Joseph Nejo, Varghese Chris, Lucocq James, McGuinness Matthew J, Tingle Samuel, Marchegiani Giovanni, Soreide Kjetil, Abu-Hilal Mohammed, Samra Jas, Besselink Marc, White Steve, Pandanaboyana Sanjay
From the Department of Surgery, University of Auckland, Auckland, New Zealand.
Department of General Surgery, NHS Lothian, Edinburgh, United Kingdom.
Ann Surg Open. 2024 Nov 19;5(4):e507. doi: 10.1097/AS9.0000000000000507. eCollection 2024 Dec.
The use of minimally invasive (laparoscopic and robotic) pancreatoduodenectomy (PD) is being increasingly adopted despite the lack of hard evidence to support its utilisation. With recent randomised controlled trials (RCTs) comparing open pancreatoduodenectomy (OPD) with robotic or laparoscopic pancreatoduodenectomy (RPD or LPD), we undertook a network meta-analysis (NMA) comparing all 3 approaches to evaluate comparative outcomes.
A systematic search of MEDLINE, EMBASE, and Cochrane CENTRAL was conducted up to May 2024 and relevant RCTs were identified. A random-effects meta-analysis and trial sequential analysis (TSA) were conducted for primary outcomes, followed by a Bayesian NMA of length of stay (LOS), duration of surgery, intraoperative blood loss, and pancreas resection-related outcomes.
Seven RCTs involving 1336 patients were included, 5 investigating LPD compared with OPD and 2 RPD to OPD. Pairwise meta-analysis indicated that LPD was associated with shorter hospital stay (mean difference [MD], -1.39; 95% confidence interval [CI], -2.33 to -0.45) and lower intraoperative blood loss compared with OPD (MD, -131; 95% CI, -146 to -117). However, LPD was associated with significantly longer operative duration (MD, 39.5; 95% CI, 34-45). TSA confirmed the robustness of the positive and negative findings on pairwise meta-analysis. In comparison, there were no significant differences between RPD and OPD in pairwise meta-analysis, which could not be confirmed by TSA. Network meta-analysis tended to favour LPD in most outcome parameters including LOS, duration of surgery, and pancreas resection-related outcomes.
The current RCT evidence suggests potential better outcomes in LPD in comparison with RPD and OPD. However, few studies demonstrated robust statistical significance in outcome measures, suggesting an underpowered evidence base and possible selection bias. Hence, with current equivocal data, there is a need for ongoing RCTs to validate the role of minimally invasive approaches in PD.
尽管缺乏确凿证据支持，但微创（腹腔镜和机器人辅助）胰十二指肠切除术（PD）的应用越来越广泛。随着近期将开放胰十二指肠切除术（OPD）与机器人或腹腔镜胰十二指肠切除术（RPD或LPD）进行比较的随机对照试验（RCT）的开展，我们进行了一项网络荟萃分析（NMA），比较这三种手术方式以评估相对疗效。
截至2024年5月，对MEDLINE、EMBASE和Cochrane CENTRAL进行了系统检索，并确定了相关的RCT。对主要结局进行随机效应荟萃分析和试验序贯分析（TSA），随后对住院时间（LOS）、手术时长、术中失血量和胰腺切除相关结局进行贝叶斯NMA。
纳入了7项涉及1336例患者的RCT，其中5项研究比较LPD与OPD，2项研究比较RPD与OPD。成对荟萃分析表明，与OPD相比，LPD的住院时间更短（平均差值[MD]，-1.39；95%置信区间[CI]，-2.33至-0.45），术中失血量更低（MD，-131；95%CI，-146至-117）。然而，LPD的手术时间显著更长（MD，39.5；95%CI，34 - 45）。TSA证实了成对荟萃分析中阳性和阴性结果的稳健性。相比之下，成对荟萃分析中RPD与OPD之间无显著差异，TSA也无法证实这一点。网络荟萃分析在包括LOS、手术时长和胰腺切除相关结局等大多数结局参数上倾向于支持LPD。
当前的RCT证据表明，与RPD和OPD相比，LPD可能具有更好的疗效。然而，很少有研究在结局指标上显示出强有力的统计学显著性，这表明证据基础不足且可能存在选择偏倚。因此，鉴于目前数据不明确，需要持续进行RCT以验证微创方法在PD中的作用。
