BACKGROUND Laparoscopy has been widely used in general surgical procedures, but total laparoscopic pancreaticoduodenectomy (TLPD) is still a complex and challenging surgery that is only performed in a small number of patients at a few large academic medical centers. Although the safety and feasibility of TLPD have been established, few studies have compared it with open pancreaticoduodenectomy (OPD) with regard to perioperative and oncological outcomes. Therefore, we carried out a meta-analysis to evaluate whether TLPD is superior to OPD. AIM To compare the treatment outcomes of TLPD and OPD in order to assess the safety and feasibility of TLPD. METHODS We conducted a systematic search of studies comparing TLPD with OPD that were published in the PubMed, EMBASE, and Cochrane Library databases through December 31, 2018. The studies comparing TLPD and OPD with at least one of the outcomes we were interested in and with more than 10 cases in each group were included in this analysis. The Newcastle-Ottawa scale was used to assess the quality of the nonrandomized controlled trials and the Jadad scale was used to assess the randomized controlled trials. Intraoperative data, postoperative complications, and oncologic outcomes were evaluated. The meta-analysis was performed using Review Manager Software version 5.3. Random or fixed-effects meta-analyses were undertaken to measure the pooled estimates. RESULTS A total of 4790 articles were initially identified for our study. After screening, 4762 articles were excluded and 28 studies representing 39771 patients (3543 undergoing TLPD and 36228 undergoing OPD) were eventually included. Patients who underwent TLPD had less intraoperative blood loss [weighted mean difference (WMD) = -260.08 mL, 95% confidence interval (CI): (-336.02, -184.14) mL, P < 0.00001], a lower blood transfusion rate [odds ratio (OR) = 0.51, 95%CI: 0.36-0.72, P = 0.0001], a lower perioperative overall morbidity (OR = 0.82, 95%CI: 0.73-0.92, P = 0.0008), a lower wound infection rate (OR = 0.48, 95%CI: 0.34-0.67, P < 0.0001), a lower pneumonia rate (OR = 0.72, 95%CI: 0.60-0.85, P = 0.0002), a shorter duration of intensive care unit (ICU) stay [WMD = -0.28 d, 95%CI (-2.88, -1.29) d, P < 0.00001] and a shorter length of hospital stay [WMD = -3.05 d, 95%CI (-3.93, -2.17), P < 0.00001], a lower rate of discharge to a new facility (OR = 0.55, 95%CI: 0.39-0.78, P = 0.0008), and a lower 30-d readmission rate (OR = 0.81, 95%CI: 0.68-0.95, P = 0.10) than those who underwent OPD. In addition, the TLPD group had a higher R0 rate (OR = 1.28, 95%CI: 1.13-1.44, P = 0.0001) and more lymph nodes harvested (WMD = 1.32, 95%CI: 0.57-2.06, P = 0.0005) than the OPD group. However, the patients who underwent TLPD experienced a significantly longer operative time (WMD = 77.92 min, 95%CI: 40.89-114.95, P < 0.0001) and had a smaller tumor size than those who underwent OPD [WMD = -0.32 cm, 95%CI: (-0.58, -0.07) cm, P = 0.01]. There were no significant differences between the two groups in the major morbidity, postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, bile leak, gastroenteric anastomosis fistula, intra-abdominal abscess, bowel obstruction, fluid collection, reoperation, ICU admission, or 30-d and 90-d mortality rates. For malignant tumors, the 1-, 2-, 3-, 4- and 5-year overall survival rates were not significantly different between the two groups. CONCLUSION This meta-analysis indicates that TLPD is safe and feasible, and may be a desirable alternative to OPD, although a longer operative time is needed and only smaller tumors can be treated.

中文翻译：

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全腹腔镜胰十二指肠切除术优于开放手术吗？荟萃分析。

背景技术腹腔镜已广泛用于一般外科手术中，但是全腹腔镜胰十二指肠切除术（TLPD）仍然是一项复杂而具有挑战性的手术，仅在少数几个大型学术医学中心的少数患者中进行。尽管已经确定了TLPD的安全性和可行性，但在围手术期和肿瘤学结局方面，很少有研究将其与开腹胰十二指肠切除术（OPD）进行比较。因此，我们进行了荟萃分析，以评估TLPD是否优于OPD。目的比较TLPD和OPD的治疗效果，以评估TLPD的安全性和可行性。方法我们对截至2018年12月31日已发表在PubMed，EMBASE和Cochrane图书馆数据库中的TLPD与OPD进行比较的研究进行了系统的研究。这项分析包括将TLPD和OPD与我们感兴趣的至少一项结局以及每组10例以上的病例进行比较的研究。纽卡斯尔-渥太华量表用于评估非随机对照试验的质量，雅达量表用于评估随机对照试验的质量。评估术中数据，术后并发症和肿瘤学结局。使用Review Manager Software 5.3版进行荟萃分析。进行了随机或固定效应的荟萃分析，以测量汇总的估计值。结果最初鉴定出4790篇文章用于我们的研究。筛选后，排除了4762篇文章，最终包括28项研究，代表39771名患者（3543名接受TLPD和36228名接受OPD）。10）比那些经历过OPD的人。此外，TLPD组的R0率更高（OR = 1.28，95％CI：1.13-1.44，P = 0.0001），淋巴结的收获也更多（WMD = 1.32，95％CI：0.57-2.06，P = 0.0005）比OPD组要多。但是，接受TLPD的患者手术时间明显更长（WMD = 77.92分钟，95％CI：40.89-114.95，P <0.0001），并且肿瘤尺寸小于接受OPD的患者[WMD = -0.32 cm，95 ％CI：（-0.58，-0.07）cm，P ＝ 0.01]。两组的主要发病率，术后胰瘘，胃排空延迟，胰切除术后出血，胆汁渗漏，肠胃吻合瘘，肠内脓肿，肠梗阻，积液，再次手术，ICU入院或30岁之间无显着差异。 -d和90-d死亡率。对于恶性肿瘤，则将1-，2-，3-，两组的4年和5年总生存率无显着差异。结论这项荟萃分析表明TLPD是安全可行的，并且可能是OPD的理想替代方案，尽管需要更长的手术时间并且只能治疗较小的肿瘤。