Distal Pancreatectomy With Different Surgical Approaches For Malignant Pancreatic Disease:A Network Meta-analysis

Objective: Minimally invasive distal pancreatectomy（MIDP）is a highly demanding surgical procedure that has progressed slowly in the development of hepatobiliary and pancreatic surgery and is difficult for clinicians to master precisely.The advantages of robotic surgical platforms include three-dimensional visualization of the surgical field and improved instrumentation flexibility,which has led to its widespread use.The aim of this study is to compare the advantages and disadvantages of minimally invasive distal pancreatectomy and open distal pancreatectomy（ODP）for the treatment of malignant pancreatic diseases using a network meta-analysis to provide a basis for clinical management.Methods: We systematically searched relevant international literature databases published from the inception to November 2021,including Pubmed,Web of science,The Cochrane library,and Embase databases.Relevant English literature comparing MIDP and ODP for benign and malignant pancreatic diseases were screened.Intraoperative（operative time,blood loss,spleen preservation rate）,postoperative（total complication rate,length of stay,pancreatic fistula rate）and oncological（R0resection rate,number of total lymph node harvested）outcomes were evaluated.All statistical analyses were performed using Stata 14.0.Results: After literature screening,sixty-nine English literatures with a total of16,220 patients were finally included,of which 39%（n=6253）were TLDP,5%（n=831）were TRDP,and 50%（n=8075）were ODP.In terms of intraoperative outcomes: the estimated blood loss（SUCRA: 92.8%）and transfusion rate（SUCRA:78.1%）were significantly lower in the TRDP group compared to TLDP,HLDP and ODP,but the TRDP group required a longer operative time（SUCRA: 33.2%）.In contrast,the RADP group had the highest rate of spleen preservation（85.7%）.Regarding postoperative outcomes: no statistically significant differences in the incidence of delayed gastric emptying,pulmonary complications and abdominal abscesses among the five DP surgical techniques.The overall complication rate（SUCRA: 87.9%）,major complication rate（SUCRA: 98.7%）,pancreatic fistula rate（SUCRA: 94.7%）,surgical site infection（SUCRA: 88.3%）,reoperation rate（SUCRA:96.2%）,local recurrence rate（SUCRA: 99.3%）,and 30-day mortality rate（SUCRA.84.3%）were lower than the other four groups of DP surgical modalities,but the total hospitalization cost was significantly higher in the TRDP group（SUCRA: 9.8%）.Additionally,the length of stay was relatively shorter in the RADP group（SUCRA:93.7%）.Conclusions: Current evidence suggests that MIDP generally improves spleen preservation rates,R0 resection rates,and the number of total lymph node harvested compared with ODP,while reducing overall complication rates,pancreatic fistula rates,reoperation rates,local recurrence rates,surgical site infection rates,estimated blood loss,and transfusion rates.However,it prolongs the operative time.Furthermore,robotic surgery has clinical and oncological advantages over laparoscopic techniques and is more suitable for surgery of malignant pancreatic disease.