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World Journal of Gastrointestinal... Jan 2017To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).
AIM
To investigate and summarise the current evidence surrounding management of Bouveret's syndrome (BS).
METHODS
A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians (Yahya AL-Habbal and Matthew Ng) in April 2016. A case of BS is also described.
RESULTS
A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available (neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images (radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.
CONCLUSION
There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.
PubMed: 28138366
DOI: 10.4240/wjgs.v9.i1.25 -
European Journal of Surgical Oncology :... Sep 2016Preoperative biliary drainage (PBD) with stenting increases complications compared with surgery without PBD. Metallic stents are considered superior to plastic stents... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Preoperative biliary drainage (PBD) with stenting increases complications compared with surgery without PBD. Metallic stents are considered superior to plastic stents when considering stent-related complications. Aim of the present systematic review and meta-analysis is to compare the rate of endoscopic re-intervention before surgery and postoperative outcomes of metal versus plastic stents in patients with resectable periampullary or pancreatic head neoplasms.
METHODS
We conducted a bibliographic research using the National Library of Medicine's PubMed database, including both randomized controlled trials (RCTs) and non-RCTs. Quantitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Statistical heterogeneity was assessed using the I(2) tests.
RESULTS
One RCT and four non-RCTs were selected, including 704 patients. Of these, 202 patients (29.5%) were treated with metal stents and 502 (70.5%) with plastic stents. The majority of patients (86.4%) had pancreatic cancer. The rate of endoscopic re-intervention after preoperative biliary drainage was significantly lower in the metal stent (3.4%) than in the plastic stent (14.8%) group (p < 0.0001). The rate of postoperative pancreatic fistula was significantly lower in the meta stent group as well (5.1% versus 11.8%, p = 0.04). The rate of post-operative surgical complications and of - post-operative mortality did not differ between the two groups.
CONCLUSIONS
Although the present systematic review and meta-analysis demonstrates that metal stent are more effective than plastic stents for PBD in patients with resectable periampullary tumors, randomized controlled trials are needed in order to confirm these data with a higher level of evidence.
Topics: Ampulla of Vater; Biliary Tract Surgical Procedures; Drainage; Humans; Jaundice, Obstructive; Metals; Pancreatectomy; Pancreatic Neoplasms; Plastics; Postoperative Complications; Preoperative Care; Risk Factors; Stents
PubMed: 27296728
DOI: 10.1016/j.ejso.2016.05.001 -
The Cochrane Database of Systematic... Feb 2016Pancreatic cancer is the fourth-leading cause of cancer death for both, men and women. The standard treatment for resectable tumours consists of a classic Whipple (CW)... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pancreatic cancer is the fourth-leading cause of cancer death for both, men and women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, postoperative mortality, complications, and quality of life.
OBJECTIVES
The objective of this systematic review was to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region.
SEARCH METHODS
We conducted searches on 28 March 2006, 11 January 2011, 9 January 2014, and 18 August 2015 to identify all randomised controlled trials (RCTs), while applying no language restrictions. We searched the following electronic databases on 18 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) from the Cochrane Library (2015, Issue 8); MEDLINE (1946 to August 2015); and EMBASE (1980 to August 2015). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010); we did not update this part of the search for the 2014 and 2015 updates because the prior searches did not contribute any additional information. We identified two additional trials through the updated search in 2015.
SELECTION CRITERIA
RCTs comparing CW versus PPW including participants with periampullary or pancreatic carcinoma.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data from the included trials. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs), and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included trials according to the standards of The Cochrane Collaboration.
MAIN RESULTS
We included eight RCTs with a total of 512 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Postoperative mortality (OR 0.64, 95% confidence interval (CI) 0.26 to 1.54; P = 0.32), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P = 0.29), and morbidity showed no significant differences, except of delayed gastric emptying, which significantly favoured CW (OR 3.03, 95% CI 1.05 to 8.70; P = 0.04). Furthermore, we noted that operating time (MD -45.22 minutes, 95% CI -74.67 to -15.78; P = 0.003), intraoperative blood loss (MD -0.32 L, 95% CI -0.62 to -0.03; P = 0.03), and red blood cell transfusion (MD -0.47 units, 95% CI -0.86 to -0.07; P = 0.02) were significantly reduced in the PPW group. All significant results were associated with low-quality evidence based on GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria.
AUTHORS' CONCLUSIONS
Current evidence suggests no relevant differences in mortality, morbidity, and survival between the two operations. However, some perioperative outcome measures significantly favour the PPW procedure. Given obvious clinical and methodological heterogeneity, future high-quality RCTs of complex surgical interventions based on well-defined outcome parameters are required.
Topics: Ampulla of Vater; Blood Loss, Surgical; Common Bile Duct Neoplasms; Female; Gastric Emptying; Humans; Male; Operative Time; Organ Sparing Treatments; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pylorus; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 26905229
DOI: 10.1002/14651858.CD006053.pub6 -
The Cochrane Database of Systematic... Feb 2016Surgical excision by removal of the head of the pancreas to decompress the obstructed ducts is one of the treatment options for people with symptomatic chronic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Surgical excision by removal of the head of the pancreas to decompress the obstructed ducts is one of the treatment options for people with symptomatic chronic pancreatitis. Surgical excision of the head of the pancreas can be performed by excision of the duodenum along with the head of the pancreas (pancreaticoduodenectomy (PD)) or without excision of the duodenum (duodenum-preserving pancreatic head resection (DPPHR)). There is currently no consensus on the method of pancreatic head resection in people with chronic pancreatitis.
OBJECTIVES
To assess the benefits and harms of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in people with chronic pancreatitis for whom pancreatic resection is considered the main treatment option.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers to June 2015 to identify randomised trials. We also searched the references of included trials to identify further trials.
SELECTION CRITERIA
We considered only randomised controlled trials (RCT) performed in people with chronic pancreatitis undergoing pancreatic head resection, irrespective of language, blinding, or publication status, for inclusion in the review.
DATA COLLECTION AND ANALYSIS
Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR), mean difference (MD), rate ratio (RaR), or hazard ratio (HR) with 95% confidence intervals (CI) based on an available-case analysis.
MAIN RESULTS
Five trials including 292 participants met the inclusion criteria for the review. After exclusion of 23 participants mainly due to pancreatic cancer or because participants did not receive the planned treatment, a total of 269 participants (with symptomatic chronic pancreatitis involving the head of pancreas and requiring surgery) were randomly assigned to receive DPPHR (135 participants) or PD (134 participants). The trials did not report the American Society of Anesthesiologists (ASA) status of the participants. All the trials were single-centre trials and included people with and without obstructive jaundice and people with and without duodenal stenosis but did not report data separately for those with and without jaundice or those with and without duodenal stenosis. The surgical procedures compared in the five trials included DPPHR (Beger or Frey procedures, or wide local excision of the head of the pancreas) and PD (pylorus-preserving pancreaticoduodenectomy or Whipple procedure). The participants were followed up for various periods of time ranging from one to 15 years. The trials were at unclear or high risk of bias. The overall quality of evidence was low or very low.The differences in short-term mortality (up to 90 days after surgery) (RR 2.89, 95% CI 0.31 to 26.87; 369 participants; 5 studies; DPPHR: 2/135 (1.5%) versus PD: 0/134 (0%); very low quality evidence) or long-term mortality (maximal follow-up) (HR 0.65, 95% CI 0.31 to 1.34; 229 participants; 4 studies; very low quality evidence), medium-term (three months to five years) (only a narrative summary was possible; 229 participants; 4 studies; very low quality evidence), or long-term quality of life (more than five years) (MD 8.45, 95% CI -0.27 to 17.18; 101 participants; 2 studies; low quality evidence), proportion of people with adverse events (RR 0.55, 95% CI 0.22 to 1.35; 226 participants; 4 studies; DPPHR: 23/113 (adjusted proportion 20%) versus PD: 41/113 (36.3%); very low quality evidence), number of people with adverse events (RaR 0.95, 95% CI 0.43 to 2.12; 43 participants; 1 study; DPPHR: 12/22 (54.3 events per 100 participants) versus PD: 12/21 (57.1 events per 100 participants); very low quality evidence), proportion of people employed (maximal follow-up) (RR 1.54, 95% CI 1.00 to 2.37; 189 participants; 4 studies; DPPHR: 65/98 (adjusted proportion 69.4%) versus PD: 41/91 (45.1%); low quality evidence), incidence proportion of diabetes mellitus (maximum follow-up) (RR 0.78, 95% CI 0.50 to 1.22; 269 participants; 5 studies; DPPHR: 25/135 (adjusted proportion 18.6%) versus PD: 32/134 (23.9%); very low quality evidence), and prevalence proportion of pancreatic exocrine insufficiency (maximum follow-up) (RR 0.83, 95% CI 0.68 to 1.02; 189 participants; 4 studies; DPPHR: 62/98 (adjusted proportion 62.0%) versus PD: 68/91 (74.7%); very low quality evidence) were imprecise. The length of hospital stay appeared to be lower with DPPHR compared to PD and ranged between a reduction of one day and five days in the trials (208 participants; 4 studies; low quality evidence). None of the trials reported short-term quality of life (four weeks to three months), clinically significant pancreatic fistulas, serious adverse events, time to return to normal activity, time to return to work, and pain scores using a visual analogue scale.
AUTHORS' CONCLUSIONS
Low quality evidence suggested that DPPHR may result in shorter hospital stay than PD. Based on low or very low quality evidence, there is currently no evidence of any difference in the mortality, adverse events, or quality of life between DPPHR and PD. However, the results were imprecise and further RCTs are required on this topic. Future RCTs comparing DPPHR with PD should report the severity as well as the incidence of postoperative complications and their impact on patient recovery. In such trials, participant and observer blinding should be performed and the analysis should be performed on an intention-to-treat basis to decrease the bias. In addition to the short-term benefits and harms such as mortality, surgery-related complications, quality of life, length of hospital stay, return to normal activity, and return to work, future trials should consider linkage of trial participants to health databases, social databases, and mortality registers to obtain the long-term benefits and harms of the different treatments.
Topics: Duodenum; Humans; Length of Stay; Organ Sparing Treatments; Pancreatectomy; Pancreaticoduodenectomy; Pancreatitis, Chronic; Randomized Controlled Trials as Topic
PubMed: 26837472
DOI: 10.1002/14651858.CD011521.pub2 -
Journal of Gastrointestinal Surgery :... Jan 2016Parenchyma-sparing local extirpation of benign tumors of the pancreatic head provides the potential benefits of preservation of functional tissue and low postoperative... (Review)
Review
BACKGROUND
Parenchyma-sparing local extirpation of benign tumors of the pancreatic head provides the potential benefits of preservation of functional tissue and low postoperative morbidity.
METHODS
Medline/PubMed, Embase, and Cochrane library databases were surveyed for studies performing limited resection of the pancreatic head and resection of a segment of the duodenum and common bile duct or preservation of the duodenum and common bile duct (CBD). The systematic analysis included 27 cohort studies that reported on limited pancreatic head resections for benign tumors. In a subgroup analysis, 12 of the cohort studies were additionally evaluated to compare the postoperative morbidity after total head resection including duodenal segment resection (DPPHR-S) and total head resection conserving duodenum and CBD (DPPHR-T).
RESULTS
Three hundred thirty-nine of a total of 503 patients (67.4%) underwent total head resections. One hundred forty-seven patients (29.2%) of them underwent segmental resection of the duodenum and CBD (DPPHR-S) and 192 patients (38.2%) underwent preservation of duodenum and CBD. One hundred sixty-four patients experienced partial head resection (32.6%). The final histological diagnosis revealed in 338 of 503 patients (67.2%) cystic neoplasms, 53 patients (10.3%) neuroendocrine tumors, and 20 patients (4.0%) low-risk periampullary carcinomas. Severe postoperative complications occurred in 62 of 490 patients (12.7%), pancreatic fistula B + C in 40 of 295 patients (13.6%), resurgery was experienced in 2.7%, and delayed gastric emptying in 12.3%. The 90-day mortality was 0.4%. The subgroup analysis comparing 143 DPPHR-S patients with 95 DPPHR-T patients showed that the respective rates of procedure-related biliary complications were 0.7% (1 of 143 patients) versus 8.4% (8 of 95 patients) (p ≤ 0.0032), and rates of duodenal complications were 0 versus 6.3% (6 of 95 patients) (p ≤ 0.0037). DPPHR-S was associated with a higher rate of delay of gastric emptying compared to DPPHR-T (18.9 vs. 2.1%, p ≤ 0.0001).
CONCLUSION
Parenchyma-sparing, limited head resection for benign tumors preserves functional pancreatic and duodenal tissue and carries in terms of fistula B + C rate, resurgery, rehospitalization, and 90-day mortality a low risk of postoperative complications. A subgroup analysis exhibited after total pancreatic head resection that preserves the duodenum and CBD an association with a significant increase in procedure-related biliary and duodenal complications compared to total head resection combined with resection of the periampullary segment of the duodenum and resection of the intrapancreatic CBD.
Topics: Common Bile Duct; Duodenum; Humans; Pancreas; Pancreatectomy; Pancreatic Neoplasms; Postoperative Complications
PubMed: 26525207
DOI: 10.1007/s11605-015-2981-2 -
World Journal of Gastroenterology Jun 2015To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer. (Review)
Review
AIM
To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer.
METHODS
A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients' characteristics, type of treatment, short and long-term outcomes were extracted and analyzed.
RESULTS
In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d.
CONCLUSION
Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.
Topics: Anastomotic Leak; Drainage; Duodenal Diseases; Duodenum; Gastrectomy; Humans; Intestinal Fistula; Length of Stay; Reoperation; Stomach Neoplasms; Time Factors; Treatment Outcome; Wound Healing
PubMed: 26140005
DOI: 10.3748/wjg.v21.i24.7571 -
Pancreatology : Official Journal of the... 2015Potential benefits of local extirpation of benign pancreatic head tumors are tissue conservation of pancreas, stomach, duodenum and common bile duct (CBD) and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Potential benefits of local extirpation of benign pancreatic head tumors are tissue conservation of pancreas, stomach, duodenum and common bile duct (CBD) and maintenance of pancreatic functions.
METHODS
Medline/PubMed, Embase and Cochrane Library databases were searched to identify studies applying duodenum-preserving total or partial pancreatic-head resection (DPPHRt/p) and reporting short- and long-term outcomes. Twenty-four studies, including 416 patients who underwent DPPHRt/p, were identified for systematic analysis. The meta-analysis was based on 10 prospective controlled and 4 retrospective controlled cohort studies, comparing 293 DPPHRt/p resections with 372 pancreato-duodenectomies (PD).
RESULTS, SYSTEMATIC ANALYSIS
Of 416 patients, 75.7% underwent total and 24.3% partial head resection, while 47.1% included segmentectomy of duodenum and CBD. The most common pathology was cystic neoplasm (65.8%) and endocrine tumors (13.4%). The frequencies of severe postoperative complications of 8.8%, pancreatic fistula of 19.2%, re-operation of 1.7% and hospital mortality of 0.48%, indicate a low level of early post-operative complications.
META-ANALYSIS
DPPHRt/p significantly preserved the level of exocrine (IV = -0.67, 95% CI -0.98 to -0.35, p = 0.0001) and endocrine (IV = 18.20, fixed, 95% CI -0.92 to 25.48, p = 0.0001) pancreatic functions compared to PD when the pre- and postoperative functional status in both groups are analyzed. There were no significant differences between DPPHRt/p and PD in frequency of pancreatic fistula, delayed gastric emptying or hospital mortality.
CONCLUSION
DPPHRt/p for benign neoplasms and neuro-endocrine tumors of the pancreatic head is associated with a low level of early-postoperative complications and a better conservation of exocrine and endocrine functions.
Topics: Common Bile Duct; Duodenum; Humans; Pancreas; Pancreatic Function Tests; Pancreatic Neoplasms
PubMed: 25732271
DOI: 10.1016/j.pan.2015.01.009 -
World Journal of Surgery Jun 2015Limited surgical procedures for benign cystic neoplasms and endocrine tumours of the pancreas have the potential advantage of pancreatic tissue sparing compared to... (Review)
Review
BACKGROUND
Limited surgical procedures for benign cystic neoplasms and endocrine tumours of the pancreas have the potential advantage of pancreatic tissue sparing compared to standard oncological resections.
METHODS
Searching PubMed/MedLine, Embase and Cochrane Library identified 86 full papers: 25 reporting on enucleation (EN), 38 on central pancreatectomy (CP) and 23 on duodenum-preserving total/partial pancreatic head resection (DPPHRt/p). The results are based on analysis of data of 838, 912 and 431 patients for EN, CP and DPPHRt/s, respectively.
RESULTS
The indication for EN for cystic neoplasms and neuro-endocrine tumours to EN was 20.5 and 73 %; for CP 62.9 and 31 %; and for DPPHRt/p 69.6 and 10.2%, respectively. The estimated mean tumour sizes were in EN-group 2.4 cm, in CP-group 2.9 cm and in DPPHRt/p-group 3.1 cm (DPPHRt/p vs EN, p = 0.035). Postoperative severe complications developed after EN, CP and DPPHRt/p in 9.6, 16.8 and 11.5% of patients; pancreatic fistula in 36.7, 35.2 and 20.1%; and reoperation was required in 4.7, 6.5 and 1.8 %, respectively. Hospital mortality after EN was 0.95 %; after CP 0.72%; and after DPPHRt/p 0.49%. Compared to EN and CP, DPPHRt/p exhibited significant lower frequency of reoperation (p = 0.029, p < 0.001) and lower rate of fistula (p < 0.001; p = 0.001).
CONCLUSION
EN, CP and DPPHRt/p applied for benign tumours are associated with low surgery-related early postoperative morbidity, a very low hospital mortality and the advantages of conservation of pancreatic functions. However, the level of evidence for EN and CP compared to standard oncological resections appears presently low. There is a high level of evidence from prospective controlled trials regarding the significant maintenance of exocrine and endocrine pancreatic functions after DPPHRt/p compared to pancreato-duodenectomy.
Topics: Hospital Mortality; Humans; Neoplasms, Cystic, Mucinous, and Serous; Neuroendocrine Tumors; Organ Sparing Treatments; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Reoperation
PubMed: 25691214
DOI: 10.1007/s00268-015-2976-x -
The Cochrane Database of Systematic... Nov 2014Background Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours consists of a... (Meta-Analysis)
Meta-Analysis Review
Background Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, mortality, complications and quality of life.Objectives The objective of this systematic review is to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region.Search methods We conducted searches on 28 March 2006, 11 January 2011 and 9 January 2014 to identify all randomised controlled trials (RCTs),while applying no language restrictions. We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects(DARE) from The Cochrane Library (2013, Issue 4); MEDLINE (1946 to January 2014); and EMBASE (1980 to January 2014). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010). We identified no additional studies upon updating the systematic review in 2014.Selection criteria We considered RCTs comparing CW versus PPW to be eligible if they included study participants with periampullary or pancreatic carcinoma. Data collection and analysis Two review authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs) and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included studies according to the standards of The Cochrane Collaboration.Main results We included six RCTs with a total of 465 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. In-hospital mortality (OR 0.49, 95% confidence interval (CI) 0.17 to 1.40; P value 0.18), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P value 0.29) and morbidity showed no significant differences. However, we noted that operating time (MD -68.26 minutes, 95% CI -105.70 to -30.83; P value 0.0004) and intraoperative blood loss (MD -0.76 mL, 95%CI -0.96 to -0.56; P value < 0.00001) were significantly reduced in the PPW group. All significant results are associated with low quality of evidence as determined on the basis of GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria.Authors' conclusions No evidence suggests relevant differences in mortality, morbidity and survival between the two operations. Given obvious clinical and methodological heterogeneity, future research must be undertaken to perform high-quality randomised controlled trials of complex surgical interventions on the basis of well-defined outcome parameters.
Topics: Ampulla of Vater; Blood Loss, Surgical; Common Bile Duct Neoplasms; Gastric Emptying; Humans; Operative Time; Organ Sparing Treatments; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pylorus; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 25387229
DOI: 10.1002/14651858.CD006053.pub5 -
The Surgeon : Journal of the Royal... Aug 2014Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach may enhance patient recovery and reduce postoperative complications comparing to open pancreaticoduodenectomy (OPD), as demonstrated for other abdominal procedures.
METHODS
A systematic literature review was conducted to identify studies comparing MIPD and OPD. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model.
RESULTS
For the metaanalysis, 8 studies including 204 patients undergoing MIPD and 419 patients undergoing OPD were considered suitable. The patients in the two groups were similar with respect to age, sex and histological diagnosis, and different with respect to tumor size, rate of pylorus preservation, and type of pancreatic anastomosis. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. MIDP resulted in lower post-operative complication rates, less intra-operative blood loss, shorter hospital stays, lower blood transfusion rates, higher numbers of harvested lymph nodes, and improved negative margin status rates. However, MIPD was associated with longer operating times when compared to OPD.
CONCLUSIONS
The MIPD procedure is feasible, safe, and effective in selected patients. MIPD may have some potential advantages over OPD, and should be performed and further developed by use in selected patients at highly experienced medical centers.
Topics: Duodenal Diseases; Humans; Laparotomy; Minimally Invasive Surgical Procedures; Pancreatic Diseases; Pancreaticoduodenectomy; Robotics; Treatment Outcome
PubMed: 24525404
DOI: 10.1016/j.surge.2014.01.006