微创与开腹胰十二指肠切除术治疗非胰腺壶腹周围癌的临床意义：系统评价和个体患者数据分析荟萃分析。
The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis.
机构信息
Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.
Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.
出版信息
Langenbecks Arch Surg. 2023 Aug 15;408(1):311. doi: 10.1007/s00423-023-03047-4.
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.
背景
大多数微创胰十二指肠切除术（MIPD）的研究将胰腺和壶腹周围癌的患者合并在一起，尽管这些肿瘤之间存在很大的异质性。因此，本研究旨在评估 MIPD 与开放胰十二指肠切除术（OPD）相比在非胰腺壶腹周围癌（NPPC）患者中的作用。
方法
两名独立的审查员对 Pubmed、Embase 和 Cochrane 数据库进行了系统回顾，以确定比较 NPPC（壶腹、远端胆管和十二指肠腺癌）（01/2015-12/2021）中 MIPD 和 OPD 的研究。所有确定的研究都需要提供个体患者数据。主要结局是（90 天）死亡率和主要发病率（Clavien-Dindo 3a-5）。次要结局是术后胰瘘（POPF）、延迟胃排空（DGE）、胰切除术后出血（PPH）、失血、住院时间（LOS）和总生存（OS）。
结果
共有 16 项研究纳入了 1949 名患者，其中包括 928 名壶腹癌患者、526 名远端胆管癌患者和 461 名十二指肠癌患者。共有 902 名（46.3%）患者接受了 MIPD，1047 名（53.7%）患者接受了 OPD。MIPD 和 OPD 之间的 90 天死亡率、主要发病率、POPF、DGE、PPH、失血量和住院时间无差异。MIPD 组的手术时间延长了 67 分钟（P=0.009）。MIPD 组壶腹癌（HR 2.27，P=0.019）和远端胆管癌（HR 1.84，P=0.025）的 DFS 下降，以及远端胆管癌（HR 1.71，P=0.045）和十二指肠癌（HR 4.59，P<0.001）的 OS 下降。
结论
本项对 NPPC 患者 MIPD 与 OPD 的个体患者数据荟萃分析表明，MIPD 在短期发病率和死亡率方面并不劣于 OPD。长期数据中的几个主要局限性突显了一个研究空白，应该在分别针对壶腹、远端胆管和十二指肠癌的前瞻性维持国际登记处或随机研究中进行研究。
方案注册
2021 年 10 月 25 日在 PROSPERO（CRD42021277495）上注册。
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