背景:接受胰十二指肠切除术(PD)的胰头癌患者通常会出现疾病复发,经常与正裕度状态(R1)相关。全中胰腺切除术(TMpE)已成为增加手术根治性和最大程度减少局部复发的潜在方法。然而,其有效性和安全性仍在评估中。
方法:我们进行了系统评价和荟萃分析,以综合目前关于TMpE结局的证据。系统搜索MEDLINE,EMBASE,科克伦,截至2024年3月,进行了WebofScience数据库,以确定将TMpE与标准胰十二指肠切除术(sPD)进行比较的研究。使用随机效应模型汇总风险比(RR)或平均差(MD)。
结果:从确定的452项研究中,共纳入9项研究,共738名患者,361(49%)接受TMpE。TMpE显著提高R0切除率(RR1.24;95%CI1.11~1.38;P<0.05),减少失血量(MD-143.70ml;95%CI-247.92,-39.49;P<0.05),淋巴结收获增加(MD7.27节点;95%CI4.81,9.73;P<0.05)。在住院期间没有观察到显著差异,术后并发症,或死亡率介于TMpE和sPD之间。TMpE还显著降低了总体复发(RR0.53;95%CI0.35-0.81;P<0.05)和局部复发(RR0.39;95%CI0.24-0.63;P<0.05)。此外,TMpE组发生胰瘘的风险较低(RR0.66;95%CI0.52-0.85;P<0.05)。
结论:与标准胰十二指肠切除术相比,全胰腺切除能显著提高R0切除率,减少局部复发,同时保持可接受的安全性。有必要进行进一步的前瞻性随机研究,以确定全胰腺切除术的最佳手术方法。
BACKGROUND: Pancreatic head cancer patients who undergo
pancreatoduodenectomy (PD) often experience disease recurrence, frequently associated with a positive margin status (R1). Total mesopancreas excision (TMpE) has emerged as a potential approach to increase surgical radicality and minimize locoregional recurrence. However, its effectiveness and safety remain under evaluation.
METHODS: We conducted a systematic review and meta-analysis to synthesize current evidence on TMpE outcomes. A systematic search of MEDLINE, EMBASE, Cochrane, and Web of Science databases was conducted up to March 2024 to identify studies comparing TMpE with standard
pancreatoduodenectomy (sPD). The risk ratio (RR) or mean difference (MD) was pooled using a random effects model.
RESULTS: From 452 studies identified, 9 studies with a total of 738 patients were included, with 361 (49%) undergoing TMpE. TMpE significantly improved the R0 resection rate (RR 1.24; 95% CI 1.11-1.38; P < 0.05), reduced blood loss (MD -143.70 ml; 95% CI -247.92, -39.49; P < 0.05), and increased lymph node harvest (MD 7.27 nodes; 95% CI 4.81, 9.73; P < 0.05). No significant differences were observed in hospital stay, postoperative complications, or mortality between TMpE and sPD. TMpE also significantly reduced overall recurrence (RR 0.53; 95% CI 0.35-0.81; P < 0.05) and local recurrence (RR 0.39; 95% CI 0.24-0.63; P < 0.05). Additionally, the risk of pancreatic fistula was lower in the TMpE group (RR 0.66; 95% CI 0.52-0.85; P < 0.05).
CONCLUSIONS: Total mesopancreas excision significantly increases the R0 resection rate and reduces locoregional recurrence while maintaining an acceptable safety profile when compared with standard
pancreatoduodenectomy. Further prospective randomized studies are warranted to determine the optimal surgical approach for total mesopancreatic resection.