Systematic Review with Meta-Analysis: Endoscopic and Surgical Resection for Ampullary Lesions

Abstract

Ampullary lesions (ALs) can be treated by endoscopic (EA) or surgical ampullectomy (SA) or pancreaticoduodenectomy (PD). However, EA carries significant risk of incomplete resection while surgical interventions can lead to substantial morbidity. We performed a systematic review and meta-analysis for R0, adverse-events (AEs) and recurrence between EA, SA and PD. Electronic databases were searched from 1990 to 2018. Outcomes were calculated as pooled means using fixed and random-effects models and the Freeman-Tukey-Double-Arcsine-Proportion-model. We identified 59 independent studies. The pooled R0 rate was 76.6% (71.8-81.4%, I² = 91.38%) for EA, 96.4% (93.6-99.2%, I² = 37.8%) for SA and 98.9% (98.0-99.7%, I² = 0%) for PD. AEs were 24.7% (19.8-29.6%, I² = 86.4%), 28.3% (19.0-37.7%, I² = 76.8%) and 44.7% (37.9-51.4%, I² = 0%), respectively. Recurrences were registered in 13.0% (10.2-15.6%, I² = 91.3%), 9.4% (4.8-14%, I² = 57.3%) and 14.2% (9.5-18.9%, I² = 0%). Differences between proportions were significant in R0 for EA compared to SA (p = 0.007) and PD (p = 0.022). AEs were statistically different only between EA and PD (p = 0.049) and recurrence showed no significance for EA/SA or EA/PD. Our data indicate an increased rate of complete resection in surgical interventions accompanied with a higher risk of complications. However, studies showed various sources of bias, limited quality of data and a significant heterogeneity, particularly in EA studies.

Keywords: ampulla of Vater; ampullectomy; pancreaticoduodenectomy; papillectomy; trans-duodenal ampullectomy.

Figure 1

Flow chart of the study selection process. Out of 2395 search results, 59 papers were finally included in the analysis. EA: endoscopic ampullectomy, SA: surgical ampullectomy, PD: pancreaticoduodenectomy.

Figure 2

Complete resection in endoscopic and surgical intervention. Proportions of meta-analyses were calculated and shown as forrest-plots for EA (A), SA (B) and PD (C). Pooled R0 rates were calculated to obtain a proportion with a 95% confidence interval (CI). The binary random effects model (DerSimonian–Laird) was used for EA and SA and a fixed effect model with inverse variance weighting was used for PD. EA: endoscopic ampullectomy, SA: surgical ampullectomy, PD: pancreaticoduodenectomy.

Figure 2

Complete resection in endoscopic and surgical intervention. Proportions of meta-analyses were calculated and shown as forrest-plots for EA (A), SA (B) and PD (C). Pooled R0 rates were calculated to obtain a proportion with a 95% confidence interval (CI). The binary random effects model (DerSimonian–Laird) was used for EA and SA and a fixed effect model with inverse variance weighting was used for PD. EA: endoscopic ampullectomy, SA: surgical ampullectomy, PD: pancreaticoduodenectomy.

Figure 3

Complications in endoscopic and surgical intervention. Proportions of meta-analyses were calculated and shown as forrest-plot for EA (A), SA (B) and PD (C). Pooled rates of complications were calculated to obtain a proportion with a 95% confidence interval (CI). The binary random effects model (DerSimonian–Laird) was used for EA and SA and a fixed effect model with inverse variance weighting for PD. EA: endoscopic ampullectomy, SA: surgical ampullectomy, PD: pancreaticoduodenectomy, AP: acute pancreatitis, NA: not available.

Figure 4

Recurrence in endoscopic and surgical intervention. Proportions of meta-analyses were calculated and shown as forrest-plots for EA (A), SA (B) and PD (C). Pooled rates of recurrence were calculated to obtain a proportion with a 95% confidence interval (CI). The binary random effects model (DerSimonian–Laird) was used for EA and SA and a fixed effect model with inverse variance weighting was used for PD. EA: endoscopic ampullectomy, SA: surgical ampullectomy, PD: pancreaticoduodenectomy.

Figure 4

Recurrence in endoscopic and surgical intervention. Proportions of meta-analyses were calculated and shown as forrest-plots for EA (A), SA (B) and PD (C). Pooled rates of recurrence were calculated to obtain a proportion with a 95% confidence interval (CI). The binary random effects model (DerSimonian–Laird) was used for EA and SA and a fixed effect model with inverse variance weighting was used for PD. EA: endoscopic ampullectomy, SA: surgical ampullectomy, PD: pancreaticoduodenectomy.

Figure 5

Analysis of publication bias. Funnel plots were drawn for EA (A) and SA (B) indicating no evidence of publication bias. Funnel plots were not used for PD as less than 10 PD papers were included in the meta-analysis. EA: endoscopic ampullectomy, SA: surgical ampullectomy, PD: pancreaticoduodenectomy.