Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.
World J Surg. 2023 Oct;47(10):2507-2518. doi: 10.1007/s00268-023-07114-1. Epub 2023 Jul 12.
Minimally-invasive pancreatoduodenectomy (MIPD) is fraught with the risk of complication-related deaths (LEOPARD-2), a significant volume-outcome relationship and a long learning curve. With rates of conversion for MIPD approaching 40%, the impact of these on overall patient outcomes, especially, when unplanned, are yet to be fully elucidated. This study aimed to compare peri-operative outcomes of (unplanned) converted MIPD against both successfully completed MIPD and upfront open PD.
A systematic review of major reference databases was undertaken. The primary outcome of interest was 30-day mortality. Newcastle-Ottawa scale was used to judge the quality of the studies. Meta-analysis was performed using pooled estimates, derived using random effects model.
Six studies involving 20,267 patients were included in the review. Pooled analysis demonstrated (unplanned) converted MIPD were associated with an increased 30-day (RR 2.83, CI 1.62- 4.93, p = 0.0002, I = 0%) and 90-day (RR 1.81, CI 1.16- 2.82, p = 0.009, I = 28%) mortality and overall morbidity (RR 1.41, CI 1.09; 1.82, p = 0.0087, I = 82%) compared to successfully completed MIPD. Patients undergoing (unplanned) converted MIPD experienced significantly higher 30-day mortality (RR 3.97, CI 2.07; 7.65, p < 0.0001, I = 0%), pancreatic fistula (RR 1.65, CI 1.22- 2.23, p = 0.001, I = 0%) and re-exploration rates (RR 1.96, CI 1.17- 3.28, p = 0.01, I = 37%) compared upfront open PD.
Patient outcomes are significantly compromised following unplanned intraoperative conversions of MIPD when compared to successfully completed MIPD and upfront open PD. These findings stress the need for objective evidence-based guidelines for patient selection for MIPD.
微创胰十二指肠切除术（MIPD）存在与并发症相关的死亡风险（LEOPARD-2）、显著的量效关系和较长的学习曲线。由于 MIPD 的转化率接近 40%，因此这些因素对整体患者结局的影响，尤其是在计划外的情况下，尚未得到充分阐明。本研究旨在比较（计划外）中转 MIPD 与成功完成的 MIPD 和直接开放 PD 的围手术期结局。
对主要参考数据库进行系统评价。主要研究结果为 30 天死亡率。使用纽卡斯尔-渥太华量表来判断研究的质量。使用随机效应模型得出的汇总估计值进行荟萃分析。
纳入了 6 项涉及 20267 名患者的研究。汇总分析显示，（计划外）中转 MIPD 与 30 天（RR 2.83，CI 1.62-4.93，p=0.0002，I=0%）和 90 天（RR 1.81，CI 1.16-2.82，p=0.009，I=28%）死亡率以及总发病率（RR 1.41，CI 1.09-1.82，p=0.0087，I=82%）显著增加相关，与成功完成的 MIPD 相比。接受（计划外）中转 MIPD 的患者 30 天死亡率显著升高（RR 3.97，CI 2.07-7.65，p<0.0001，I=0%）、胰瘘（RR 1.65，CI 1.22-2.23，p=0.001，I=0%）和再次探查率（RR 1.96，CI 1.17-3.28，p=0.01，I=37%）均高于直接开放 PD。
与成功完成的 MIPD 和直接开放 PD 相比，MIPD 术中计划外转化后的患者结局显著受损。这些发现强调需要为 MIPD 患者选择制定客观的基于证据的指南。
