Perioperative and short-term oncological outcomes following laparoscopic versus open pancreaticoduodenectomy after learning curve in the past 10 years: a systematic review and meta-analysis

Abstract

Background: To compare perioperative and short-term oncologic outcomes of laparoscopic pancreaticoduodenectomy (LPD) to open pancreaticoduodenectomy (OPD) using data from large-scale retrospective cohorts and randomized controlled trials (RCTs) in the last 10 years.

Methods: A meta-analysis to assess the safety and feasibility of LDP and OPD registered with PROSPERO: (CRD42020218080) was performed according to the PRISMA guidelines. Studies comparing LPD with OPD published between January 2010 and October 2020 were included; only clinical studies reporting more than 30 cases for each operation were included. Two authors performed data extraction and quality assessment independently. The primary endpoint was operative times, blood loss, and 90 days mortality. Secondary endpoints included reoperation, length of hospital stay (LOS), morbidity, Clavien-Dindo ≥3 complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0-resection, lymph node dissection).

Results: Overall, the final analysis included 15 retrospective cohorts and 3 RCTs comprising 12,495 patients (2,037 and 10,458 patients underwent LPD and OPD). It seems OPD has more lymph nodes harvested but no significant differences [weighted mean difference (WMD): 1.08; 95% confidence interval (CI): 0.02 to 2.14; P=0.05]. Nevertheless, compared with OPD, LPD was associated with a higher R0 resection rate [odds ratio (OR): 1.26; 95% CI: 1.10-1.44; P=0.0008] and longer operative time (WMD: 89.80 min; 95% CI: 63.75-115.84; P<0.00001), patients might benefit from lower rate of wound infection (OR: 0.36; 95% CI: 0.33-0.59; P<0.0001), much less blood loss (WMD: -212.25 mL; 95% CI: -286.15 to -138.14; P<0.00001) and lower blood transfusion rate (OR: 0.58; 95% CI: 0.43-0.77; P=0.0002) and shorter LOS (WMD: -1.63 day; 95% CI: -2.73 to -0.51; P=0.004). No significant differences in 90-day mortality, overall morbidity, Clavien-Dindo ≥3 complications, reoperation, POPF, DGE and PPH between LPD and OPD.

Conclusions: Our study suggests that after learning curve, LPD is a safe and feasible alternative to OPD as it provides similar perioperative and acceptable oncological outcomes when compared with OPD.

Keywords: Pancreatic cancer; laparoscopic pancreaticoduodenectomy (LPD); meta-analysis; open pancreaticoduodenectomy (OPD).

Figure 1

Flow chart of study identification and selection.

Figure 2

Quality assessment of included studies. Overall (left) and study-level risk of bias (right), using Cochrane’s risk of bias assessment tool. Studies were deemed to be at high, low or unclear risk of bias based on adequacy of sequence generation, allocation concealment, blinding, method of addressing incomplete data, selective reporting, and other biases. The review authors’ judgments about each risk of bias item are presented as percentages across all included studies, and for each included study.

Figure 3

Forest plot of comparison of LPD versus OPD for operative outcomes. (A) Forest plot for operative time; (B) forest plot for operative time; (C) forest plot for operative time. LPD, laparoscopic pancreaticoduodenectomy; OPD, open pancreaticoduodenectomy.

Figure 4

Forest plot of comparison of LPD versus OPD for Postoperative outcomes. (A) Forest plot for length of stay; (B) forest plot for overall complication rates; (C) forest plot for Cliavien-Dindo grade ≥ III; (D) forest plot for 90-day mortality. LPD, laparoscopic pancreaticoduodenectomy; OPD, open pancreaticoduodenectomy.

Figure 5

Forest plot of comparison of LPD versus OPD for overall complication rates. (A) Forest plot for postpancreatectomy hemorrhage; (B) forest plot for wound infection; (C) forest plot for postoperative pancreatic fistula; (D) forest plot for delayed gastric emptying; (E) forest plot for reoperation. LPD, laparoscopic pancreaticoduodenectomy; OPD, open pancreaticoduodenectomy.

Figure 6

Forest plot of comparison of LPD versus OPD for short-term oncological outcomes. (A) Forest plot for R0 resection rate; (B) forest plot for lymph node dissection. LPD, laparoscopic pancreaticoduodenectomy; OPD, open pancreaticoduodenectomy.

Figure 7

Funnel plots for postoperative pancreatic fistula.