Is total laparoscopic pancreaticoduodenectomy superior to open procedure? A meta-analysis

doi:10.3748/wjg.v25.i37.5711

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World Journal of Gastroenterology

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Meta-Analysis

World J Gastroenterol. Oct 7, 2019; 25(37): 5711-5731
Published online Oct 7, 2019. doi: 10.3748/wjg.v25.i37.5711

Table 1 Characteristics of 28 included studies.

First author	Year	Country	Study design	Sample size		Conver-sion n (%)	ISGPF	ISGPS	Clavien-Dindo	Quali-ty Scor-es
First author	Year	Country	Study design	TLPD	OPD	Conver-sion n (%)	ISGPF	ISGPS	Clavien-Dindo	Quali-ty Scor-es
Zimmerman	2018	USA	Retrospective analysis	280	6336	78 (27.86)	NR	NR	NR	7^a
Tran	2016	USA	Retrospective analysis	681	14893	NR	NR	NR	NR	7^a
Tee	2015	USA	Retrospective analysis	113	225	NR	YES	YES	YES	8^a
Tan	2015	China	Retrospective analysis	30	30	NR	YES	YES	NR	9^a
Stauffer	2017	USA	Retrospective analysis	58	193	NR	YES	YES	YES	8^a
Song	2015	Korea	Matched case-control study	97	198	NR	YES	YES	YES	8^a
Sharpe	2015	USA	Retrospective analysis	384	4037	NR	NR	NR	NR	7^a
Senthilna-than	2015	India	Retrospective analysis	45	118	NR	NR	NR	NR	8^a
Poves	2018	Spain	RCT	32	29	8 (25.00)	YES	YES	YES	4^b
Palanivelu	2017	India	RCT	32	32	1 (3.13)	YES	YES	YES	3^b
Meng	2018	China	Retrospective analysis	58	58	NR	YES	YES	YES	9^a
Lee	2018	Korea	Matched case-control study	31	31	NR	NR	NR	NR	9^a
Khaled	2018	UK	Matched case-control study	15	15	1 (6.67)	YES	YES	YES	9^a
Kantor	2017	USA	Retrospective analysis	828	7385	NR	NR	NR	NR	7^a
Hakeem	2014	UK	Matched case-control study	12	12	NR	NR	NR	YES	9^a
Gerber	2017	USA	Retrospective analysis	52	50	NR	NR	NR	NR	8^a
Dokmak	2015	France	Matched case-control study	46	46	3 (6.52)	YES	YES	YES	9^a
Delitto	2016	USA	Retrospective analysis	52	50	NR	YES	YES	YES	8^a
Croome	2014	USA	Retrospective analysis	108	214	7 (6.48)	YES	YES	YES	8^a
Conrad	2017	USA	Retrospective analysis	40	25	9 (22.50)	YES	YES	YES	8^a
Chopinet	2018	France	Retrospective analysis	65	290	NR	YES	YES	YES	8^a
Chen	2018	China	Retrospective analysis	47	55	NR	YES	YES	YES	8^a
Chapman	2018	USA	Retrospective analysis	22	25	0 (0)	YES	YES	YES	8^a
Chapman	2018	USA	Retrospective analysis	248	1520	74 (29.84)	NR	NR	NR	7^a
Asbun	2012	USA	Retrospective analysis	53	215	9 (15.00)	YES	YES	NR	8^a
Zureikat	2011	USA	Matched case-control study	14	14	2 (14.29)	YES	NR	YES	9^a
Mesleh	2013	USA	Retrospective analysis	75	48	10 (13.33)	YES	YES	YES	8^a
Speicher	2014	USA	Retrospective analysis	25	84	NR	YES	NR	NR	8^a

^aNewcastle-Ottawa scale;

^bJadad scale. TLPD: Total laparoscopic pancreaticoduodenectomy; OPD: Open pancreaticoduodenectomy; ISGPF: International Study Group of Pancreatic Fistula; ISGPS: International Study Group on Pancreatic Surgery; Clavien-Dindo: The Clavien-Dindo Classification of Surgical Complications; RCT: Randomized controlled trial; NR: Not reported.

Table 2 Meta-analysis of intraoperative and perioperative results

Outcome of interest	No. of studies	Sample size		Heterogeneity		Model	Overall effect size	95%CI of overall effect	P-value
Outcome of interest	No. of studies	TLPD	OPD	P	I²	Model	Overall effect size	95%CI of overall effect	P-value
Operative time	11	642	1129	< 0.00001	99%	R	WMD = 77.92	40.89, 114.95	< 0.0001
EBL	10	612	1324	< 0.00001	98%	R	WMD = -260.08	-336.02, -184.14	< 0.00001
Transfusion rate	12	1254	15964	0.003	60%	R	OR = 0.51	0.36, 0.72	0.0001
Overall morbidity	12	1407	22126	0.10	37%	F	OR = 0.82	0.73, 0.92	0.0008
Major morbidity	16	886	1704	0.05	41%	F	OR = 0.88	0.70, 1.10	0.25
POPF	17	954	7629	0.42	3%	F	OR = 0.95	0.79, 1.15	0.62
POPF (grade B/C)	18	942	1821	0.47	0	F	OR = 0.96	0.76, 1.22	0.75
DGE	13	890	7452	0.98	0	F	OR = 0.99	0.78, 1.24	0.90
DGE (grade B/C)	7	479	994	0.60	0	F	OR = 0.63	0.45, 0.88	0.006
PPH	13	771	7363	0.74	0	F	OR = 1.12	0.89, 1.42	0.34
PPH (grade B/C)	7	454	966	0.91	0	F	OR = 1.02	0.65, 1.60	0.95
Bile leak	8	289	522	0.96	0	F	OR = 1.11	0.57, 2.16	0.76
Gastroente-ric anastomosis fistula	4	201	423	0.77	0	F	OR = 0.62	0.16, 2.40	0.49
Wound infection	10	612	7033	0.38	7%	F	OR = 0.48	0.34, 0.67	< 0.0001
Intra-abdominal abscess	6	455	6676	0.32	14%	F	OR = 0.97	0.71, 1.31	0.82
Bowel obstruction	2	73	73	0.33	0	F	OR = 1.00	0.14, 7.31	1.00
Fluid collection	3	142	367	0.20	37%	F	OR = 1.50	0.90, 2.48	0.12
Pneumonia	13	1489	22399	0.99	0	F	OR = 0.72	0.60, 0.85	0.0002
Cardiac event	6	1200	21877	0.75	0	F	OR = 1.04	0.82, 1.32	0.75
Reoperation	14	881	7616	0.40	5%	F	OR = 1.10	0.83, 1.47	0.51
ICU admission	2	171	283	0.40	0	F	OR = 0.90	0.53, 1.54	0.71
ICU stay	2	65	227	0.62	0	F	WMD = -2.08	-2.88, -1.29	< 0.00001
Diet Start Time	3	175	284	<0.0001	90%	R	WMD = -1.75	-3.38, -0.12	0.04
LOS	10	1544	11922	< 0.00001	78%	R	WMD = -3.05	-3.93, -2.17	< 0.00001
Discharge to a new facility	4	498	6826	0.74	0	F	OR = 0.55	0.39, 0.78	0.0008
30-d readmission	10	2006	19786	0.30	15%	F	OR = 0.81	0.68, 0.95	0.010
90-d readmission	4	136	279	0.70	0	F	OR = 1.07	0.62, 1.84	0.81
30-d mortality	18	2870	35337	0.70	0	F	OR = 1.00	0.81, 1.24	1.00
90-d mortality	11	1273	9159	0.77	0	F	OR = 0.77	0.58, 1.01	0.06

EBL: Estimated blood loss; Major morbidity: Clavien-Dindo classification ≥ III; POPF: Postoperative pancreatic fistula; DGE: Delayed gastric emptying; PPH: Postpancreatectomy hemorrhage; LOS: Length of hospital stay; ICU: Intensive care unit; WMD: Weighted mean difference; OR: Odds ratio; CI: Confidence interval; F: Fixed-effects model; R: Random-effects model; TLPD: Total laparoscopic pancreaticoduodenectomy; OPD: Open pancreaticoduodenectomy.

Table 3 Meta-analysis of oncological outcomes

Outcome of interest	No. of studies	Sample size		Heterogeneity		Model	Overall effect size	95%CI of overall effect	P-value
Outcome of interest		TLPD	OPD	P	I²	Model	Overall effect size	95%CI of overall effect	P-value
Tumor size	10	814	4782	< 0.00001	85%	R	WMD = -0.32	-0.58, -0.07	0.01
RLNs	12	1600	12347	< 0.00001	77%	R	WMD = 1.32	0.57, 2.06	0.0005
R0 rate	19	1991	14477	0.88	0	F	OR = 1.28	1.13, 1.44	0.0001
Time to adjuvant chemotherapy	2	867	7526	0.39	0	F	WMD = -2.44	-4.39, -0.49	0.01
RFS of all malignant tumor patients
1-yr RFS	2	52	37	NA	NA	F	OR = 0.44	0.16, 1.23	0.12
3-yr RFS	2	52	37	0.22	35%	F	OR = 0.53	0.19, 1.47	0.22
5-yr RFS	2	52	37	0.31	4%	F	OR = 0.40	0.12, 1.33	0.14
OS of all malignant tumor patients
1-yr OS	5	412	2206	0.007	72%	R	OR = 0.62	0.33, 1.19	0.15
2-yr OS	4	400	2194	0.03	66%	R	OR = 0.61	0.32, 1.17	0.14
3-yr OS	5	412	2206	0.08	51%	R	OR = 0.80	0.40, 1.62	0.54
4-yr OS	4	400	2194	0.60	0	F	OR = 0.73	0.41, 1.30	0.28
5-yr OS	6	520	2420	0.52	0	F	OR = 0.78	0.38, 1.59	0.49
OS of PDAC patients
1-yr OS	3	349	1947	0.28	22%	F	OR = 0.93	0.74, 1.18	0.57
2-yr OS	3	349	1947	0.21	37%	F	OR = 0.93	0.70, 1.24	0.63
3-yr OS	3	349	1947	0.60	0	F	OR = 0.86	0.56, 1.34	0.52
4-yr OS	3	349	1947	0.95	0	F	OR = 0.97	0.49, 1.92	0.94
5-yr OS	3	349	1947	0.27	17%	F	OR = 0.65	0.19, 2.23	0.49
OS of periampullary adenocarcinoma patients
1-yr OS	3	349	1947	0.28	22%	F	OR = 0.93	0.74, 1.18	0.57
2-yr OS	3	349	1947	0.21	37%	F	OR = 0.93	0.70, 1.24	0.63
3-yr OS	3	349	1947	0.60	0	F	OR = 0.86	0.56, 1.34	0.52
4-yr OS	3	349	1947	0.95	0	F	OR = 0.97	0.49, 1.92	0.94
5-yr OS	3	349	1947	0.27	17%	F	OR = 0.65	0.19, 2.23	0.49
5-yr OS	6	520	2420	0.52	0	F	OR = 0.78	0.38, 1.59	0.49

RLNs: Retrieved lymph nodes; RFS: Recurrence-free survival; OS: Overall survival; PDAC: Pancreatic ductal adenocarcinoma; OR: Odds Ratio; CI: Confidence interval; F: Fixed-effects model; R: Random-effects model; NA: Not applicable; TLPD: Total laparoscopic pancreaticoduodenectomy; OPD: Open pancreaticoduodenectomy.

Table 4 Results of sensitivity analysis of total laparoscopic pancreaticoduodenectomy vs open pancreaticoduodenectomy

Outcomes of interest	No. of Studies	Sample size		Heterogeneity		Model	Overall effect size	95%CI of overall effect	P-value
Outcomes of interest	No. of Studies	TLPD	OPD	P	I²	Model	Overall effect size	95%CI of overall effect	P-value
Operative time	10	577	1064	< 0.00001	98%	R	WMD = 74.66	43.71, 105.62	< 0.00001
EBL	9	547	1034	< 0.00001	95%	R	WMD = -280.46	-347.73, -213.19	< 0.00001
Transfusion rate	10	573	1071	0.15	32%	F	OR = 0.45	0.35, 0.58	< 0.00001
Overall morbidity	9	381	607	0.31	15%	F	OR = 0.88	0.65, 1.18	0.38
Major morbidity	15	829	1414	0.49	0	F	OR = 0.75	0.59, 0.96	0.02
POPF	15	617	1003	0.61	0	F	OR = 0.82	0.64, 1.05	0.11
POPF (grade B/C)	17	877	1531	0.89	0	F	OR = 0.86	0.66, 1.11	0.24
DGE	10	523	801	0.93	0	F	OR = 0.93	0.64, 1.34	0.69
DGE (grade B/C)	7	479	994	0.60	0	F	OR = 0.63	0.45, 0.88	0.006
PPH	11	434	737	0.84	0	F	OR = 1.48	0.93, 2.36	0.10
PPH (grade B/C)	7	454	966	0.91	0	F	OR = 1.02	0.65, 1.60	0.95
Bile leak	7	232	232	0.93	0	F	OR = 1.00	0.45, 2.25	0.99
Gastroente-ric anastomosis fistula	3	136	133	0.54	0	F	OR = 0.49	0.09, 2.73	0.42
Wound infection	9	332	697	0.46	0	F	OR = 0.57	0.39, 0.84	0.005
Intra-abdominal abscess	5	175	340	0.23	29%	F	OR = 0.74	0.39, 1.38	0.34
Bowel obstruction	2	73	73	0.33	0	F	OR = 1.00	0.14, 7.31	1.00
Fluid collection	2	77	77	0.96	0	F	OR = 0.63	0.21, 1.89	0.41
Pneumonia	10	463	880	0.99	0	F	OR = 0.79	0.54, 1.15	0.21
Cardiac event	4	239	648	0.48	0	F	OR = 1.11	0.75, 1.62	0.61
Reoperation	12	544	990	0.46	0	F	OR = 0.76	0.48, 1.21	0.25
ICU admission	2	171	283	0.40	0	F	OR = 0.90	0.53, 1.54	0.71
ICU stay	2	65	227	0.62	0	F	WMD = -2.08	-2.88, -1.29	< 0.00001
Diet start time	3	175	284	<0.0001	90%	R	WMD = -1.75	-3.38, -0.12	0.04
LOS	8	332	500	0.004	67%	R	WMD = -3.69	-4.90, -2.48	< 0.00001
Discharge to a new facility	3	218	490	0.60	0	F	OR = 0.50	0.28, 0.87	0.01
30-d readmission	6	340	508	0.77	0	F	OR = 1.04	0.68, 1.59	0.86
90-d readmission	4	136	279	0.70	0	F	OR = 1.07	0.62, 1.84	0.81
30-d mortality	12	527	1271	0.76	0	F	OR = 1.26	0.59, 2.68	0.55
90-d mortality	9	312	661	0.96	0	F	OR = 0.60	0.31, 1.17	0.14
Time to adjuvant chemothe-rapy	1	39	141	NA	NA	F	WMD = -5.50	-12.71, 1.71	0.14
Tumor size	9	430	745	0.0002	73%	R	WMD = -0.36	-0.63, -0.09	0.008
RLNs	10	388	925	< 0.00001	79%	R	WMD = 1.28	0.29, 2.27	0.01
R0 rate	16	605	1535	0.87	0	F	OR = 1.44	1.07, 1.94	0.02
OS of PDAC
1-yr OS	2	65	427	0.49	0	F	OR = 0.65	0.37, 1.13	0.12
2-yr OS	2	65	427	0.74	0	F	OR = 0.54	0.27, 1.07	0.08
3-yr OS	2	65	427	0.37	0	F	OR = 0.98	0.46, 2.10	0.96
4-yr OS	2	65	427	0.82	0	F	OR = 1.04	0.43, 2.52	0.93
5-yr OS	2	65	427	0.27	17%	F	OR = 0.65	0.19, 2.23	0.49
OS of periampullary adenocarcinoma patients
1-yr OS	2	23	234	0.004	88%	R	OR = 0.85	0.01, 107.31	0.95
3-yr OS	2	23	234	0.01	84%	R	OR = 0.90	0.01, 86.00	0.96
5-yr OS	2	23	234	0.26	20%	F	OR = 1.57	0.43, 5.73	0.49

NA: Not applicable; EBL: Estimated blood loss; Major morbidity: Clavien-Dindo classification ≥ III; RLNs: Retrieved lymph nodes; POPF: Postoperative pancreatic fistula; DGE: Delayed gastric emptying; PPH: Postpancreatectomy hemorrhage; LOS: Length of hospital stay; ICU: Intensive care unit; RFS: Recurrence-free survival; OS: Overall survival; PDAC: Pancreatic ductal adenocarcinoma; WMD: Weighted mean difference; OR: Odds ratio; CI: Confidence interval; F: Fixed-effects model; R: Random-effects model; TLPD: Total laparoscopic pancreaticoduodenectomy; OPD: Open pancreaticoduodenectomy.

Citation: Zhang H, Lan X, Peng B, Li B. Is total laparoscopic pancreaticoduodenectomy superior to open procedure? A meta-analysis. World J Gastroenterol 2019; 25(37): 5711-5731
URL: https://www.wjgnet.com/1007-9327/full/v25/i37/5711.htm
DOI: https://dx.doi.org/10.3748/wjg.v25.i37.5711