Open and minimally invasive pancreatic surgery—a review of the literature

Abstract

Background: There is increasing evidence demonstrating the safety, feasibility and improved postoperative recovery of laparoscopic pancreas resections. The purpose of this study is to review recent advances in laparoscopic distal pancreatectomy (LDP) and minimally invasive pancreaticoduodenectomy (MIPD) with an emphasis on laparoscopic technique, intraoperative outcomes, perioperative outcomes, and oncologic outcomes. Methods: A systematic literature search was performed using MEDLINE, Web of Science, and Embase. Studies were included if they were an original series in adult patients comparing laparoscopic and open pancreatectomies between 2005 and 2015 with ten or more patients in the laparoscopic group. Patient demographics and intraoperative, postoperative, and oncologic variables were recorded. Odds ratios (ORs) were calculated from dichotomous data and the mean difference (MD) from the continuous data, both with 95% confidence intervals (CIs). Results: A total of 495 articles were reviewed, 42 of which were selected and included in the distal pancreatectomy group and 19 studies in the pancreaticoduodenectomy group. LDP was performed in 20.2% (n=3,759/18,587) of patients. MIPD was performed in 14.8% (n=3,692/24,923) of patients. Patients in the LDP group had longer operating times (P<0.001), lower estimated blood loss (P<0.001), reduced number of red blood cell transfusions (P<0.001), higher rate of spleen preservation (P<0.001), lower positive margin (P<0.001), lower overall complication rates (P<0.001), reduced 30-day mortality or in-hospital mortality (P=0.012), less post-operative bleeding (P=0.003), decreased wound infections (P<0.001), shorter length of hospital stay (P<0.001), earlier return of bowel function (P<0.001), quicker time to PO intake (P<0.001), and fewer days of IV narcotics (P=0.016). The LDP group had similar lymph node (LN) retrieval (P=0.325), number of patients with positive LN (P=0.734), pancreatic fistula rates (P=0.539), need for re-operation (P=0.354), readmission rates (P=0.898), and time to ambulation (P=0.081) as the open group. The MIPD group had longer operating room times (P<0.001), fewer intra-operative red blood cell transfusions (P=0.009), lower positive margin rate (P=0.022), increased post-operative bleeding (P=0.024), shorter length of hospital stay (P<0.001), lower readmission rate (P=0.048), earlier return of bowel function (P<0.001), and shorter time to PO intake (P<0.001) in comparison to the open group. However, both groups had similar LN retrieval (P=0.142), number of patients with positive LNs (P=0.099), overall morbidity (P=0.145), 30-day or in-hospital mortality (P=0.853), pancreatic fistula (P=0.685), delayed gastric emptying (DGE) (P=0.092), bile leak (P=0.617), wound infections (P=0.061), and similar reoperation rates (P=0.863). Conclusions: Analysis of the available literature suggests that laparoscopic pancreatectomies are feasible, safe, and potentially have improved perioperative recovery; while achieving equivalent oncologic outcomes when compared to open resection. Further investigation with randomized controlled trials is needed to avoid selection bias and control for confounding factors inherently found in the studies reviewed. However, this analysis does suggest a growing acceptance of laparoscopic pancreas surgery.