Propensity-Score Matched Analyses Comparing Clinical Outcomes of Minimally Invasive Versus Open Distal Pancreatectomies: A Single-Center Experience

A Comparison of Robotic Versus Laparoscopic Distal Pancreatectomy for Benign or Malignant Lesions: A Meta-Analysis

Background: The momentum of robotic surgery is increasing, and it has great prospects in pancreatic surgery. It has been widely accepted and expanding to more and more centers. Robotic distal pancreatectomy (RDP) is the most recent advanced minimally invasive approach for pancreatic lesions and malignancies. However, laparoscopic distal pancreatectomy (LDP) also showed good efficacy. We compared the effect of RDP with LDP using a meta-analysis. Methods: From January 2010 to June 2023, clinical trials of RDP versus LDP were determined by searching PubMed, Medline, and EMBASE. A meta-analysis was conducted to compare the effect of RDP with LDP. This meta-analysis evaluated the R0 resection rate, lymph node metastasis rate, conversion to open surgery rate, spleen preservation rate, intraoperative blood loss, postoperative pancreatic fistula, postoperative hospital stay, 90-day mortality rate, surgical cost, and total cost. Results: This meta-analysis included 38 studies. Conversion to open surgery, blood loss, and 90-day mortality in the RDP group were all significantly less than that in the LDP group (P < .05). There was no difference in lymph node resection rate, R0 resection rate, or postoperative pancreatic fistula between the two groups (P > .05). Spleen preservation rate in the LDP group was higher than that in the RDP group (P < .05). Operation cost and total cost in the RDP group were both more than that in the LDP group (P < .05). It is uncertain which group has an advantage in postoperative hospital stay. Conclusions: To some degree, RDP and LDP were indeed worth comparing in clinical practice. However, it may be difficult to determine which is absolute advantage according to current data. Large sample randomized controlled trials are needed to confirm which is better treatment. PROSPERO ID: CRD4202345576.

Advantages of laparoscopic distal pancreatectomy: Systematic review and meta-analysis of randomized and matched studies

BACKGROUND

We sought to provide a meta-analysis and credibility assessment of available randomized controlled trials and propensity score matched studies when assessing early and oncologic outcomes of laparoscopic distal pancreatectomy compared with open distal pancreatectomy.

METHODS

The MEDLINE, Scopus, Web of Science, and Cochrane databases were searched for pertinent literature up to June 2022. Random-effect meta-analyses were applied. Trial sequential analysis was applied to verify whether results were true- or false-positive or -negative findings.

RESULTS

Thirteen studies were identified (2 randomized controlled trials and 11 propensity score matched studies). The early outcomes were assessed on 12 studies, including 4,346 patients. In this population, laparoscopic distal pancreatectomy decreased postoperative stay (mean difference = 1.8 days; P = .001) and estimated blood loss (mean difference = 148 mL; P = .001), and trial sequential analysis confirmed these as true-positive findings. Laparoscopic distal pancreatectomy and open distal pancreatectomy had similar operating times (P = .165), and trial sequential analysis confirmed this as a true-negative finding. Major morbidity, mortality, and readmission were similar, but results were inconclusive by trial sequential analysis. Oncologic outcomes were assessed on 5 studies, including 2,430 patients. In this population, laparoscopic distal pancreatectomy showed higher R0 resection rate (OR = 1.46; P = .001) and shorter time to adjuvant therapy (mean difference 4.0 days P = .003). A survival benefit was observed at 1 year after laparoscopic distal pancreatectomy (OR = 1.45; P = .001), which was not confirmed at 3 years (P = .650).

CONCLUSION

Laparoscopic distal pancreatectomy is superior to open distal pancreatectomy for most of the early outcomes analyzed. The operating time was equalized as a result of the learning curve. Results from patients with pancreatic cancer suggest at least an oncologic noninferiority of laparoscopic distal pancreatectomy compared with open distal pancreatectomy.

Robotic versus laparoscopic distal pancreatectomy on perioperative outcomes: a systematic review and meta-analysis

Robotic surgery has become a promising surgical method in minimally invasive pancreatic surgery due to its three-dimensional visualization, tremor filtration, motion scaling, and better ergonomics. Numerous studies have explored the benefits of RDP over LDP in terms of perioperative safety and feasibility, but no consensus has been achieved yet. This article aimed to evaluate the benefits and drawbacks of RDP and LDP for perioperative outcomes. By June 2022, all studies comparing RDP to LDP in the PubMed, the Embase, and the Cochrane Library database were systematically reviewed. According to the heterogeneity, fix or random-effects models were used for the meta-analysis of perioperative outcomes. Odds ratio (OR), weighted mean differences (WMD), and 95% confidence intervals (CI) were calculated. A sensitivity analysis was performed to explore potential sources of high heterogeneity and a trim and fill analysis was used to evaluate the impact of publication bias on the pooled results. Thirty-four studies met the inclusion criteria. RDP provides greater benefit than LDP for higher spleen preservation (OR 3.52 95% CI 2.62-4.73, p < 0.0001) and Kimura method (OR 1.93, 95% CI 1.42-2.62, p < 0.0001) in benign and low-grade malignant tumors. RDP is associated with lower conversion to laparotomy (OR 0.41, 95% CI 0.33-0.52, p < 0.00001), and shorter postoperative hospital stay (WMD - 0.57, 95% CI - 0.92 to - 0.21, p = 0.002), but it is more costly. In terms of postoperative complications, there was no difference between RDP and LDP except for 30-day mortality (RDP versus LDP, 0.1% versus 1.0%, p = 0.03). With the exception of its high cost, RDP appears to outperform LDP on perioperative outcomes and is technologically feasible and safe. High-quality prospective randomized controlled trials are advised for further confirmation as the quality of the evidence now is not high.

The effect of minimally invasive or open radical antegrade modular pancreatosplenectomy on pancreatic cancer: A multicenter randomized clinical trial protocol

Background

Radical antegrade modular pancreatosplenectomy (RAMPS) has been proven to improve R0 resection and lymph harvest in treating patients with distal pancreatic cancer. The development of minimally invasive surgery has advantages in postoperative recovery. Therefore, minimally invasive (MI-) RAMPS may combine the advantages of both benefits to improve survival. Nevertheless, evidence to validate the safety and efficacy of MI-RAMPS is limited.

Method/Design

The MIRROR trial will be the first multicenter prospective randomized clinical trial to investigate the outcome of MI-RAMPS. The hypothesis is that MI-RAMPS is superior in postoperative recovery. The primary outcome is the length of postoperative stay. Based on the hypothesis and primary outcome, the sample size is 250 patients (125 participants in each group). The trial will investigate factors related to surgical safety, short-term outcome, pathological assessment, and survival as secondary outcomes.

Conclusion

This study will offer a relatively higher level of evidence to further illustrate the accessibility and benefits of MI-RAMPS for the treatment of distal pancreatic cancer.

Clinical Trial Registration

Clinicaltrials.gov, NCT03770559.