Expanding laparoscopic pancreaticoduodenectomy to pancreatic-head and periampullary malignancy: major findings based on systematic review and meta-analysis

Abstract

BackgroundLaparoscopic pancreaticoduodenectomy (LPD) remains to be established as a safe and effective alternative to open pancreaticoduodenectomy (OPD) for pancreatic-head and periampullary malignancy. The purpose of this meta-analysis was to compare LPD with OPD for these malignancies regarding short-term surgical and long-term survival outcomes.MethodsA literature search was conducted before March 2018 to identify comparative studies in regard to outcomes of both LPD and OPD for the treatment of pancreatic-head and periampullary malignancies. Morbidity, postoperative pancreatic fistula (POPF), mortality, operative time, estimated blood loss, hospitalization, retrieved lymph nodes, and survival outcomes were compared.ResultsAmong eleven identified studies, 1196 underwent LPD, and 8247 were operated through OPD. The pooled data showed that LPD was associated with less morbidity (OR = 0.57, 95%CI: 0.41~ 0.78, P < 0.01), less blood loss (WMD = − 372.96 ml, 95% CI, − 507.83~ − 238.09 ml, P < 0.01), shorter hospital stays (WMD = − 197.49 ml, 95% CI, − 304.62~ − 90.37 ml, P < 0.01), and comparable POPF (OR = 0.85, 95%CI: 0.59~ 1.24, P = 0.40), and overall survival (HR = 1.03, 95%CI: 0.93~ 1.14, P = 0.54) compared to OPD. Operative time was longer in LPD (WMD = 87.68 min; 95%CI: 27.05~ 148.32, P < 0.01), whereas R0 rate tended to be higher in LPD (OR = 1.17; 95%CI: 1.00~ 1.37, P = 0.05) and there tended to be more retrieved lymph nodes in LPD (WMD = 1.15, 95%CI: -0.16~ 2.47, P = 0.08), but these differences failed to reach statistical significance.ConclusionsLPD can be performed as safe and effective as OPD for pancreatic-head and periampullary malignancy with respect to both surgical and oncological outcomes. LPD is associated with less intraoperative blood loss and postoperative morbidity and may serve as a promising alternative to OPD in selected individuals in the future.

Comparison of Minimally Invasive versus Open Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Propensity Score Matching Analysis

“…Perioperative outcomes showed that there were differences in the operation time in the non-corrected data and PSM data. This result suggests that regardless of disease severity, MIPD is a more lengthy procedure because of technical difficulties; this result is also similar to the findings of previous reports [14,23,29,30]. However, despite the longer operation time of MIPD, overall complication and in-hospital / late complication rates did not differ between the two groups.…”

“…The development of MIPD was based on Gagner and Pomp's original LPD description from 1994 [22]. Several studies from high-volume centers have reported that MIPD might be feasible and confer advantages over OPD for benign lesions and periampullary malignancy [23][24][25]. However, reservations concerning the safety of MIPD persist as the majority of hospitals performing MIPD were low-volume centers, and its use has been associated with increased morbidity and mortality [26][27][28].…”

Pitfalls for laparoscopic pancreaticoduodenectomy: Need for a stepwise approach

“…Surgical indications for Lap PD may be similar to those for Open PD . Benign and low‐grade malignant (borderline malignant) periampullary tumors are the best indications for Lap PD when considering long‐term survival and quality of life, as minimal or no lymphadenectomy is needed .…”

“…Intraoperatively, wise decision‐making for open conversion to laparotomy is paramount. For patient safety, failure to progress within 1 hour of dissection as a result of severe pancreatitis or adhesions, unexpected vascular invasion, unexpected adjacent organ involvement requiring combined organ resection, unusual vascular anatomy, and uncontrolled bleeding may warrant open conversion to laparotomy . Although combined segmental resection of the major venous system is feasible and safe, only expert surgeons can carry out this difficult intraoperative situation to complete a safe and successful Lap PD.…”

Minimally Invasive Surgery of Pancreatic Cancer: Feasibility and Rationale

“…Apart from distal pancreatectomy and enucleation, minimally invasive pancreatic surgery, including robot-assisted surgery, has not yet gained widespread acceptance in the surgical community around the world. It is associated with reduced morbidity, enhanced postoperative recovery, and shorter hospital stay [2,3,4]; however, recent studies also found that its widespread use can also increase morbidity and mortality [5]. Thus, more widespread use of minimally invasive pancreatoduodenectomy requires structured training programs.…”