CRD summary

This review concluded that laparoscopic distal pancreatectomy was safe compared with open surgery, with less blood loss, a lower risk of postoperative complications and wound infections, a shorter hospital stay, and no increase in operative time. These conclusions reflected the evidence, but may be affected by publication bias and a lack of evidence from randomised controlled trials.

Authors' objectives

To compare laparoscopic distal pancreatectomy with open distal pancreatectomy.

Searching

PubMed, EMBASE and The Cochrane Library were searched up to January 2011; search terms were reported. Only studies published in English were included. The related articles function was used to widen the search. The reference lists of the retrieved papers were searched.

Study selection

Studies comparing laparoscopic with open distal pancreatectomy, with or without the hand-assisted technique, were eligible for inclusion if they reported the surgical characteristics and perioperative outcomes. They had to report an objective evaluation of at least one of the following outcomes: operative (operation time, intra-operative blood loss, or transfusion rate); postoperative recovery (time to ambulation, time to oral food intake, time to flatus, or duration of hospital stay); oncologic safety (lymph node status or margin status); or postoperative complications (overall, major complications, surgical site infections, reoperation rate, pancreatic fistulae, or mortality). Studies of laparoscopic enucleation, debridement, or necrosectomy and pancreatectomy for trauma, and those involving exclusively robotic techniques were excluded.

In the included studies, where reported, the mean patient age ranged from 47 to 68 years, and the conversion rates from laparoscopic to open procedures ranged from zero to 30%. The definitions of postoperative pancreatic fistula varied between studies.

Studies were selected by two reviewers independently.

Assessment of study quality

Studies were quality assessed, using modified versions of the Newcastle-Ottawa scale and the Quality Assessment Tool for Systematic Reviews of Observational Studies. These covered patient selection, comparability of groups, and outcome assessment. Studies could score between zero and nine, with scores of six or more considered to be high quality. The authors did not report how many reviewers performed the assessment.

Data extraction

Odds ratios were calculated, for dichotomous outcomes, and mean differences, for continuous outcomes, both with 95% confidence intervals. If studies reported medians and ranges, standard deviations were estimated. The data were extracted by two reviewers independently.

Methods of synthesis

Odds ratios were pooled, using the Mantel-Haenszel random-effects model, and mean differences were pooled, using the inverse-variance random-effects model. Heterogeneity was evaluated using Ι² and Χ².

Sensitivity analyses were undertaken for the following: studies with more than 20 patients in each group; those matching groups for their clinicopathological factors; those of high quality; and prospective studies or retrospective reviews of prospectively maintained databases.

Results of the review

Eighteen studies were included, with 1,814 patients; 773 had laparoscopic and 1,041 had open surgery. Ten studies were retrospective reviews, seven were retrospective reviews of prospectively maintained databases, and one was a combination of both types. Ten studies had more than 20 patients in both groups, and twelve matched groups on clinically important factors. The use of intention-to-treat analysis was not reported or varied between studies. Quality scores ranged from four to eight.

Operative outcomes: Blood loss was significantly lower in the laparoscopic group (MD -354.98mL, 95% CI -529.29 to -180.66; 13 studies), with significant heterogeneity. Laparoscopic surgery significantly reduced the odds of a blood transfusion (OR 0.23, 95% CI 0.07 to 0.72; six studies), with no significant heterogeneity. Fifteen studies reported the mean operative time, but overall there was no significant difference between laparoscopic and open procedures.

Postoperative recovery: Laparoscopic surgery had a significantly shorter length of hospital stay (MD -4.05 days, 95% CI -5.37 to -2.73; 17 studies) and lower time to oral intake (MD -1.53 days, 95% CI -2.54 to -0.52; five studies), compared with open surgery. Significant heterogeneity was seen for both outcomes. No significant difference was seen for time to first flatus.

Postoperative complications: Laparoscopic surgery had a significantly lower incidence of postoperative morbidity (OR 0.73, 95% CI 0.57 to 0.95; 18 studies) and surgical site infections (OR 0.45, 95% CI 0.24 to 0.82; 11 studies). Readmission rates were lower with laparoscopic surgery (OR 0.58, 95% CI 0.35 to 0.96; three studies). There was no significant heterogeneity for any outcome. There were no significant differences between types of surgery in the reoperation rates, mortality and pancreatic fistulae.

The results for oncological outcomes, subgroups, and sensitivity analyses were reported.

Authors' conclusions

Laparoscopic distal pancreatectomy was a safe alternative to the open technique. It was associated with less blood loss, a lower risk of postoperative complications and wound infections, and a shorter hospital stay, with no increase in operative time.

CRD commentary

This review stated clear inclusion criteria. A few relevant databases were searched, but no attempts were made to locate unpublished research and only studies in English were included, putting the review at risk of language and publication bias. Appropriate tools for observational studies were used to assess study quality, but the modifications to these tools and the assessment results were not reported in full, making it difficult to judge the reliability of the evidence.

Study selection and data extraction were conducted by two people to reduce errors and bias, but it was not reported if the quality assessment was performed in the same way. The methods of meta-analysis seem to have been appropriate, but statistical heterogeneity was high in some cases; additional analyses were performed to explore the possible reasons for this.

The authors' conclusions reflected the synthesised evidence, but high levels of variation and the lack of large prospective studies, in which differences could be attributed solely to treatment, mean that the conclusions may not be reliable.

Implications of the review for practice and research

Practice: The authors stated that the improved complication profile, with no compromise to the margin status, suggested that laparoscopic distal pancreatectomy was a reasonable option for some cancer patients.

Research: The authors stated that more meta-analyses of oncologic safety were needed and they should report lymph node status. Primary research should be conducted into the cost-effectiveness of laparoscopic surgery, investigating the reduction in costs compared with open surgery.

Funding

Not stated.

Bibliographic details

Venkat R, Edil BH, Schulick RD, Lidor AO, Makary MA, Wolfgang CL. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Annals of Surgery 2012; 255(6): 1048-1059. [PubMed: 22511003]

Original Paper URL

http://journals.lww.com/annalsofsurgery/Abstract/2012/06000/Laparoscopic_Distal_Pancreatectomy_Is_Associated.8.aspx

Indexing Status

Subject indexing assigned by NLM

MeSH

Aged; Humans; Laparoscopy; Middle Aged; Morbidity; Pancreatectomy /adverse effects /methods; Pancreatic Diseases /surgery; Pancreatic Neoplasms /pathology /surgery

AccessionNumber

12012028044

Database entry date

07/01/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.