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Medicine Dec 2017Minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging abdominal procedures. Safety and feasibility remain controversial when comparing... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Minimally invasive pancreaticoduodenectomy (MIPD) remains one of the most challenging abdominal procedures. Safety and feasibility remain controversial when comparing MIPD with open pancreaticoduodenectomy (OPD). The aim of this systematic review and meta-analysis was to evaluate the feasibility and safety of MIPD versus OPD.
METHODS
A systematic review of the literature was performed to identify studies comparing MIPD and OPD. Postoperative complications, intraoperative outcomes and oncologic data, and postoperative recovery were compared.
RESULTS
There were 27 studies that matched the selection criteria. Totally 1306 cases of MIPD and 5603 cases of OPD were included. MIPD was associated with a reduction in postoperative hemorrhage (odds ratio [OR] 1.60; 95% confidence interval [CI] 1.03-2.49; P = .04) and wound infection (OR 0.44, 95% CI 0.30-0.66, P < .0001). MIPD was also associated with less estimated blood loss (mean difference [MD] -300.14 mL, 95% CI -400.11 to -200.17 mL, P < .00001), a lower transfusion rate (OR 0.46, 95% CI 0.35-0.61; P < .00001) and a shorter length of hospital stay (MD -2.95 d, 95% CI -3.91 to -2.00 d, P < .00001) than OPD. Meanwhile, the MIPD group had a higher R0 resection rate (OR 1.45, 95% CI 1.18-1.78, P = .0003) and more lymph nodes harvested (MD 1.34, 95% CI 0.14-2.53, P = .03). However, the minimally invasive approach proved to have much longer operative time (MD 71.00 minutes; 95% CI 27.01-115.00 minutes; P = .002) than OPD. Finally, there were no significant differences between the 2 procedures in postoperative pancreatic fistula (P = .30), delayed gastric emptying (P = .07), bile leakage (P = .98), mortality (P = .88), tumor size (P = .15), vascular resection (P = .68), or reoperation rate (P = .11).
CONCLUSIONS
Our results suggest that MIPD is currently safe, feasible, and worthwhile. Future large-volume, well-designed randomized controlled trials (RCT) with extensive follow-up are awaited to further clarify this role.
Topics: Blood Loss, Surgical; Blood Transfusion; Humans; Laparoscopy; Length of Stay; Pancreaticoduodenectomy; Postoperative Complications; Surgical Procedures, Operative
PubMed: 29390259
DOI: 10.1097/MD.0000000000008619 -
Annals of Surgery Oct 2023Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula... (Meta-Analysis)
Meta-Analysis
Systematic Review and Meta-analysis of the Role of Total Pancreatectomy as an Alternative to Pancreatoduodenectomy in Patients at High Risk for Postoperative Pancreatic Fistula: Is it a Justifiable Indication?
OBJECTIVE
Examine the potential benefit of total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high risk for postoperative pancreatic fistula (POPF).
SUMMARY BACKGROUND DATA
TP is mentioned as an alternative to PD in patients at high risk for POPF, but a systematic review is lacking.
METHODS
Systematic review and meta-analyses using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published up to October 2022, comparing elective single-stage TP for any indication versus PD in patients at high risk for POPF. The primary endpoint was short-term mortality. Secondary endpoints were major morbidity (i.e., Clavien-Dindo grade ≥IIIa) on the short-term and quality of life.
RESULTS
After screening 1212 unique records, five studies with 707 patients (334 TP and 373 high-risk PD) met the eligibility criteria, comprising one randomized controlled trial and four observational studies. The 90-day mortality after TP and PD did not differ (6.3% vs. 6.2%; RR=1.04 [95%CI 0.56-1.93]). Major morbidity rate was lower after TP compared to PD (26.7% vs. 38.3%; RR=0.65 [95%CI 0.48-0.89]), but no significance was seen in matched/randomized studies (29.0% vs. 36.9%; RR = 0.73 [95%CI 0.48-1.10]). Two studies investigated quality of life (EORTC QLQ-C30) at a median of 30-52 months, demonstrating comparable global health status after TP and PD (77% [±15] vs. 76% [±20]; P =0.857).
CONCLUSIONS
This systematic review and meta-analysis found no reduction in short-term mortality and major morbidity after TP as compared to PD in patients at high risk for POPF. However, if TP is used as a bail-out procedure, the comparable long-term quality of life is reassuring.
Topics: Humans; Pancreatectomy; Pancreaticoduodenectomy; Pancreatic Fistula; Quality of Life; Pancreas; Postoperative Complications
PubMed: 37161977
DOI: 10.1097/SLA.0000000000005895 -
Digestive Surgery 2015The use of somatostatin analogues (SAs) following pancreaticoduodenectomy (PD) is controversial. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The use of somatostatin analogues (SAs) following pancreaticoduodenectomy (PD) is controversial.
METHOD
Literature databases were searched systematically for relevant articles. A meta-analysis of all randomized controlled trials (RCTs) evaluating prophylactic SAs in PD was performed.
RESULTS
Fifteen RCTs involving 1,352 patients were included. There was a towards reduced incidences of pancreatic fistulas (p = 0.26), clinically significant pancreatic fistulas (p = 0.08), and bleeding (p = 0.05) in prophylactic SAs group. In subgroup analyses, prophylactic somatostatin significantly reduced the incidence of pancreatic fistulas(p = 0.02), with a nonsignificant trend toward reduced incidence of clinically significantly pancreatic fistulas (p = 0.06).Pasireotide significantly reduced the incidence of clinically significantly pancreatic fistulas (p = 0.03). Octreotide had no influence on the incidence of pancreatic fistulas.
CONCLUSION
The current best evidence suggests prophylactic treatment with somatostatin or pasireotide has a potential role in reducing the incidence of pancreatic fistulas, while octreotide had no influence on the incidence of pancreatic fistulas.High-quality RCTs assessing the role of somatostatin and pasireotide are required for further verification.
Topics: Gastrointestinal Agents; Humans; Models, Statistical; Octreotide; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Postoperative Hemorrhage; Somatostatin; Treatment Outcome
PubMed: 25872003
DOI: 10.1159/000381032 -
Journal of Cancer Research and Clinical... Aug 2023ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes. However,... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes. However, evidence on cost benefit of ERAS in pancreaticoduodenectomy remains scarce. This review aimed to investigate cost benefit, compliance, and clinical benefits of ERAS in pancreaticoduodenectomy.
METHODS
A comprehensive literature search was conducted on Medline, Embase, PubMed, CINAHL and the Cochrane library to identify studies conducted between 2000 and 2021, comparing effect of ERAS programmes and traditional care on hospital cost, length of stay (LOS), complications, delayed gastric emptying (DGE), readmission, reoperation, mortality, and compliance.
RESULTS
The search yielded 3 RCTs and 28 cohort studies. Hospital costs were significantly reduced in the ERAS group (SMD = - 1.41; CL, - 2.05 to - 0.77; P < 0.00001). LOS was shortened by 3.15 days (MD = - 3.15; CI, - 3.94 to - 2.36; P < 0.00001) in the ERAS group. Fewer patients in the ERAS group had complications (RR = 0.83; CI, 0.76-0.91; P < 0.0001). Incidences of DGE significantly decreased in the ERAS group (RR = 0.72; CI, 0.55-0.94; P = 0.01). The number of deaths was fewer in the ERAS group (RR = 0.76; CI, 0.58-1.00; P = 0.05).
CONCLUSION
This review demonstrated that ERAS is safe and feasible in pancreaticoduodenectomy, improves clinical outcome such as LOS, complications, DGE and mortality rates, without changing readmissions and reoperations, while delivering significant cost savings. Higher compliance is associated with better clinical outcomes, especially LOS and complications.
Topics: Humans; Pancreaticoduodenectomy; Enhanced Recovery After Surgery; Pancreatectomy; Intestines; Cost-Benefit Analysis; Length of Stay; Postoperative Complications
PubMed: 36629919
DOI: 10.1007/s00432-022-04508-x -
World Journal of Surgery Jan 2023Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD). The diagnosis of DGE is based on International Study Group for Pancreatic... (Review)
Review
BACKGROUND
Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD). The diagnosis of DGE is based on International Study Group for Pancreatic Surgery (ISGPS) clinical criteria and objective assessments of DGE are infrequently used. The present literature review aimed to identify objective measures of DGE following PD and determine whether these measures correlate with the clinical definition of DGE.
METHODS
A systematic search was performed using the MEDLINE Ovid, EMBASE, Google Scholar and CINAHL databases for studies including pancreatic surgery, delayed gastric emptying and gastric motility until June 2022. The primary outcome was modalities undertaken for the objective measurement of DGE following PD and correlation between objective measurements and clinical diagnosis of DGE. Relevant risk of bias analysis was performed.
RESULTS
The search revealed 4881 records, of which 46 studies were included in the final analysis. There were four objective modalities of DGE assessment including gastric scintigraphy (n = 28), acetaminophen/paracetamol absorption test (n = 10), fluoroscopy (n = 6) and the C-acetate breath test (n = 3). Protocols were inconsistent, and reported correlations between clinical and objective measures of DGE were variable; however, amongst these measures, at least one study directly or indirectly inferred a correlation, with the greatest evidence accumulated for gastric scintigraphy.
CONCLUSION
Several objective modalities to assess DGE following PD have been identified and evaluated, however are infrequently used. Substantial variability exists in the literature regarding indications and interpretation of these tests, and there is a need for a real-time objective modality which correlates with ISGPS DGE definition after PD.
Topics: Humans; Gastric Stump; Gastroparesis
PubMed: 36274094
DOI: 10.1007/s00268-022-06784-7 -
HPB : the Official Journal of the... Sep 2020The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD.
METHODS
Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals.
RESULTS
Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620).
DISCUSSION
Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.
Topics: Anastomosis, Surgical; Humans; Ligaments; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications
PubMed: 32631806
DOI: 10.1016/j.hpb.2020.05.003 -
World Journal of Gastroenterology Feb 2015To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy (PD) with or without prophylactic drainage. (Meta-Analysis)
Meta-Analysis Review
AIM
To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy (PD) with or without prophylactic drainage.
METHODS
Relevant comparative randomized and non-randomized studies were systemically searched based on specific inclusion and exclusion criteria. Postoperative outcomes were compared between patients with and those without routine drainage. Pooled odds ratios (OR) with 95%CI were calculated using either fixed effects or random effects models.
RESULTS
One randomized controlled trial and four non-randomized comparative studies recruiting 1728 patients were analyzed. Patients without prophylactic drainage after PD had significantly higher mortality (OR=2.32, 95%CI: 1.11-4.85; P=0.02), despite the fact that they were associated with fewer overall complications (OR=0.62, 95%CI: 0.48-0.82; P=0.00), major complications (OR=0.75, 95%CI: 0.60-0.93; P=0.01) and readmissions (OR=0.77, 95%CI: 0.60-0.98; P=0.04). There were no significant differences in the rates of pancreatic fistula, intra-abdominal abscesses, postpancreatectomy hemorrhage, biliary fistula, delayed gastric emptying, reoperation or radiologic-guided drains between the two groups.
CONCLUSION
Indiscriminate abandonment of intra-abdominal drainage following PD is associated with greater mortality, but lower complication rates. Future randomized trials should compare routine vs selective drainage.
Topics: Adult; Aged; Chi-Square Distribution; Drainage; Female; Humans; Male; Middle Aged; Odds Ratio; Pancreaticoduodenectomy; Patient Readmission; Postoperative Complications; Risk Factors; Time Factors; Treatment Outcome
PubMed: 25741162
DOI: 10.3748/wjg.v21.i8.2510 -
HPB : the Official Journal of the... Oct 2022The effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic review and meta-analysis was to investigate the effect of EOF on clinical outcomes after PD, such as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and length of stay (LOS).
METHODS
A systematic review and meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and assimilated evidence from studies reporting outcomes for patients who received EOF after PD compared to enteral tube feeding (EN) or parenteral nutrition (PN).
RESULTS
Four studies reported outcomes after EOF compared to EN/PN after PD and included 553 patients. Meta-analyses showed no difference in rates of CR-POPF (OR 0.74; 95%CI 0.44-1.24; p = 0.25) or DGE (Grade B/C) (OR 0.83; 95%CI 0.31-2.21; p = 0.70). LOS was significantly shorter in the EOF group compared to the EN/PN group (Mean Difference -3.40 days; 95% -6.11-0.70 days; p = 0.01).
CONCLUSION
Current available evidence suggests that EOF after PD is not associated with increased risk of DGE, does not exacerbate POPF and appears to reduce length of stay.
Topics: Humans; Pancreaticoduodenectomy; Pancreatic Fistula; Enteral Nutrition; Length of Stay; Parenteral Nutrition; Postoperative Complications
PubMed: 35606323
DOI: 10.1016/j.hpb.2022.04.005 -
HPB : the Official Journal of the... Jun 2017There is an increasing needed to consider pancreaticoduodenectomy (PD) for the treatment of pancreatic and periampullary malignancy in patients aged 80 and over, given... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There is an increasing needed to consider pancreaticoduodenectomy (PD) for the treatment of pancreatic and periampullary malignancy in patients aged 80 and over, given the increasing aging population.
METHODS
A systematic literature search was undertaken to identify selected studies that compared the outcomes of patients aged 80 years or over to those younger undergoing PD.
RESULTS
In total 18 studies were included for evaluation. Octogenarian or older populations had significantly higher 30-day post-operative mortality rate (OR: 2.22, 95% CI = 1.48-3.31, p < 0.001) and length of hospital stay (OR: 2.23, 95% CI = 1.36-3.10, p < 0.001). The overall post-operative complication rate was higher in the older group compared to the younger population (OR: 1.51, 95% CI = 1.25-1.83, p < 0.001). Elderly patients were more likely to develop pneumonia (OR: 1.72, 95% CI = 1.39-2.13, p < 0.001) and experience delayed gastric emptying (DGE) (OR: 1.77, 95% CI = 1.35-2.31, p < 0.001). The incidence of post-operative pancreatic fistula and bile leak were not significantly different between the groups. Rehabilitation and home nursing care services was also more frequently required by the older patient group at the time of hospital discharge.
CONCLUSION
Patients aged 80 years and older have approximately double the risk of 30-day post-operative mortality and 50% increased rate of complications following PD. Careful patient selection is required when offering surgery in this age group.
Topics: Age Factors; Aged; Aged, 80 and over; Chi-Square Distribution; Female; Health Status; Humans; Length of Stay; Male; Odds Ratio; Pancreaticoduodenectomy; Patient Selection; Postoperative Complications; Risk Factors; Time Factors; Treatment Outcome
PubMed: 28292633
DOI: 10.1016/j.hpb.2017.01.018 -
Annals of Medicine and Surgery (2012) Apr 2021POPF derives from the pancreatic stump, which follows pancreatic resection and the pancreatoenteric anastomosis following pancreaticoduodenectomy. Since 1978 sealants... (Review)
Review
BACKGROUND
POPF derives from the pancreatic stump, which follows pancreatic resection and the pancreatoenteric anastomosis following pancreaticoduodenectomy. Since 1978 sealants have been used in pancreatic surgery to prevent pancreatic fistula after resection of the pancreatic head and tail or for the management of trauma and the treatment of low-output pancreatic fistula. Different types of fibrin sealants have been evaluated for their potential to reduce the occurrence of POPF.
METHODS
A systematic search of the electronic literature was performed using PubMed, Cochrane Library, and Scopus databases to obtain access to all publications, especially clinical trials, randomised controlled trials, and systematic reviews concerning fibrin sealants pancreatic surgery. Searching for "fibrin sealants pancreas," we found a total of 73 results on Pubmed, 61 on Scopus, and 14 on Cochrane Library (148 total results).
RESULTS
Eighteen studies were found on literature, following the criteria already described, concerning the use of fibrin sealants in pancreatic surgery. All articles described were published in the period between 1989 and 2019.Most of these were single centre studies. A total of 1032 patients were enrolled in this review. In the studies, sealants were used to reinforce pancreatic anastomoses and for the occlusion of the main pancreatic duct.
CONCLUSION
CR-POPF is a fearful complication of pancreatic surgery; among the possible solutions to reduce the risk of onset, sealants were used on the pancreatic stump; today the sealants should be considered such as an option to reduce the CR-POPF, but the routine use in clinical practice has to be validated.
PubMed: 33898024
DOI: 10.1016/j.amsu.2021.102244