Effectiveness and safety of central pancreatectomy in benign or low-grade malignant pancreatic body lesions: a systematic review and meta-analysis

Abstract

Background: The best approach for treating benign or low-grade malignant lesions localized in the pancreatic neck or body remains debatable. Conventional pancreatoduodenectomy and distal pancreatectomy (DP) are associated with a risk of impairment of pancreatic function at long-term follow-up. With advances in technology and surgical skills, the use of central pancreatectomy (CP) has gradually increased. Objectives: The objective was to compare the safety, feasibility, and short-term and long-term clinical benefits of CP and DP in matched cases. Methods: The PubMed, MEDLINE, Web of Science, Cochrane, and EMBASE databases were systematically searched to identify studies published from database inception to February 2022 that compared CP and DP. This meta-analysis was performed using R software. Results: Twenty-six studies matched the selection criteria, including 774 CP and 1713 DP cases. CP was significantly associated with longer operative time ( P <0.0001), less blood loss ( P <0.01), overall and clinically relevant pancreatic fistula ( P <0.0001), postoperative hemorrhage ( P <0.0001), reoperation ( P =0.0196), delayed gastric emptying ( P =0.0096), increased hospital stay ( P =0.0002), intra-abdominal abscess or effusion ( P =0.0161), higher morbidity ( P <0.0001) and severe morbidity ( P <0.0001) but with a significantly lower incidence of overall endocrine and exocrine insufficiency ( P <0.01), and new-onset and worsening diabetes mellitus ( P <0.0001) than DP. Conclusions: CP should be considered as an alternative to DP in selected cases such as without pancreatic disease, length of the residual distal pancreas is more than 5 cm, branch-duct intraductal papillary mucinous neoplasms, and a low risk of postoperative pancreatic fistula after adequate evaluation.

Comment on ‘Effectiveness and safety of central pancreatectomy in benign or low-grade malignant pancreatic body lesions: a systematic review and meta-analysis’

“…We read with great interest the systematic review and meta-analysis by Bi et al . 1 comparing the safety and efficacy of central pancreatectomy (CP) versus distal pancreatectomy (DP) for benign or low-grade malignant pancreatic body lesions. Their meta-analysis found that CP was associated with longer operative times, greater blood loss, and higher rates of most postoperative complications, including pancreatic fistula, hemorrhage, morbidity, and longer hospital stays than DP 1 .…”

“…This is an important topic as surgeons continue to debate the appropriate pancreatic parenchymal-sparing operation for small, low-grade pancreatic neck/body lesions. The present investigation included 26 studies comprising nearly 2500 patients, thereby constituting the most extensive examination of the subject to date 1 . The authors are worthy of commendations on the comprehensive analyses.…”

“…Nevertheless, the presence of significant heterogeneity in meta-analyses warrants thorough investigation of its causes. In the original meta-analysis 1 , a high degree of heterogeneity was found for operative time (i.e. 90%) and blood loss when comparing CP and DP.…”

“…90%) and blood loss when comparing CP and DP. The authors performed subgroup analyses based on the surgical approach and study design without identifying significant sources of heterogeneity 1 . Given the inclusion of studies from multiple countries across Asia, Europe, and North America, we hypothesized that geographic regions may be a source of heterogeneity.…”

“…Surgical practices, training, and techniques may differ between countries in a way that affects operative times for complex pancreatic resections, such as CP. To further analyze this, we collected the raw data of the original meta-analysis 1 and divided the included studies by country into Asian (China, Japan, and Korea) and non-Asian (the USA, Italy, Germany, Spain, France, and Romania) subgroups. Our subgroup analysis was performed using the Cochrane Review Manager (RevMan 5.3; Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014) as previously reported 2 .…”