Laparoscopic vs. Open Pancreaticoduodenectomy After Learning Curve: A Systematic Review and Meta-Analysis of Single-Center Studies

Abstract

Background: Although laparoscopic pancreaticoduodenectomy (LPD) is a safe and feasible treatment compared with open pancreaticoduodenectomy (OPD), surgeons need a relatively long training time to become technically proficient in this complex procedure. In addition, the incidence of complications and mortality of LPD will be significantly higher than that of OPD in the initial stage. This meta-analysis aimed to compare the safety and overall effect of LPD to OPD after learning curve based on eligible large-scale retrospective cohorts and randomized controlled trials (RCTs), especially the difference in the perioperative and short-term oncological outcomes. Methods: PubMed, Web of Science, EMBASE, Cochrane Central Register, and ClinicalTrials.gov databases were searched based on a defined search strategy to identify eligible studies before March 2021. Only clinical studies reporting more than 40 cases for LPD were included. Data on operative times, blood loss, and 90-day mortality, reoperation, length of hospital stay (LOS), overall morbidity, Clavien-Dindo ≥III complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0 resection, lymph node dissection, positive lymph node numbers, and tumor size) were subjected to meta-analysis. Results: Overall, the final analysis included 13 retrospective cohorts and one RCT comprising 2,702 patients (LPD: 1,040, OPD: 1,662). It seems that LPD has longer operative time (weighted mean difference (WMD): 74.07; 95% CI: 39.87-108.26; p < 0.0001). However, compared with OPD, LPD was associated with a higher R0 resection rate (odds ratio (OR): 1.43; 95% CI: 1.10-1.85; p = 0.008), lower rate of wound infection (OR: 0.35; 95% CI: 0.22-0.56; p < 0.0001), less blood loss (WMD: -197.54 ml; 95% CI -251.39 to -143.70; p < 0.00001), lower blood transfusion rate (OR: 0.58; 95% CI 0.43-0.78; p = 0.0004), and shorter LOS (WMD: -2.30 day; 95% CI -3.27 to -1.32; p < 0.00001). No significant differences were found in 90-day mortality, overall morbidity, Clavien-Dindo ≥ III complications, reoperation, POPF, DGE, PPH, lymph node dissection, positive lymph node numbers, and tumor size between LPD and OPD. Conclusion: Comparative studies indicate that after the learning curve, LPD is a safe and feasible alternative to OPD. In addition, LPD provides less blood loss, blood transfusion, wound infection, and shorter hospital stays when compared with OPD.

Keywords: laparoscopic; meta-analysis; pancreatic cancer; pancreaticoduodenectomy; whipple.

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 risk of the bias assessment tool. Studies were deemed to be at high, low, or unclear risk of bias based on the adequacy of sequence generation, allocation concealment, blinding, method of addressing incomplete data, selective reporting, and other biases. The review judgments of authors 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 vs. OPD for operative outcomes. (A) Forest plot for the length of stay; (B) forest plot for blood loss; and (C) forest plot for blood transfusion.

Figure 4

Forest plot of comparison of LPD vs. OPD for postoperative outcomes. (A) Forest plot for operative time; (B) forest plot for overall complication rates; (C) forest plot for Clavien–Dindo grade ≥ III; and (D) forest plot for 90-day mortality.

Figure 5

Forest plot of comparison of LPD vs. 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; and (E) forest plot for reoperation.

Figure 6

Forest plot of comparison of LPD vs. OPD for short-term oncological outcomes. (A) Forest plot for R0 resection rate; (B) forest plot for lymph node dissection; (C) forest plot for positive lymph node number; and (D) forest plot for tumor size.

Figure 7

Funnel plots for postoperative pancreatic fistula.