Meta-Analysis of Trials Comparing Minimally-Invasive and Open Distal Pancreatectomy

Introduction: Current literature suggests that minimally-invasive distal pancreatectomy (MIDP) is associated with faster post-operative recovery and decreased morbidity compared to open surgery. However most studies have been limited by a small sample size and single-institution design. To overcome these limitations, we performed a meta-analysis of studies comparing MIDP and open distal pancreatectomy (ODP). Methods: A systematic literature review was conducted to detect studies comparing MIDP and ODP. Study endpoints included post-operative overall morbidity and mortality, rates of pancreatic fistula, blood loss, time to oral intake and length of hospital stay. Meta-analyses were performed using a random-effects model. Variables were pooled only if evaluated by 3 or more studies. Both qualitative and quantitative data were pooled using a random-effects model. Results: Ten studies comparing MIDP and ODP were considered suitable for the meta-analysis; the reports were primarily retrospective studies of comparable patients. A total of 349 patients underwent MIDP and 380 had ODP. Patients in the two groups were similar with respect to age, BMI, ASA classification, and indication for surgery (mostly for non-malignant disease). The MIDP group had a higher proportion of females than the ODP group (odds ratio 0.44, 95% CI 0.22 - 0.85). Operative times were longer for MIDP but the difference was neither clinically relevant, nor statistically significant (19 minutes, 95% CI -8.2 - 46.4, p=0.17). The conversion rates from laparoscopic to hand-assisted- and open- procedures were 0.11 (95% CI 0.07 - 0.15) and 0.37 (95% CI 0.10 - 0.64), respectively. Patients undergoing MIDP had less blood loss (difference 309 mL, 95% CI 171 - 447), shorter time to oral intake (difference 2.6 days, 95% CI 1.0 - 4.2), and a shorter post-operative hospital stay (difference 12 days, 95% CI 7.5 - 17.1). Mortality and re-operative rates did not differ between MIDP and ODP. MIDP had fewer overall complications (odds ratio 0.49, 95% CI 0.27 - 0.90), major complications (odds ratio 0.57, 95% CI 0.34 - 0.96), surgical site infections (odds ratio 0.32, 95% CI 0.19 - 0.54), and pancreatic fistulas (odds ratio 0.68, 95% CI 0.47 - 0.98). Conclusions: Our meta-analysis indicates that MIDP is feasible, safe and associated with reduced blood losses, time to oral intake, post-operative hospital stay and overall complications. Furthermore, a minimally-invasive approach seems to reduce rates of pancreatic leaks and surgical site infections following distal pancreatectomy.