The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis

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Abstract

Background

Most studies on minimally invasive pancreatoduodenectomy (MIPD) combine patients with pancreatic and periampullary cancers even though there is substantial heterogeneity between these tumors. Therefore, this study aimed to evaluate the role of MIPD compared to open pancreatoduodenectomy (OPD) in patients with non-pancreatic periampullary cancer (NPPC).

Methods

A systematic review of Pubmed, Embase, and Cochrane databases was performed by two independent reviewers to identify studies comparing MIPD and OPD for NPPC (ampullary, distal cholangio, and duodenal adenocarcinoma) (01/2015–12/2021). Individual patient data were required from all identified studies. Primary outcomes were (90-day) mortality, and major morbidity (Clavien-Dindo 3a-5). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood-loss, length of hospital stay (LOS), and overall survival (OS).

Results

Overall, 16 studies with 1949 patients were included, combining 928 patients with ampullary, 526 with distal cholangio, and 461 with duodenal cancer. In total, 902 (46.3%) patients underwent MIPD, and 1047 (53.7%) patients underwent OPD. The rates of 90-day mortality, major morbidity, POPF, DGE, PPH, blood-loss, and length of hospital stay did not differ between MIPD and OPD. Operation time was 67 min longer in the MIPD group ( P = 0.009). A decrease in DFS for ampullary (HR 2.27, P = 0.019) and distal cholangio (HR 1.84, P = 0.025) cancer, as well as a decrease in OS for distal cholangio (HR 1.71, P = 0.045) and duodenal cancer (HR 4.59, P < 0.001) was found in the MIPD group.

Conclusions

This individual patient data meta-analysis of MIPD versus OPD in patients with NPPC suggests that MIPD is not inferior in terms of short-term morbidity and mortality. Several major limitations in long-term data highlight a research gap that should be studied in prospective maintained international registries or randomized studies for ampullary, distal cholangio, and duodenum cancer separately.

Protocol registration

PROSPERO (CRD42021277495) on the 25th of October 2021.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-023-03047-4.

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Most cited references 69

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The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception. Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.

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The PRISMA 2020 statement: An updated guideline for reporting systematic reviews

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Author and article information

Contributors

Bas A. Uijterwijk: basuijterwijk@live.nl

Mohammed Abu Hilal: abuhilal9@gmail.com

Journal

Journal ID (nlm-ta): Langenbecks Arch Surg

Journal ID (iso-abbrev): Langenbecks Arch Surg

Title: Langenbeck's Archives of Surgery

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 1435-2443

ISSN (Electronic): 1435-2451

Publication date (Electronic): 15 August 2023

Publication date PMC-release: 15 August 2023

Publication date (Print): 2023

Volume: 408

Issue: 1

Electronic Location Identifier: 311

Affiliations

[1 ]GRID grid.415090.9, ISNI 0000 0004 1763 5424, Department of Surgery, , Fondazione Poliambulanza Istituto Ospedaliero, ; Brescia, Italy

[2 ]GRID grid.7177.6, ISNI 0000000084992262, Department of Surgery, Amsterdam UMC, , Location University of Amsterdam, ; Amsterdam, the Netherlands

[3 ]Department of Surgery, Meiwa Hospital, Hyogo, Japan

[4 ]GRID grid.415356.0, ISNI 0000 0004 5935 6538, Department of Surgical Gastroenterology and Hepatopancreatobiliary Surgery, , GEM Hospital and Research Center, ; Ramanathapuram, Coimbatore, Tamil Nadu India

[5 ]GRID grid.440209.b, ISNI 0000 0004 0501 8269, Department of Surgery, , OLVG, ; Amsterdam, the Netherlands

[6 ]GRID grid.411142.3, ISNI 0000 0004 1767 8811, Hepatobiliary and Pancreatic Surgery Unit, , Hospital del Mar. Universitat Pompeu Fabra, ; Barcelona, Spain

[7 ]GRID grid.7700.0, ISNI 0000 0001 2190 4373, Department of General, Visceral and Transplantation Surgery, , University of Heidelberg, ; Heidelberg, Germany

[8 ]GRID grid.413967.e, ISNI 0000 0001 0842 2126, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, , University of Ulsan College of Medicine and Asan Medical Center, ; Seoul, Korea

[9 ]GRID grid.31501.36, ISNI 0000 0004 0470 5905, Department of Surgery and Cancer Research Institute, , Seoul National University College of Medicine, ; Seoul, South Korea

[10 ]GRID grid.15276.37, ISNI 0000 0004 1936 8091, Division of Surgical Oncology, General Surgery, , University of Florida, ; Gainesville, USA

[11 ]GRID grid.24704.35, ISNI 0000 0004 1759 9494, Department of Surgery, , Careggi University Hospital, ; Florence, Italy

[12 ]GRID grid.415928.3, Department of Surgery, , Misericordia Hospital of Grosseto, ; Grosseto, Italy

[13 ]Division of Oncologic and Mini-Invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

[14 ]GRID grid.46699.34, ISNI 0000 0004 0391 9020, Department of Liver Transplant and HPB Unit, , King’s College Hospital, ; London, UK

[15 ]GRID grid.163555.1, ISNI 0000 0000 9486 5048, Department of Hepatopancreatobiliary and Transplant Surgery, , Singapore General Hospital, ; Singapore, Singapore

[16 ]GRID grid.412793.a, ISNI 0000 0004 1799 5032, Department of Biliary-Pancreatic Surgery, , Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, ; Wuhan, China

Article

Publisher ID: 3047

DOI: 10.1007/s00423-023-03047-4

PMC ID: 10427526

PubMed ID: 37581763

SO-VID: 47dd1554-f2f8-4d35-a282-9652dffa6f15

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 12 April 2023

Date accepted : 3 August 2023

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100000051, National Human Genome Research Institute;

Award ID: T32 HG0008958

Award Recipient : Kelly M. Herremans

Funded by: FundRef http://dx.doi.org/10.13039/100004374, Medtronic;

Funded by: FundRef http://dx.doi.org/10.13039/100009933, Ethicon;

Custom metadata

ScienceOpen disciplines: Surgery

Keywords: minimally invasive surgery,minimally invasive pancreatoduodenectomy,ampulla of vater carcinoma,duodenal adenocarcinoma,distal cholangiocarcinoma,individual patient data meta-analysis

Data availability:

ScienceOpen disciplines: Surgery

Keywords: minimally invasive surgery, minimally invasive pancreatoduodenectomy, ampulla of vater carcinoma, duodenal adenocarcinoma, distal cholangiocarcinoma, individual patient data meta-analysis

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The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis

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Abstract

Background

Methods

Results

Conclusions

Protocol registration

Supplementary Information

Related collections

25th European Students' Conference

Most cited references 69

The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials

The Clavien-Dindo classification of surgical complications: five-year experience.

The PRISMA 2020 statement: An updated guideline for reporting systematic reviews

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Contributors

Journal

Affiliations

Article

History

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