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HPB : the Official Journal of the... Jan 2016To review the evidence on the safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers. (Review)
Review
OBJECTIVES
To review the evidence on the safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers.
METHODS
Medline and EMBASE were systematically searched for papers of hepatopancreatoduodenectomy in patients with biliary and gallbladder cancers.
RESULTS
Eighteen studies involving 397 patients were reviewed. Major hepatectomy was undertaken in 81.3% of the 397 patients and the R0 resection rate was 71.3%. The morbidity and mortality rates were 78.9% and 10.3%, respectively. The 5-year overall survival rate ranged from 3% to 50% (median = 31%). The 5-year survival rate in patients who underwent curative resection was 18-68.8% (median = 51.3%), and 0% in patients who received non-curative resection.
CONCLUSIONS
Hepatopancreatoduodenectomy is a challenging procedure with high morbidity and mortality rates. However, this procedure can provide a chance of long-term survival in patients in whom curative resection is feasible.
Topics: Aged; Biliary Tract Neoplasms; Female; Gallbladder Neoplasms; Hepatectomy; Humans; Male; Middle Aged; Pancreaticoduodenectomy; Risk Factors; Survival Analysis; Survival Rate; Time Factors; Treatment Outcome
PubMed: 26776844
DOI: 10.1016/j.hpb.2015.07.008 -
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 -
International Journal of Surgery... May 2022Pancreaticoduodenectomy (PD) is a challenging procedure with peri-operative complications. Robotic surgery offers improved dexterity, visibility, and accessibility.... (Review)
Review
BACKGROUND
Pancreaticoduodenectomy (PD) is a challenging procedure with peri-operative complications. Robotic surgery offers improved dexterity, visibility, and accessibility. Recently, many centres have reported improved clinical outcomes for robotic PD. We reviewed the safety and efficacy of robotic PD in comparison to open PD using 'Therapeutic Index' (TI).
METHODS
A systematic review of the literature was conducted in various databases. Articles published between January 2010 and March 2021 reporting totally-robotic and open PD were included, according to the PRISMA and AMSTAR-2 guidelines. The Cochrane tool was used for risk of bias assessment. We compared 30-day mortality rates (MR), lymphadenectomy rates (LR), R0 resection rates (RRR) and therapeutic index (TI). STATA 16.1 was used for statistical analysis.
RESULTS
The four studies that met inclusion criteria included 5090 PDs, out of which 617 were totally-robotic (RPD) and 4473 were open (OPD). Variance ratio tests demonstrated a)Higher TI for RPD versus OPD (1807.42 vs 1723.37, p = 0.86), b)Significantly smaller MR (2.50 vs 19.00, p = 0.0004), c)Significantly lower RRR (130.50 vs 939.25, p = 0.00) and d)No significant difference in LR between RPD and OPD (35.63 vs 38.25, p = 0.81). Meta-regression analysis showed a significantly higher TI coefficient of RPD than OPD (0.66 vs -0.40, p = 0.08, α = 0.1).
CONCLUSION
Our study suggests that robotic PD is safe and not inferior to open PD and our analysis RPD demonstrated a higher therapeutic index than OPD. Randomised controlled trials are required to establish the efficacy of robotic PD. Also, standardisation of reporting mortality, survival and oncological outcomes is needed for the effective calculation of TI.
Topics: Humans; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Robotic Surgical Procedures; Therapeutic Index
PubMed: 35487420
DOI: 10.1016/j.ijsu.2022.106633 -
HPB : the Official Journal of the... Nov 2013Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with... (Review)
Review
BACKGROUND
Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with significant mortality and morbidity. Some recent publications have advocated the use of endoscopic papillectomy for the treatment of early ampullary adenocarcinoma. This article reviews investigations and surgical treatment options of ampullary tumours.
METHODS
A systematic review of English-language articles was carried out using an electronic search of the Ovid MEDLINE (from 1996 onwards), PubMed and Cochrane Database of Systematic Reviews databases to identify studies related to the investigation and management of ampullary tumours.
RESULTS
Distinguishing between ampullary adenoma and adenocarcinoma is challenging given the inaccuracy of endoscopic biopsy, for which high false negative rates of 25-50% have been reported. Endoscopic ultrasound is the most accurate method for local staging of ampullary lesions, but distinguishing between T1 and T2 adenocarcinomas is difficult. Lymph node metastasis occurs early in the disease process; it is lowest for T1 tumours, but the risk is still high at 8-45%. Case reports of successful endoscopic resection and transduodenal ampullectomy of T1 adenocarcinomas have been published, but their duration of follow-up is limited.
CONCLUSIONS
Optimal staging should be used to distinguish between ampullary adenoma and adenocarcinoma. Pancreaticoduodenectomy remains the treatment of choice for all ampullary adenocarcinomas.
Topics: Adenocarcinoma; Ampulla of Vater; Biopsy; Cholangiopancreatography, Endoscopic Retrograde; Common Bile Duct Neoplasms; Endosonography; Humans; Image-Guided Biopsy
PubMed: 23458317
DOI: 10.1111/hpb.12038 -
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 -
World Journal of Surgery Dec 2023The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative results after pancreaticoduodenectomy (PD). (Meta-Analysis)
Meta-Analysis Review
The Presence of an Aberrant Right Hepatic Artery Did Not Influence Surgical and Oncological Outcomes After Pancreaticoduodenectomy: A Comprehensive Systematic Review and Meta-Analysis.
BACKGROUND
The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative results after pancreaticoduodenectomy (PD).
METHODS
A systematic review and metanalysis were conducted, including all comparative studies having patients who underwent PD without (na-RHA) or with a-RHA. The results were reported as risk ratios (RRs), mean differences (MDs), or hazard ratios (HRs) with 95% confidence intervals (95 CI). The random effects model was used to calculate the effect sizes. The endpoints were distinguished as critical and important. Critical endpoints were: R1 resection, overall survival (OS), morbidity, mortality, and biliary fistula (BL). Important endpoints were: postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT).
RESULTS
Considering the R1 rate no significant differences were observed between the two groups (RR 1.06; 0.89 to 1.27). The two groups have a similar OS (HR 0.95; 0.85 to 1.06). Postoperative morbidity and mortality were similar between the two groups, with a RR of 0.97 (0.88 to 1.06) and 0.81 (0.54 to 1.20), respectively. The biliary fistula rate was similar between the two groups (RR of 1.09; 0.72 to 1.66). No differences were observed for non-critical endpoints.
CONCLUSION
The presence of a-RHA does not affect negatively the short-term and long-term clinical outcomes of PD.
Topics: Humans; Pancreaticoduodenectomy; Pancreatectomy; Biliary Fistula; Hepatic Artery; Pancreas; Pancreatic Fistula; Postoperative Complications
PubMed: 37816977
DOI: 10.1007/s00268-023-07191-2 -
Bioscience Trends Sep 2016We aimed to evaluate the feasibility of pancreaticoduodenectomy (PD) in elderly patients. We retrospectively analyzed data from 206 patients who underwent PD between... (Review)
Review
We aimed to evaluate the feasibility of pancreaticoduodenectomy (PD) in elderly patients. We retrospectively analyzed data from 206 patients who underwent PD between 2008 and 2015. The patients were divided into two groups: patients aged < 70 years (n = 117) and those aged ≥ 70 years (n = 89). To update the outcome of PD in elderly patients, we performed a systematic review of published work. The preoperative patient characteristics were similar between the two groups except for hypertension, which was significantly more frequent in the older group (25% vs. 52%; p < 0.001). There was no difference in the mortality (0% vs. 1%; p = 0.43) or morbidity (26% vs. 20%; p = 0.41) rates between the two groups. The overall survival rate in patients with pancreatic cancer between the two groups did not differ (p = 0.40). Twenty-one studies, including our own, were identified in the published work. The overall median morbidity and mortality rates of the elderly patients were 41.5% (range, 20-78%) and 5.8% (range, 0-10.5%), respectively. PD is feasible in elderly patients with acceptable morbidity and mortality rates.
Topics: Adult; Age Factors; Aged; Female; Humans; Male; Middle Aged; Nutrition Assessment; Pancreaticoduodenectomy; Postoperative Complications; Survival Rate; Treatment Outcome
PubMed: 27396698
DOI: 10.5582/bst.2016.01093 -
Robotic Surgery (Auckland) 2019Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using... (Review)
Review
INTRODUCTION
Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis.
METHODS
A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations.
RESULTS
We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001). Moreover, all anastomoses needed more time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001).
CONCLUSION
Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.
PubMed: 31921934
DOI: 10.2147/RSRR.S186768 -
The American Surgeon Feb 2024Pancreaticoduodenectomy (PD) is associated with better outcomes in high-volume hospitals. However, it is unknown whether and to what extent the improved performance of... (Review)
Review
Racial and Socioeconomic Differences and Surgical Outcomes in Pancreaticoduodenectomy Patients: A Systematic Review of High- Versus Low-Volume Hospitals in the United States.
BACKGROUND
Pancreaticoduodenectomy (PD) is associated with better outcomes in high-volume hospitals. However, it is unknown whether and to what extent the improved performance of high-volume hospitals may be associated with racial and socioeconomic factors, which have been shown to impact operative and postoperative outcomes in major surgeries. This review aims to identify the differences in racial and socioeconomic characteristics of patients who underwent PD surgery in high- and low-volume hospitals.
METHODS
PubMed, Cochrane, and Web of Science were systematically searched between May 1, 2023 and May 7, 2023 without any time restriction on publication date. Studies that were conducted in the United States and had a direct comparison between high- and low-volume hospitals were included.
RESULTS
A total of 30 observational studies were included. When racial proportions were compared by hospital volume, thirteen studies reported that compared to high-volume hospitals, a higher percentage of racial minorities underwent PD in low-volume hospitals. Disparities in traveling distance, education levels, and median income at baseline between high- and low-volume hospitals were reported by four, three, and two studies, respectively.
CONCLUSION
A racial difference at baseline between high- and low-volume hospitals was observed. Socioeconomic factors were less frequently included in existing literature. Future studies are needed to understand the socioeconomic differences between patients receiving PD surgery in high- and low-volume hospitals.
Topics: Humans; United States; Hospitals, Low-Volume; Pancreaticoduodenectomy; Hospitals, High-Volume; Socioeconomic Factors; Treatment Outcome
PubMed: 37941362
DOI: 10.1177/00031348231211040 -
International Journal of Surgery... Dec 2016Duct-to-mucosa and invagination are two commonly used techniques of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy. Previously, we conducted a systematic... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Duct-to-mucosa and invagination are two commonly used techniques of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy. Previously, we conducted a systematic review comparing the safety and efficacy of the two PJ techniques. Here, we added new evidence and updated our previous conclusion.
METHODS
We systematically searched multiple databases and included randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination techniques of PJ. The quality of evidence was assessed using Jadad score, and reporting bias was evaluated using funnel plots. Meta-analysis was performed using a random-effects model. Risk ratio (RR) and 95% confidence interval (CI) were calculated. The primary outcome was pancreatic fistula, and the secondary outcomes included mortality, reoperation, morbidity and postoperative hospital stay. Trial sequential analysis was performed to calculate the required information size.
RESULTS
Seven RCTs with 850 participants were included. No significant difference was detected in the rates of pancreatic fistula (RR 0.98, 95% CI 0.63 to 1.53), mortality (RR 0.94, 95% CI 0.40 to 2.18), reoperation (RR 1.23, 95% CI 0.69 to 2.20) and morbidity (RR 0.98, 95% CI 0.82 to 1.16) between the two groups. However, patients who underwent duct-to-mucosa PJ had a significantly shorter postoperative hospital stay (mean difference -2.80, 95% CI -5.08 to -0.52). Trial sequential analysis showed that another 279 participants were needed for conclusive results.
CONCLUSIONS
Given the current evidence, duct-to-mucosa PJ did not decrease the rates of pancreatic fistula and other adverse events as compared to invagination PJ; however, it did reduce postoperative hospital stay. Further RCTs are needed.
Topics: Anastomosis, Surgical; Humans; Intestinal Mucosa; Length of Stay; Mortality; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Randomized Controlled Trials as Topic; Reoperation; Safety
PubMed: 27826046
DOI: 10.1016/j.ijsu.2016.11.008