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Robotic-assisted versus open pancreaticoduodenectomy for patients with benign and malignant periampullary disease: a systematic review and meta-analysis of short-term outcomes

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Abstract

Background

Although several non-randomized studies comparing robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) recently demonstrated that the two operative techniques could be equivalent in terms of safety outcomes and short-term oncologic efficacy, no definitive answer has arrived yet to the question as to whether robotic assistance can contribute to reducing the high rate of postoperative morbidity.

Methods

Systematic literature search was performed using MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE databases. Prospective and retrospective studies comparing RPD and OPD as surgical treatment for periampullary benign and malignant lesions were included in the systematic review and meta-analysis with no limits of language or year of publication.

Results

18 non-randomized studies were included for quantitative synthesis with 13,639 patients allocated to RPD (n = 1593) or OPD (n = 12,046). RPD and OPD showed equivalent results in terms of mortality (3.3% vs 2.8%; P = 0.84), morbidity (64.4% vs 68.1%; P = 0.12), pancreatic fistula (17.9% vs 15.9%; P = 0.81), delayed gastric emptying (16.8% vs 16.1%; P = 0.98), hemorrhage (11% vs 14.6%; P = 0.43), and bile leak (5.1% vs 3.5%; P = 0.35). Estimated intra-operative blood loss was significantly lower in the RPD group (352.1 ± 174.1 vs 588.4 ± 219.4; P = 0.0003), whereas operative time was significantly longer for RPD compared to OPD (461.1 ± 84 vs 384.2 ± 73.8; P = 0.0004). RPD and OPD showed equivalent results in terms of retrieved lymph nodes (19.1 ± 9.9 vs 17.3 ± 9.9; P = 0.22) and positive margin status (13.3% vs 16.1%; P = 0.32).

Conclusions

RPD is safe and feasible as surgical treatment for malignant or benign disease of the pancreatic head and the periampullary region. Equivalency in terms of surgical radicality including R0 curative resection and number of harvested lymph nodes between the two groups confirmed the reliability of RPD from an oncologic point of view.

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Authors and Affiliations

  1. Department of General, Emergency and Minimally Invasive Surgery, Policlinico Universitario “D. Casula”, University of Cagliari, SS 554, Km 4,500, 09042, Monserrato, Cagliari, Italy

    Mauro Podda & Adolfo Pisanu

  2. Centro Di Politiche Regolatorie in Sanità, IRCCS – Istituto di Ricerche Farmacologiche ‘‘Mario Negri’’, Milan, Italy

    Chiara Gerardi

  3. Department of Surgery, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK

    Salomone Di Saverio & R. Justin Davies

  4. Department of General and Emergency Surgery, Azienda Ospedaliera – Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy

    Marco Vito Marino

  5. Department of Advanced Medical and Surgical Sciences, Università Della Campania “Luigi Vanvitelli”, Naples, Italy

    Gianluca Pellino

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  1. Mauro Podda
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Contributions

MP: Study conception and design, literature search, acquisition, interpretation and analysis of data; drafting and critically revising the article for important intellectual content; and final approval of the version to be published. CG: Study conception and design, literature search, acquisition, interpretation and analysis of data (statistical expertise); drafting and critically revising the article for important intellectual content; and final approval of the version to be published. SDS: Study conception and design, interpretation and analysis of data; drafting and critically revising the article for important intellectual content; editing and revising the English for the final version to be published; and final approval of the version to be published. MVM: Interpretation and analysis of data; drafting and critically revising the article for important intellectual content; and final approval of the version to be published. RJD: Interpretation and analysis of data; drafting and critically revising the article for important intellectual content; editing and revising the English for the final version to be published; and final approval of the version to be published. GP: Interpretation and analysis of data; drafting and critically revising the article for important intellectual content; and final approval of the version to be published. AP: Study conception and design, literature search, acquisition, interpretation and analysis of data; drafting and critically revising the article for important intellectual content; and final approval of the version to be published.

Corresponding author

Correspondence to Mauro Podda.

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Mauro Podda, Chiara Gerardi, Salomone Di Saverio, Marco Vito Marino, R Justin Davies, Gianluca Pellino, and Adolfo Pisanu have no conflict of interest of finantial ties to disclose.

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PROSPERO ID: CRD42019133843.

Electronic supplementary material

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Supplemental Digital Content Table 1. Search Strategy (DOC 12 kb)

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Supplemental Digital Content Table 2. General Characteristics of the Studies Included for the Systematic Review and Meta-analysis (DOC 46 kb)

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Supplemental Digital Content Table 3. Risk of Bias in the Published Studies (By the Risk Of Bias In Non-Randomised Studies – of Interventions - ROBINS-I Tool) (DOC 31 kb)

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Supplemental Digital Content Table 4. Summary of Outcomes_1: Clinical Outcomes (Mortality, Morbidity, Overall POPF, Grade B POPF, Grade C POPF, Overall DGE, Overall PPH, Bile Leak, SSI, Clavien-Dindo Grade I-II Complications, Clavien-Dindo Grade III-V Complications) (DOC 73 kb)

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Supplemental Digital Content Table 5. Summary of Outcomes_2: Operative Outcomes (Conversion, Estimated Blood Loss, Operative Time); Post-operative Outcomes (Length of Hospital Stay, Reoperation); Costs (Operative Costs, Total Costs) (DOC 48 kb)

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Supplemental Digital Content Table 6. Summary of Pathology Outcomes (Tumor Size, Retrieved Lymph Nodes, Positive Margin, Pancreatic Adenocarcinoma, Distal Common Bile Duct Adenocarcinoma, Duodenal Adenocarcinoma, Ampullary Adenocarcinoma, Malignant Neuroendocrine Neoplasia, IPMN, Others Benign, Others Malignant) (DOC 73 kb)

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Supplemental Digital Content Table 7. Summary results of the meta-analyses comparing Totally RPD and Open PD (Subgroup Analysis) (DOC 42 kb)

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Supplemental Digital Content. Fig. 1. Funnel plots of Mortality [A]. Morbidity [B]. Post-Operative Pancreatic Fistula [C]. Delayed Gastric Emptying [D]. Post-Pancreatectomy Hemorrhage [E]. Surgical Site Infection [F]. Operative Time [G]. Estimated Blood Loss [H]. and Length of Hospital Stay [I] (TIFF 122 kb)

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Supplemental Digital Content. Fig. 2. Meta-analyses of Patients Characteristics: Charlson Comorbidity Index [A]. Age [B]. BMI [C]. Neoadjuvant Chemotherapy [D]. Vascular Resection [E]. Male Sex [F]. Subgroup Analyses: Totally Robotic and Hybrid RPD (TIFF 460 kb)

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Supplemental Digital Content. Fig. 3. Meta-analyses of Pathology Outcomes: Tumor Size [A]. Pancreatic Adenocarcinoma [B]. Distal Common Bile Duct Adenocarcinoma [C]. Duodenal Adenocarcinoma [D]. Ampullary Adenocarcinoma [E]. Malignant Neuroendocrine Neoplasia [F]. Others Benign [G]. IPMN [H]. Subgroup Analyses: Totally Robotic and Hybrid RPD (TIFF 412 kb)

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Supplemental Digital Content. Fig. 4. Sensitivity analyses excluding large registry studies: Morbidity [A]. Overall POPF [B]. Overall PPH [C]. SSI [D]. Operative Time [E]. Estimated Blood Loss [F]. Subgroup Analyses: Totally Robotic and Hybrid RPD (TIFF 417 kb)

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Podda, M., Gerardi, C., Di Saverio, S. et al. Robotic-assisted versus open pancreaticoduodenectomy for patients with benign and malignant periampullary disease: a systematic review and meta-analysis of short-term outcomes. Surg Endosc 34, 2390–2409 (2020). https://doi.org/10.1007/s00464-020-07460-4

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