微创胰十二指肠切除术的安全性和可行性的系统评价

Systemic review and Meta-analysis of safety and feasibility of minimally invasive pancreaticoduodenectomy

目的探讨微创胰十二指肠切除术的手术安全性和应用可行性。方法计算机检索在2017年7月31日前在PubMed(Medline)、Embase、Web of science、Science direct等数据库的关于微创胰十二指肠切除术(minimally invasive pancreaticodu odenectomy,MIPD)与开腹胰十二指肠切除术(open pancreaticoduodenectomy,OPD)比较的随机对照试验或严格设计的临床对照试验,按纳入排除标准由2位研究者独立进行文献筛选(PRISMA标准)、资料提取和方法学质量评价后,采用RevMan5.3.0软件进行Meta分析。结果共纳入39篇文献,共包含其中MIPD病人4 868例,OPD病人32 230例,其中7篇为多中心临床研究。Meta分析表明:MIPD组较OPD组手术时间长、术中出血量较少、术中R0切除率较高、术后切口感染的发生率较低、术后住院时间较短(P<0.05);同时两组术后的总并发症发生率、术后胰瘘、胃排空延迟、出血、胆瘘、再手术、整体手术费用、远期生存率的差异均无统计学意义(均P>0.05)。结论 MIPD因其术后恢复快,术后住院时间短,切口感染发生率较低,且术后总体以及相关并发症发生率与OPD无明显差异凸显了其微创优势,对于合适的病例和一定手术量的胰腺外科中心,可常规地开展MIPD。

Objective To evaluate the current evidence of the surgical safety and application feasibility in minimally invasive pancreaticoduodenectomy(MIPD).Methods Medline,Embase,Web of science,Science direct and the relevant databases were retrieved by computer from inception to July2017 to collect the RCT articles or clinical trials of the comparison between the MIPD and the open pancreaticoduodenectomy(OPD).The quality of the included trials was assessed according to the inclusive and exclusive criteria(the PRISMA statement)by 2 researchers independently,and then the data were extracted and analyzed by using RevMan 5.3.0 software.Results A total of 39 clinical trial articles involving 4 868 patients of MIPD and 32 230 patients of OPD were included in the study.The Meta analysis revealed that MIPD had longer operation time,lower blood loss,higher R0 resection rate,less surgical site infection rate and lower length of hospital stay than OPD(P<0.05).There were no significant differences in terms of overall complications,the postoperative pancreatic fistula rate,the delayed gastric emptying rate,the postoperative hemorrhage rate,biliary fistula rate,reoperation rate,overall cost and the long-term survival(P>0.05).Conclusions Due to the faster postoperative recovery,the shorter postoperative hospital stay,the less incidence of surgical site infection,and no significant difference in terms of the overall complications comparing to OPD,the MIPD should be closely monitored and probably done only within structured training programs in high-volume pancreatic centers.