t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e8
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
Duodenopancreatectomy: Open or minimally invasive approach? Giuseppe Nigri*, Niccolo` Petrucciani, Marco La Torre, Paolo Magistri, Stefano Valabrega, Paolo Aurello, Giovanni Ramacciato Department of Surgery, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy
article info
abstract
Article history:
Background: Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure,
Received 13 December 2013
offered to selected patients at institutions highly experienced with the procedure. It is still
Accepted 11 January 2014
not clear if this approach may enhance patient recovery and reduce postoperative com-
Available online xxx
plications comparing to open pancreaticoduodenectomy (OPD), as demonstrated for other abdominal procedures.
Keywords:
Methods: A systematic literature review was conducted to identify studies comparing MIPD
Pancreaticoduodenectomy
and OPD. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates,
Duodenopancreatectomy
blood loss) constituted the study end points. Metaanalyses were performed using a
Laparoscopic
random-effects model.
Robotic
Results: For the metaanalysis, 8 studies including 204 patients undergoing MIPD and 419
Minimally invasive
patients undergoing OPD were considered suitable. The patients in the two groups were similar with respect to age, sex and histological diagnosis, and different with respect to tumor size, rate of pylorus preservation, and type of pancreatic anastomosis. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. MIDP resulted in lower post-operative complication rates, less intra-operative blood loss, shorter hospital stays, lower blood transfusion rates, higher numbers of harvested lymph nodes, and improved negative margin status rates. However, MIPD was associated with longer operating times when compared to OPD. Conclusions: The MIPD procedure is feasible, safe, and effective in selected patients. MIPD may have some potential advantages over OPD, and should be performed and further developed by use in selected patients at highly experienced medical centers. ª 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail addresses: [email protected], [email protected] (G. Nigri). URL: http://w3.uniroma1.it/nigri 1479-666X/$ e see front matter ª 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2014.01.006
Please cite this article in press as: Nigri G, et al., Duodenopancreatectomy: Open or minimally invasive approach?, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.01.006
2
t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e8
Introduction For a number of abdominal procedures, minimal-access surgery has been shown to reduce postoperative pain, increase patient mobility, enhance recovery, and facilitate early patient discharge, when compared with use of open surgery.1e4 Accordingly, laparoscopic approaches have proven to be feasible, safe, and oncologically equivalent to open procedures for treatment of many abdominal malignancies, and produce comparable postoperative and long-term outcomes. Laparoscopic pancreatic surgery was initially used for staging of pancreatic neoplasms,5 but in recent years, advances in laparoscopic techniques, instruments, and experience have allowed surgeons to perform laparoscopic resection of the pancreas. Minimally invasive distal pancreatectomy (MIDP) has gained popularity among general and gastrointestinal surgeons because the procedure does not require anastomosis or other reconstruction, and presents fewer challenges than other major laparoscopic procedures.6,7 A study comparing patient outcomes following open and laparoscopic distal pancreatectomies showed reduced postoperative pain, faster recovery, fewer wound related problems, and decreased morbidity for patients receiving MIDP.8 MIPD, both laparoscopic and robotic, is a technically demanding procedure, requiring extensive retroperitoneal dissection around delicate vascular structures, and a prolonged reconstruction including three anastomoses.9,10 However, pancreaticoduodenectomy has a high morbidity rate (20e40%), mainly related to failure of the pancreatic anastomosis and delayed gastric emptying. The procedure also requires a long hospital stay (8e14 days), and it has been thought that a minimally invasive approach would not significantly shorten patient recovery time.11e13 Additionally, the complexity of pancreaticoduodenectomy necessitates a long operative time, which has been thought would be increased by a minimally invasive technique.14,15 No randomized clinical trials have been conducted comparing MIPD with open pancreaticoduodenectomy (OPD); however, MIPD is offered to selected patients at institutions highly experienced with the procedure. While single institution retrospective studies comparing MIPD with OPD have been conducted, these studies were limited by small sample sizes and their single institution design. Therefore, we conducted a systematic review of the literature and a metaanalysis of the selected studies to compare surgical and oncologic outcomes of MIPD vs those achieved with OPD.
Methods Study selection A systematic literature search was performed using Embase, Medline, Cochrane, and PubMed databases to identify all studies published up to and including February 2013 that compared minimally invasive pancreaticoduodenectomy with open pancreaticoduodenectomy. The meta-analysis was conducted according to the QUORUM guidelines.16
Minimally invasive pancreaticoduodenectomy was defined as either a laparoscopic pancreaticoduodenectomy or a robotic-assisted laparoscopic pancreaticoduodenectomy. The following MESH search headings were used: “laparoscopic AND pancreaticoduodenectomy OR duodenopancreatectomy”, “minimally invasive AND pancreaticoduodenectomy OR duodenopancreatectomy”, “robotic AND pancreaticoduodenectomy OR duodenopancreatectomy”. The “related articles” function was used to broaden the search, and all abstracts, studies, and citations scanned were reviewed.
Inclusion criteria Studies included in our analysis were required to1: compare characteristics and perioperative outcomes of patients undergoing minimally invasive pancreaticoduodenectomy and open pancreaticoduodenectomy, and2 involve a previously unreported patient group (if patient material was reported more than once by the same institution, the most informative and recent article was included in our analysis). We also included studies in which a portion of the reconstruction (mainly the pancreatic anastomosis) was done through a mini-laparotomy, which is always needed to remove a surgical specimen.
Exclusion criteria The following types of studies were not considered for inclusion in our meta-analysis1: studies in which the outcomes of interest (specified later) for both minimally invasive and open techniques were not reported or were impossible to calculate2; “how I do” articles, animal studies, and non-English language studies.
Data extraction Two reviewers independently extracted the following information from each study: first author, year of publication, study population characteristics, study design, indications for operation, number of subjects who underwent an operation with each technique, rate of conversion from a minimally invasive to an open technique or hand-assisted technique, surgical techniques, and perioperative outcomes.
Outcomes of interest and definition All studies were abstracted for the following relevant data: patient baseline characteristics (age, sex, and body mass index [BMI]), tumor characteristics (size, histology), type of procedure (standard pancreaticoduoenectomy, pylorus-preserving pancreaticoduoenectomy), technique of pancreatic anastomosis (pancreaticojejunostomy, gastrojejunostomy), operative outcomes (operative time, intraoperative blood loss, and conversion to hand-assisted or open surgery), extension of lymphoadenectomy, resection margins, postoperative recovery time (duration of hospital stay), reoperation rate, and postoperative complications (morbidity and mortality).
Please cite this article in press as: Nigri G, et al., Duodenopancreatectomy: Open or minimally invasive approach?, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.01.006
3
t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e8
Statistical analysis Statistical analyses and meta-analysis were performed using MedCalc for Windows, version 10.2.0.0 software (MedCalc Software, MariaKerke, Belgium). The ManteleHaenszel method was used for calculating the weighted summary odds ratio under the fixed effects model, and the heterogeneity statistic (I2) was incorporated to calculate the summary odds ratio under the random effects model. The total odds ratio with 95% CI is given both for the fixed effects model and the random effects model. If the value 1 is not within the 95% CI, then the odds ratio is considered to be statistically significant at the 5% level (P < 0.05). For meta-analysis of studies with a continuous measure (comparison of means between treated cases and controls), the Hedges g statistic was used as a formulation for the standardized mean difference (SMD) under the fixed effects model. Next, the heterogeneity statistic was incorporated to calculate the summary standardized mean difference under the random effects model. If the value 0 is not within the 95% CI, the SMD is considered to be statistically significant at the 5% level (P < 0.05). Statistical heterogeneity of trial results was assessed on the basis of a test for heterogeneity (standard chi-squared test on N degrees of freedom, where N equals the number of trials contributing data minus one). Three possible causes for heterogeneity were pre-specified: (i) differing response according to a difference in trial quality; (ii) differing response according to sample size; (iii) differing response according to clinical heterogeneity. If the test for heterogeneity was statistically significant (P < 0.05), greater emphasis was placed on the random effects model.
CI ¼ 0.568e0.0814), proportions of PPPD performed (OR ¼ 2.309; 95% CI ¼ 1.360e3920), proportions of Whipple procedure performed (OR ¼ 0.253; 95% CI ¼ 0.118e0.543), and proportions of pancreato-gastric (PG) anastomoses performed (OR ¼ 7.572; 95% CI ¼ 2.964e19.345) (Table 1).
Peri- and postoperative outcomes The perioperative and post-operative outcomes of the two types of procedures are shown in Table 2. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. Compared to OPD, use of MIPD resulted in lower postoperative complication rates (OR ¼ 0.675; 95% CI ¼ 0.473e0.964) (Fig. 1), less intra-operative blood loss (SMD ¼ 0.935; 95% CI ¼ 1.252e0.618) (Fig. 2), better and shorter hospital stays (OR ¼ 0.392; 95% CI ¼ 0.758 to 0.0258) (Fig. 3), lower blood transfusion rates (OR ¼ 0.399; 95% CI ¼ 0.232e0.686) (Fig. 4), higher numbers of harvested lymph nodes (SMD ¼ 0.383; 95% CI ¼ 0.160e0.605) (Fig. 5), and improved negative margin status rates (OR ¼ 2.653; 95% CI ¼ 1.301e5.408) (Fig. 6). However, MIPD was associated with longer operating times when compared to ODP (SMD ¼ 1.053;
Table 1 e Clinical, pathologic and operative characteristics (SMD [ standardized mean difference, PDAC [ pancreatic ductal adenocarcinoma, PPPD [ pylorus-preserving pancreatico-duodenectomy, IPMN [ intraductal papillary mucinous neoplasia, PG and PJ anastomosis [ pancreato-gastric and pancreatojejunal anastomosis). Variable Age
Results Eight studies comparing MIPD and OPD, and published between 2009 and 2012, were included in our meta-analysis.17e24 All the reports were retrospective comparisons of MIPD and OPD, and included a total of 204 patients who underwent MIPD and 419 patients who underwent OPD.
Clinical, pathologic and operative characteristics Overall, 204 patients who underwent MIPD and 419 patients who underwent OPD were included in our meta-analysis. The patients in the two groups were similar with respect to age (SMD ¼ 0.0457; 95% CI ¼ 0.241e0.332), proportion of male patients (OR ¼ 1.312; 95% CI ¼ 0.921e1870), BMI (OR ¼ 0.279; 95% CI ¼ 0.778e0.219), presence of malignant disease (OR ¼ 1.085; 95% CI ¼ 0.513e2291) presence of pancreatic ductal adenocarcinoma (OR ¼ 0.972; 95% CI ¼ 0.666e1.418), presence of ampullary carcinoma (OR ¼ 1.437; 95% CI ¼ 0.852e2.424), presence of chronic pancreatitis (OR ¼ 0.528; 95% CI ¼ 0.241e1.157), and presence of IPMN (OR ¼ 1.337; 95% CI ¼ 0.802e2.228). The two groups showed differences in terms of tumor size (SMD ¼ 0.325; 95%
Sex (male gender) BMI
MIPD
OPD
OR or SMD
95% CI
0.0457 0.241 to 0.332 112/204 202/419 1312 0.921 to 1870 204
419
0.279
196
411
Malignant disease PDAC
48/64
80/106
75/204
166/419
Ampullary carcinoma Tumor size
27/204
46/419
101
250
Chronic pancreatitis IPMN
9/151
33/366
33/204
54/419
PPPD
103/204 173/419 2309
1085 0.972 1437 0.325 0.528 1337
Whipple 86/204 194/419 0.253 procedure PJ 145/204 372/419 0.240 anastomosis PG 24/204 2/419 7572 anastomosis
p 0.0288 0.6564
0.778
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
Duodenopancreatectomy: Open or minimally invasive approach? Giuseppe Nigri*, Niccolo` Petrucciani, Marco La Torre, Paolo Magistri, Stefano Valabrega, Paolo Aurello, Giovanni Ramacciato Department of Surgery, Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy
article info
abstract
Article history:
Background: Minimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure,
Received 13 December 2013
offered to selected patients at institutions highly experienced with the procedure. It is still
Accepted 11 January 2014
not clear if this approach may enhance patient recovery and reduce postoperative com-
Available online xxx
plications comparing to open pancreaticoduodenectomy (OPD), as demonstrated for other abdominal procedures.
Keywords:
Methods: A systematic literature review was conducted to identify studies comparing MIPD
Pancreaticoduodenectomy
and OPD. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates,
Duodenopancreatectomy
blood loss) constituted the study end points. Metaanalyses were performed using a
Laparoscopic
random-effects model.
Robotic
Results: For the metaanalysis, 8 studies including 204 patients undergoing MIPD and 419
Minimally invasive
patients undergoing OPD were considered suitable. The patients in the two groups were similar with respect to age, sex and histological diagnosis, and different with respect to tumor size, rate of pylorus preservation, and type of pancreatic anastomosis. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. MIDP resulted in lower post-operative complication rates, less intra-operative blood loss, shorter hospital stays, lower blood transfusion rates, higher numbers of harvested lymph nodes, and improved negative margin status rates. However, MIPD was associated with longer operating times when compared to OPD. Conclusions: The MIPD procedure is feasible, safe, and effective in selected patients. MIPD may have some potential advantages over OPD, and should be performed and further developed by use in selected patients at highly experienced medical centers. ª 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail addresses: [email protected], [email protected] (G. Nigri). URL: http://w3.uniroma1.it/nigri 1479-666X/$ e see front matter ª 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.surge.2014.01.006
Please cite this article in press as: Nigri G, et al., Duodenopancreatectomy: Open or minimally invasive approach?, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.01.006
2
t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e8
Introduction For a number of abdominal procedures, minimal-access surgery has been shown to reduce postoperative pain, increase patient mobility, enhance recovery, and facilitate early patient discharge, when compared with use of open surgery.1e4 Accordingly, laparoscopic approaches have proven to be feasible, safe, and oncologically equivalent to open procedures for treatment of many abdominal malignancies, and produce comparable postoperative and long-term outcomes. Laparoscopic pancreatic surgery was initially used for staging of pancreatic neoplasms,5 but in recent years, advances in laparoscopic techniques, instruments, and experience have allowed surgeons to perform laparoscopic resection of the pancreas. Minimally invasive distal pancreatectomy (MIDP) has gained popularity among general and gastrointestinal surgeons because the procedure does not require anastomosis or other reconstruction, and presents fewer challenges than other major laparoscopic procedures.6,7 A study comparing patient outcomes following open and laparoscopic distal pancreatectomies showed reduced postoperative pain, faster recovery, fewer wound related problems, and decreased morbidity for patients receiving MIDP.8 MIPD, both laparoscopic and robotic, is a technically demanding procedure, requiring extensive retroperitoneal dissection around delicate vascular structures, and a prolonged reconstruction including three anastomoses.9,10 However, pancreaticoduodenectomy has a high morbidity rate (20e40%), mainly related to failure of the pancreatic anastomosis and delayed gastric emptying. The procedure also requires a long hospital stay (8e14 days), and it has been thought that a minimally invasive approach would not significantly shorten patient recovery time.11e13 Additionally, the complexity of pancreaticoduodenectomy necessitates a long operative time, which has been thought would be increased by a minimally invasive technique.14,15 No randomized clinical trials have been conducted comparing MIPD with open pancreaticoduodenectomy (OPD); however, MIPD is offered to selected patients at institutions highly experienced with the procedure. While single institution retrospective studies comparing MIPD with OPD have been conducted, these studies were limited by small sample sizes and their single institution design. Therefore, we conducted a systematic review of the literature and a metaanalysis of the selected studies to compare surgical and oncologic outcomes of MIPD vs those achieved with OPD.
Methods Study selection A systematic literature search was performed using Embase, Medline, Cochrane, and PubMed databases to identify all studies published up to and including February 2013 that compared minimally invasive pancreaticoduodenectomy with open pancreaticoduodenectomy. The meta-analysis was conducted according to the QUORUM guidelines.16
Minimally invasive pancreaticoduodenectomy was defined as either a laparoscopic pancreaticoduodenectomy or a robotic-assisted laparoscopic pancreaticoduodenectomy. The following MESH search headings were used: “laparoscopic AND pancreaticoduodenectomy OR duodenopancreatectomy”, “minimally invasive AND pancreaticoduodenectomy OR duodenopancreatectomy”, “robotic AND pancreaticoduodenectomy OR duodenopancreatectomy”. The “related articles” function was used to broaden the search, and all abstracts, studies, and citations scanned were reviewed.
Inclusion criteria Studies included in our analysis were required to1: compare characteristics and perioperative outcomes of patients undergoing minimally invasive pancreaticoduodenectomy and open pancreaticoduodenectomy, and2 involve a previously unreported patient group (if patient material was reported more than once by the same institution, the most informative and recent article was included in our analysis). We also included studies in which a portion of the reconstruction (mainly the pancreatic anastomosis) was done through a mini-laparotomy, which is always needed to remove a surgical specimen.
Exclusion criteria The following types of studies were not considered for inclusion in our meta-analysis1: studies in which the outcomes of interest (specified later) for both minimally invasive and open techniques were not reported or were impossible to calculate2; “how I do” articles, animal studies, and non-English language studies.
Data extraction Two reviewers independently extracted the following information from each study: first author, year of publication, study population characteristics, study design, indications for operation, number of subjects who underwent an operation with each technique, rate of conversion from a minimally invasive to an open technique or hand-assisted technique, surgical techniques, and perioperative outcomes.
Outcomes of interest and definition All studies were abstracted for the following relevant data: patient baseline characteristics (age, sex, and body mass index [BMI]), tumor characteristics (size, histology), type of procedure (standard pancreaticoduoenectomy, pylorus-preserving pancreaticoduoenectomy), technique of pancreatic anastomosis (pancreaticojejunostomy, gastrojejunostomy), operative outcomes (operative time, intraoperative blood loss, and conversion to hand-assisted or open surgery), extension of lymphoadenectomy, resection margins, postoperative recovery time (duration of hospital stay), reoperation rate, and postoperative complications (morbidity and mortality).
Please cite this article in press as: Nigri G, et al., Duodenopancreatectomy: Open or minimally invasive approach?, The Surgeon (2014), http://dx.doi.org/10.1016/j.surge.2014.01.006
3
t h e s u r g e o n x x x ( 2 0 1 4 ) 1 e8
Statistical analysis Statistical analyses and meta-analysis were performed using MedCalc for Windows, version 10.2.0.0 software (MedCalc Software, MariaKerke, Belgium). The ManteleHaenszel method was used for calculating the weighted summary odds ratio under the fixed effects model, and the heterogeneity statistic (I2) was incorporated to calculate the summary odds ratio under the random effects model. The total odds ratio with 95% CI is given both for the fixed effects model and the random effects model. If the value 1 is not within the 95% CI, then the odds ratio is considered to be statistically significant at the 5% level (P < 0.05). For meta-analysis of studies with a continuous measure (comparison of means between treated cases and controls), the Hedges g statistic was used as a formulation for the standardized mean difference (SMD) under the fixed effects model. Next, the heterogeneity statistic was incorporated to calculate the summary standardized mean difference under the random effects model. If the value 0 is not within the 95% CI, the SMD is considered to be statistically significant at the 5% level (P < 0.05). Statistical heterogeneity of trial results was assessed on the basis of a test for heterogeneity (standard chi-squared test on N degrees of freedom, where N equals the number of trials contributing data minus one). Three possible causes for heterogeneity were pre-specified: (i) differing response according to a difference in trial quality; (ii) differing response according to sample size; (iii) differing response according to clinical heterogeneity. If the test for heterogeneity was statistically significant (P < 0.05), greater emphasis was placed on the random effects model.
CI ¼ 0.568e0.0814), proportions of PPPD performed (OR ¼ 2.309; 95% CI ¼ 1.360e3920), proportions of Whipple procedure performed (OR ¼ 0.253; 95% CI ¼ 0.118e0.543), and proportions of pancreato-gastric (PG) anastomoses performed (OR ¼ 7.572; 95% CI ¼ 2.964e19.345) (Table 1).
Peri- and postoperative outcomes The perioperative and post-operative outcomes of the two types of procedures are shown in Table 2. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. Compared to OPD, use of MIPD resulted in lower postoperative complication rates (OR ¼ 0.675; 95% CI ¼ 0.473e0.964) (Fig. 1), less intra-operative blood loss (SMD ¼ 0.935; 95% CI ¼ 1.252e0.618) (Fig. 2), better and shorter hospital stays (OR ¼ 0.392; 95% CI ¼ 0.758 to 0.0258) (Fig. 3), lower blood transfusion rates (OR ¼ 0.399; 95% CI ¼ 0.232e0.686) (Fig. 4), higher numbers of harvested lymph nodes (SMD ¼ 0.383; 95% CI ¼ 0.160e0.605) (Fig. 5), and improved negative margin status rates (OR ¼ 2.653; 95% CI ¼ 1.301e5.408) (Fig. 6). However, MIPD was associated with longer operating times when compared to ODP (SMD ¼ 1.053;
Table 1 e Clinical, pathologic and operative characteristics (SMD [ standardized mean difference, PDAC [ pancreatic ductal adenocarcinoma, PPPD [ pylorus-preserving pancreatico-duodenectomy, IPMN [ intraductal papillary mucinous neoplasia, PG and PJ anastomosis [ pancreato-gastric and pancreatojejunal anastomosis). Variable Age
Results Eight studies comparing MIPD and OPD, and published between 2009 and 2012, were included in our meta-analysis.17e24 All the reports were retrospective comparisons of MIPD and OPD, and included a total of 204 patients who underwent MIPD and 419 patients who underwent OPD.
Clinical, pathologic and operative characteristics Overall, 204 patients who underwent MIPD and 419 patients who underwent OPD were included in our meta-analysis. The patients in the two groups were similar with respect to age (SMD ¼ 0.0457; 95% CI ¼ 0.241e0.332), proportion of male patients (OR ¼ 1.312; 95% CI ¼ 0.921e1870), BMI (OR ¼ 0.279; 95% CI ¼ 0.778e0.219), presence of malignant disease (OR ¼ 1.085; 95% CI ¼ 0.513e2291) presence of pancreatic ductal adenocarcinoma (OR ¼ 0.972; 95% CI ¼ 0.666e1.418), presence of ampullary carcinoma (OR ¼ 1.437; 95% CI ¼ 0.852e2.424), presence of chronic pancreatitis (OR ¼ 0.528; 95% CI ¼ 0.241e1.157), and presence of IPMN (OR ¼ 1.337; 95% CI ¼ 0.802e2.228). The two groups showed differences in terms of tumor size (SMD ¼ 0.325; 95%
Sex (male gender) BMI
MIPD
OPD
OR or SMD
95% CI
0.0457 0.241 to 0.332 112/204 202/419 1312 0.921 to 1870 204
419
0.279
196
411
Malignant disease PDAC
48/64
80/106
75/204
166/419
Ampullary carcinoma Tumor size
27/204
46/419
101
250
Chronic pancreatitis IPMN
9/151
33/366
33/204
54/419
PPPD
103/204 173/419 2309
1085 0.972 1437 0.325 0.528 1337
Whipple 86/204 194/419 0.253 procedure PJ 145/204 372/419 0.240 anastomosis PG 24/204 2/419 7572 anastomosis
p 0.0288 0.6564
0.778
