions, has diverse impacts on endocrine and metabolism system. The study aims to... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIMS
Partial pancreatectomy, commonly used for chronic pancreatitis, or pancreatic lesions, has diverse impacts on endocrine and metabolism system. The study aims to determine the global prevalence of new-onset, worsening, and resolution of diabetes following partial pancreatectomy.
METHODS
The authors searched PubMed, Embase, Web of Science, and Cochrane Library from inception to October, 2023. DerSimonian-Laird random-effects model with Logit transformation was used. Sensitivity analysis, meta-regression, and subgroup analysis were employed to investigate determinants of the prevalence of new-onset diabetes.
RESULTS
A total of 82 studies involving 13 257 patients were included. The overall prevalence of new-onset diabetes after partial pancreatectomy was 17.1%. Univariate meta-regression indicated that study size was the cause of heterogeneity. Multivariable analysis suggested that income of country or area had the highest predictor importance (49.7%). For subgroup analysis, the prevalence of new-onset diabetes varied from 7.6% (France, 95% CI: 4.3-13.0) to 38.0% (UK, 95% CI: 28.2-48.8, P <0.01) across different countries. Patients with surgical indications for chronic pancreatitis exhibited a higher prevalence (30.7%, 95% CI: 21.8-41.3) than those with pancreatic lesions (16.4%, 95% CI: 14.3-18.7, P <0.01). The type of surgical procedure also influenced the prevalence, with distal pancreatectomy having the highest prevalence (23.7%, 95% CI: 22.2-25.3, P <0.01). Moreover, the prevalence of worsening and resolution of preoperative diabetes was 41.1 and 25.8%, respectively.
CONCLUSIONS
Postoperative diabetes has a relatively high prevalence in patients undergoing partial pancreatectomy, which calls for attention and dedicated action from primary care physicians, specialists, and health policy makers alike.
Topics: Humans; Pancreatectomy; Diabetes Mellitus; Pancreas; Pancreatitis, Chronic; Pancreatic Neoplasms
PubMed: 38126341
DOI: 10.1097/JS9.0000000000000998 -
World Journal of Surgery Aug 2022There is no consensus on the pancreatic transection during distal pancreatectomy (DP) to reduce postoperative pancreatic fistula (POPF). This meta-analysis aimed to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There is no consensus on the pancreatic transection during distal pancreatectomy (DP) to reduce postoperative pancreatic fistula (POPF). This meta-analysis aimed to evaluate the effects of a reinforced stapler on the postoperative outcomes of DP.
METHODS
We systematically searched electronic databases and bibliographic reference lists in The PubMed/MEDLINE, Google Scholar, Cochrane Library's Controlled Trials Registry and Database of Systematic Reviews, Embase, and Scopus. Review Manager Software was used for pooled estimates.
RESULTS
Seven eligible studies published between 2007 and 2021 were included with 553 patients (267 patients in the reinforced stapler group and 286 patients in the standard stapler group). The reinforced stapler reduced the POPF grade B and C (OR = 0.33; 95% CI [0.19, 0.57], p < 0.01). There was no difference between the reinforced stapler group and standard stapler group in terms of mortality rate (OR = 0.39; 95% CI [0.04, 3.57], p = 0.40), postoperative haemorrhage (OR = 0.53; 95% CI [0.20, 1.43], p = 0.21), and reoperation rate (OR = 0.91; 95% CI [0.40, 2.06], p = 0.82).
CONCLUSIONS
Reinforced stapling in DP is safe and seems to reduce POPF grade B/C with similar mortality rates, postoperative bleeding, and reoperation rate. The protocol of this systematic review with meta-analysis was registered in PROSPERO (ID: CRD42021286849).
Topics: Humans; Incidence; Pancreas; Pancreatectomy; Pancreatic Fistula; Postoperative Complications; Risk Factors
PubMed: 35525852
DOI: 10.1007/s00268-022-06572-3