Middle Segment-Preserving Pancreatectomy to Avoid Pancreatic Insufficiency: Individual Patient Data Analysis of All Published Cases from 2003–2021
Abstract
:1. Introduction
2. Materials and Methods
2.1. Search Strategy and Eligibility Criteria
2.2. Quality Control and Risk of Bias
2.3. Extracted Data and Definitions
2.4. Outcomes and Analysis
2.4.1. Patient Baseline Characteristics
2.4.2. Surgical Resection and Intraoperative Outcomes
2.4.3. Postoperative Course
2.4.4. Long-Term Follow-Up and Survival
3. Results
3.1. Literature Review and Risk of Bias
3.2. Pre-Operative Baseline
3.3. Surgical Resections and Intraoperative Outcomes
3.3.1. MPP Surgical Procedures
3.3.2. MPP Intraoperative Outcomes
3.3.3. Comparison of Intraoperative Outcomes with TP Patients
3.4. Postoperative Course and Complications
3.4.1. MPP Postoperative Outcomes
3.4.2. MPP Postoperative Pancreatic Function
3.4.3. Comparison of Postoperative Course with TP Patients
3.5. MPP Long-Term Follow-Up and Survival Analysis
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
First Author | Primary Institution | Last Contact | Risk of Bias | |||||
---|---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | Score | |||
Lloyd [18] | Methodist Hospital, Indianapolis | 8 November 2021 | N | Y | Y | Y | Y | Moderate |
Miura [29] | Teikyo University School of Medicine, Tokyo | 27 March 2019 | Y | Y | Y | Y | Y | Low |
Partelli [30] | University of Verona Hospital, Verona | 15 Decemeber 2020 | Y | Y | Y | Y | Y | Low |
Kitasato [31] | Nagasaki University Hospital, Nagasaki | 12 February 2019 | N | Y | Y | Y | Y | Moderate |
Ohzato [32] | Sakai Municipal Hospital, Osaka | 7 January 2019 | N | Y | Y | Y | Y | Moderate |
Sperti [33] | University of Padua Hospital, Padua | 7 January 2019 | Y | Y | Y | Y | Y | Low |
Chen [34] | The First People’s Hospital of Fo Shan, Guang Dong | 4 January 2019 | N | Y | Y | Y | Y | Moderate |
Horiguchi [35] | Fujita Health University, Toyoake | 12 February 2019 | Y | Y | Y | Y | Y | Low |
Noda [36] | Saitama Medical Center, Saitama | 20 February 2019 | Y | Y | Y | Y | Y | Low |
Aryal [37] | Kagoshima University Hospital, Kagoshima | 15 February 2019 | N | Y | Y | Y | Y | Moderate |
Nishi [38] | Ehime Prefectural Central Hospital, Matsuyama | 16 February 2019 | N | Y | Y | Y | Y | Moderate |
Tanemura [40] | Mie University School of Medicine, Tsu | 24 February 2019 | N | Y | Y | Y | Y | Moderate |
Usui [41] | Mie University School of Medicine, Tsu | 12 February 2019 | N | Y | Y | Y | Y | Moderate |
Lu [42] | First Affiliated Hospital of Nanjing Medical University, Jiangsu | 2 February 2019 | Y | Y | Y | Y | Y | Low |
Addeo [45] | Hôpital de Hautepierre-Strasbourg University Hospital, Strasbourg | 2 February 2021 | N | Y | Y | Y | Y | Moderate |
Nitta [46] | Shizuoka Cancer Center, Shizuoka | 6 Decemeber 2020 | N | Y | Y | Y | Y | Moderate |
Iguchi [47] | Saiseikai Fukuoka General Hospital, Fukuoka | 31 January 2022 | N | Y | Y | Y | Y | Moderate |
Appendix B
Factor | MPP | TP | Statistic | p |
---|---|---|---|---|
Mean Age ± SE | 59.97 ± 3.17 | 63.07 ± 2.76 | t38.68 = 0.74 | 0.465 |
ASA° ≤ 2 | 18 (62%) | 9 (64%) | χ21 = 0.02 | 0.888 |
ASA° > 2 | 11 (38%) | 5 (36%) | ||
Female | 15 (52%) | 9 (64%) | χ21 = 0.60 | 0.437 |
Male | 14 (48%) | 5 (36%) | ||
Neoplastic | 12 (41%) | 8 (57%) | Fisher’s | 0.065 |
Synchronous | 10 (34%) | 3 (21%) | ||
Metastatic | 6 (21%) | 0 (0%) | ||
Non-Neoplastic | 1 (3%) | 3 (2%) | ||
Diabetic | 5 (17%) | 3 (21%) | Fisher’s | 1.000 |
Non-Diabetic | 24 (83%) | 11 (79%) |
MPP | TP | |||||
---|---|---|---|---|---|---|
Pathology | Head | Tail | Total | Head | Tail | Total |
AC | 2 | 0 | 2 | 0 | 0 | 0 |
BD-IPMN | 5 | 4 | 9 | 2 | 1 | 3 |
CC | 1 | 0 | 1 | 0 | 0 | 0 |
CP | 1 | 5 | 6 | 3 | 3 | 6 |
IPMN | 0 | 1 | 1 | 0 | 0 | 0 |
MCA | 0 | 1 | 1 | 0 | 0 | 0 |
MD-IPMN | 0 | 1 | 1 | 0 | 2 | 2 |
dBDC | 2 | 0 | 2 | 0 | 0 | 0 |
mDFSP | 1 | 1 | 2 | 0 | 0 | 0 |
mPCC | 1 | 1 | 2 | 0 | 0 | 0 |
mRC | 1 | 1 | 2 | 0 | 0 | 0 |
mRCC | 3 | 3 | 6 | 0 | 0 | 0 |
MT-IPMN | 1 | 1 | 2 | 7 | 6 | 13 |
PDAC | 2 | 1 | 3 | 0 | 0 | 0 |
PNEN | 7 | 7 | 14 | 1 | 2 | 3 |
Retention Cyst | 1 | 0 | 1 | 0 | 0 | 0 |
SCA | 0 | 0 | 0 | 1 | 0 | 1 |
SPN | 1 | 2 | 3 | 0 | 0 | 0 |
Response | Factor | All Surgeries | Multi-Visceral Excluded | ||||
---|---|---|---|---|---|---|---|
df | F-Value | p-Value | df | F-Value | p-Value | ||
Log operation time (log min) * | Surgery Type | 1 | 31.99 | <0.001 | 1 | 27.19 | <0.001 |
Age Group | 1 | 5.01 | 0.031 | 1 | 6.41 | 0.016 | |
ASA° | 1 | 1.07 | 0.307 | 1 | 0.92 | 0.344 | |
Sex | 1 | 0.73 | 0.398 | 1 | 0.04 | 0.849 | |
Residuals | 38 | 33 | |||||
Blood loss (mL) † | Surgery Type | 1 | 0.09 | 0.760 | 1 | 0.15 | 0.700 |
Age Group | 1 | 0.97 | 0.331 | 1 | 0.14 | 0.708 | |
ASA° | 1 | 6.36 | 0.017 | 1 | 5.78 | 0.023 | |
Sex | 1 | 1.77 | 0.193 | 1 | 2.17 | 0.152 | |
Residuals | 33 | 28 | |||||
Remnant length (cm) ‡ | Surgery Type | 1 | 2.43 | 0.129 | 1 | 2.82 | 0.105 |
Age Group | 1 | 0.49 | 0.488 | 1 | 1.09 | 0.306 | |
ASA° | 1 | 0.03 | 0.853 | 1 | 0.04 | 0.847 | |
Sex | 1 | 1.78 | 0.192 | 1 | 2.06 | 0.163 | |
Residuals | 32 | 26 |
Outcome | Selected Model | ΔAICc | χ2 | df | p | r2 |
---|---|---|---|---|---|---|
Length of stay | Surgical outcomes | −10.3 | 18.99 | 21, 24 | <0.001 | 0.53 |
Uneventful course | Surgical outcomes | +0.9 | 6.88 | 21, 24 | 0.076 | 0.33 |
Uneventful course | Pathological dignity | +1.0 | 1.41 | 23, 24 | 0.235 | 0.08 |
Morbidity | Surgical outcomes | −10.1 | 17.97 | 21, 24 | <0.001 | 0.74 |
POPF | Surgical outcomes | −2.1 | 9.99 | * 20, 23 | 0.019 | 0.45 |
DGE | Null | 0.0 | ||||
Other complications | Null | 0.0 | ||||
Readmission | Surgical outcomes | −2.7 | 10.54 | 21, 24 | 0.015 | 0.66 |
Endocrine insufficiency | Patient characteristics | +1.3 | 6.73 | * 19, 22 | 0.081 | 0.34 |
New-onset DM | Patient characteristics | +1.2 | 7.10 | * 17, 20 | 0.069 | 0.40 |
New-onset DM | Pathological dignity | +1.6 | 0.87 | * 19, 20 | 0.350 | 0.06 |
Exocrine insufficiency | Pathological dignity | −3.2 | 5.61 | * 22, 23 | 0.018 | 0.29 |
Exocrine insufficiency † | Surgical outcomes | +0.1 | 8.53 | * 15, 18 | 0.036 | 0.56 |
Predictor | Outcome | Odds Ratio (95% CI) | z-Value | p-Value |
---|---|---|---|---|
Age | Endocrine insufficiency | 2.78 (1.02–10.35) | 1.79 | 0.074 |
New-onset DM | 6.22 (1.44–76.29) | 1.91 | 0.056 | |
ASA° | Endocrine insufficiency | 0.10 (0.01–1.06) | −1.76 | 0.078 |
New-onset DM | 0.15 (0.01–1.87) | −1.37 | 0.171 | |
Sex | Endocrine insufficiency | 1.10 (0.12–9.10) | 0.09 | 0.927 |
New-onset DM | 0.57 (0.03–6.61) | −0.43 | 0.666 |
Predictor | Outcome | Odds Ratio (95% CI) | z-Value | p-Value |
---|---|---|---|---|
Operation time | Length of stay | 1.36 (1.09–1.72) | 2.60 | 0.009 |
Uneventful course | 1.09 (0.35–3.26) | 0.16 | 0.875 | |
Morbidity | 0.75 (0.05–11.90) | −0.24 | 0.813 | |
POPF | 1.23 (0.45–3.85) | 0.40 | 0.689 | |
Readmission | 0.15 (0.00–2.26) | −0.91 | 0.366 | |
Exocrine insufficiency * | 0.05 (0.00–1.15) | −1.15 | 0.248 | |
Blood loss | Length of stay | 1.33 (1.02–1.75) | 2.25 | 0.025 |
Uneventful course | 0.57 (0.15–1.65) | −0.99 | 0.323 | |
Morbidity | 1.25 (0.22–6.57) | 0.29 | 0.775 | |
POPF | 2.20 (0.75–8.14) | 1.37 | 0.171 | |
Readmission | 22.32 (0.83–>100) | 1.17 | 0.243 | |
Exocrine insufficiency * | 0.38 (0.00–7.64) | −0.52 | 0.606 | |
Remnant length | Length of stay | 0.83 (0.63–1.08) | −1.60 | 0.111 |
Uneventful course | 2.73 (0.94–10.67) | 1.67 | 0.096 | |
Morbidity | 0.03 (0.00–0.26) | −2.26 | 0.024 | |
POPF | 0.28 (0.05–0.98) | −1.77 | 0.077 | |
Readmission | 0.03 (0.00–0.69) | −1.25 | 0.210 | |
Exocrine insufficiency * | 2.38 (0.30–36.70) | 0.73 | 0.466 |
Pathological Dignity | |||
---|---|---|---|
Outcome | Odds Ratio (95% CI) | z-Value | p-Value |
Exocrine insufficiency | 0.11 (0.01–0.70) | −2.20 | 0.028 |
Outcome (Model) | Factor | Odds Ratio (95% CI) | z-Value | p-Value |
---|---|---|---|---|
Length of stay (negative binomial) χ238, 42 = 25.41, p < 0.001, r2 = 0.45 | Surgery Type | 2.02 (1.40–2.88) | 3.82 | <0.001 |
Age | 1.40 (1.15–1.68) | 3.68 | <0.001 | |
ASA° | 1.24 (0.88–1.77) | 1.20 | 0.232 | |
Sex | 0.74 (0.53–1.03) | −1.77 | 0.076 | |
Uneventful stay (logistic regression) χ238, 42 = 5.13, p = 0.274, r2 = 0.16 | Surgery Type | 1.30 (0.28–7.18) | 0.33 | 0.744 |
Age | 0.47 (0.21–0.95) | −2.00 | 0.045 | |
ASA° | 1.31 (0.26–6.49) | 0.33 | 0.738 | |
Sex | 1.52 (0.35–6.72) | 0.57 | 0.571 | |
Morbidity (logistic regression) χ238, 42 = 2.04, p = 0.728, r2 = 0.07 | Surgery Type | 1.03 (0.19–4.94) | 0.04 | 0.972 |
Age | 1.32 (0.62–2.81) | 0.74 | 0.462 | |
ASA° | 1.20 (0.24–6.77) | 0.22 | 0.829 | |
Sex | 0.43 (0.09–1.84) | −1.13 | 0.258 | |
Other complications (logistic regression) χ238, 42 = 9.14, p = 0.058, r2 = 0.26 | Surgery Type | 0.13 (0.02–0.53) | −2.67 | 0.008 |
Age | 1.12 (0.56–2.37) | 0.31 | 0.753 | |
ASA° | 0.77 (0.17–3.35) | −0.35 | 0.726 | |
Sex | 0.84 (0.21–3.38) | −0.25 | 0.802 | |
Exocrine insufficiency * (logistic regression) χ237, 41 = 19.50, p < 0.001, r2 = 0.50 | Surgery Type | 0.02 (0.00–0.17) | −3.17 | 0.002 |
Age | 0.79 (0.37–1.67) | −0.64 | 0.523 | |
ASA° | 0.42 (0.05–2.63) | −0.90 | 0.367 | |
Sex | 1.22 (0.24–6.69) | 0.24 | 0.812 |
Patient 12 | Patient 15 | Patient 17 | Patient 19 | Patient 22 | Patient 23 | |
---|---|---|---|---|---|---|
Study ID | 8 | 8 | 10 | 12 | 14 | 14 |
Age | 69 | 83 | 80 | 67 | 81 | 48 |
Sex | m | m | f | m | f | m |
ASA° | ≤2 | >2 | >2 | >2 | ≤2 | ≤2 |
Indication | Neoplasia | Synchronous | Synchronous | Metastatic | Metastatic | Metastatic |
Dignity of Pancreatic Disease | Malignant (splenic lymphoma) * | Malignant (dBDC) | Malignant (dBDC) | Malignant (mRC) | Malignant (mRCC) | Malignant (mDFSP) |
DFS (months) | 0 | 110 | 51 | 0 | NA | NA |
PFS (months) | NA | NA | NA | 3 | NA | NA |
Local Recurrence | 0 | 0 | 0 | 0 | 0 | 0 |
Malignancy Recurrence | 0 | 0 | 1 | 1 | 1 | 1 |
OS (months) | 16 | 110 | 58 | 36 | 41.3 | 8.7 |
Cause of Death | Malignant lymphoma | Cerebral infarction | Recurrent dBDC | Disease progression | Malignancy progressed to diffuse metastases | Malignancy progressed to diffuse metastases |
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Ref. | Study ID | First Author | Year | Country | Indication | Pathological Dignity |
---|---|---|---|---|---|---|
[17] | NA | * Siassi | 1999 | Germany | NA | NA |
[18] | 1 | Lloyd | 2003 | USA | Neoplasia | Benign |
[29] | 2 | † Miura | 2007 | Japan | Synchronous | Malignant |
[30] | NA | ‡ Chiang | 2009 | Taiwan | NA | NA |
[31] | 3 | Partelli | 2009 | Italy | Neoplasia | Benign |
Neoplasia | Benign | |||||
Neoplasia | Malignant | |||||
Synchronous | Benign | |||||
Synchronous | Benign | |||||
[32] | 4 | Kitasato | 2010 | Japan | Metastatic | Malignant |
[33] | 5 | Ohzato | 2010 | Japan | Metastatic | Malignant |
[34] | 6 | Sperti | 2010 | Italy | Synchronous | Benign |
[35] | 7 | Chen | 2011 | China | Synchronous | Malignant |
[36] | 8 | Horiguchi | 2011 | Japan | Neoplasia | Malignant |
Neoplasia | Malignant | |||||
Neoplasia | Malignant | |||||
Synchronous | Malignant | |||||
[37] | 9 | Noda | 2011 | Japan | Synchronous | Malignant |
[38] | NA | ‡ Otani | 2011 | Japan | NA | NA |
[39] | NA | ‡ Cheng | 2013 | China | NA | NA |
[40] | 10 | Aryal | 2014 | Japan | Synchronous | Malignant |
[41] | 11 | Nishi | 2014 | Japan | Neoplasia | Benign |
[42] | NA | * Takeshi | 2014 | Japan | NA | NA |
[43] | 12 | Tanemura | 2014 | Japan | Metastatic | Malignant |
[44] | 13 | Usui | 2014 | Japan | Neoplasia | Benign |
[45] | 14 | Lu | 2016 | China | Non-neoplastic | Benign |
Neoplasia | Malignant | |||||
Metastatic | Malignant | |||||
Metastatic | Malignant | |||||
Metastatic | Malignant | |||||
[46] | NA | * Yamada | 2017 | Japan | NA | NA |
[47] | NA | ‡ Patyutko | 2019 | Russia | NA | NA |
[48] | 15 | Addeo | 2020 | France | Neoplasia | Malignant |
[49] | 16 | Nitta | 2020 | Japan | Neoplasia | Malignant |
[50] | 17 | Iguchi | 2021 | Japan | Synchronous | Malignant |
NA | NA | NA | 2020 | Germany | Synchronous | Benign |
DP | SPDP | Operation Time (min) | Blood Loss (mL) | Remnant Length (cm) | Remnant Volume (% Original) | ||
---|---|---|---|---|---|---|---|
N (%) | N (%) | Mean ± SE | Mean ± SE | Mean ± SE | Mean ± SE | ||
Proximal operation | Duodenum-preserving pancreatic head resection (Beger, Bern, Frey) | 0 (0%) | 2 (7%) | 506.5 ± 136.5 | 1110.0 ± 90.0 | 4.8 ± 0.2 | 18.4 |
Inferior pancreatic head resection | 1 (3%) | 1 (3%) | 454.0 ± 86.0 | 1160.0 ± 260.0 | NA | NA | |
Pancreaticoduodenectomy (Kausch-Whipple procedure) | 6 (21%) | 1 (3%) | 512.6 ± 34.6 | 1440.7 ± 632.6 | 5.3 ± 0.4 | 33.8 ± 4.0 | |
Pylorus-preserving pancreaticoduodenectomy (Traverso-Longmire procedure) | 9 (31%) | 3 (10%) | 378.8 ± 38.0 | 981.6 ± 431.0 | 5.7 ± 0.6 | 28.6 ± 3.7 | |
Subtotal stomach-preserving pancreaticoduodenectomy | 4 (14%) | 1 (3%) | 520.0 ± 48.0 | 885.8 ± 215.0 | 6.3 ± 0.7 | 33.4 ± 8.3 | |
Uncinate process resection | 1 (3%) | 0 (0%) | 440.0 | 1720.0 | 5.0 | 40.0 | |
Surgical extent | Pancreas only | 17 (59%) | 6 (21%) | 430.3 ± 24.0 | 975.8 ± 215.4 | 5.9 ± 0.4 | 31.0 ± 3.2 |
Multi-visceral | 4 (14%) | 2 (7%) | 533.2 ± 62.1 | 1685.0 ± 777.3 | 4.7 ± 0.4 | 31.8 ± 4.7 |
Survived | Died | Test | p-Value | |
---|---|---|---|---|
Indication: Metastatic | 1 (17%) | 3 (50%) | Fisher’s | 0.351 |
Indication: Neoplasms | 4 (67%) | 1 (17%) | ||
Indication: Synchronous | 1 (17%) | 2 (33%) | ||
Dignity: Benign | 3 (50%) | 0 (0%) | Fisher’s | 0.182 |
Dignity: Malignant | 3 (50%) | 6 (100%) | ||
Malignancy recurrence: No | 6 (100%) | 2 (33%) | Fisher’s | 0.061 |
Malignancy recurrence: Yes | 0 (0%) | 4 (67%) | ||
ASA° ≤ 2 | 5 (83%) | 3 (50%) | Fisher’s | 0.546 |
ASA° > 2 | 1 (17%) | 3 (50%) | ||
Age | 56.0 ± 7.8 | 71.3 ± 5.4 | t8.88 = 1.61 | 0.141 |
Operation time (min) | 462.2 ± 47.5 | 428.5 ± 65.7 | t9.10 = 0.42 | 0.688 |
Blood loss (mL) | 630.0 ± 212.8 | 1575.8 ± 720.4 | t5.87 = 1.26 | 0.256 |
Remnant length (cm) | 7.1 ± 0.6 | 4.9 ± 0.6 | t8.00 = 2.46 | 0.040 |
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Pausch, T.M.; Liu, X.; Dincher, J.; Contin, P.; Cui, J.; Wei, J.; Heger, U.; Lang, M.; Tanaka, M.; Heap, S.; et al. Middle Segment-Preserving Pancreatectomy to Avoid Pancreatic Insufficiency: Individual Patient Data Analysis of All Published Cases from 2003–2021. J. Clin. Med. 2023, 12, 2013. https://doi.org/10.3390/jcm12052013
Pausch TM, Liu X, Dincher J, Contin P, Cui J, Wei J, Heger U, Lang M, Tanaka M, Heap S, et al. Middle Segment-Preserving Pancreatectomy to Avoid Pancreatic Insufficiency: Individual Patient Data Analysis of All Published Cases from 2003–2021. Journal of Clinical Medicine. 2023; 12(5):2013. https://doi.org/10.3390/jcm12052013
Chicago/Turabian StylePausch, Thomas M., Xinchun Liu, Josefine Dincher, Pietro Contin, Jiaqu Cui, Jishu Wei, Ulrike Heger, Matthias Lang, Masayuki Tanaka, Stephen Heap, and et al. 2023. "Middle Segment-Preserving Pancreatectomy to Avoid Pancreatic Insufficiency: Individual Patient Data Analysis of All Published Cases from 2003–2021" Journal of Clinical Medicine 12, no. 5: 2013. https://doi.org/10.3390/jcm12052013
APA StylePausch, T. M., Liu, X., Dincher, J., Contin, P., Cui, J., Wei, J., Heger, U., Lang, M., Tanaka, M., Heap, S., Kaiser, J., Klotz, R., Probst, P., Miao, Y., & Hackert, T. (2023). Middle Segment-Preserving Pancreatectomy to Avoid Pancreatic Insufficiency: Individual Patient Data Analysis of All Published Cases from 2003–2021. Journal of Clinical Medicine, 12(5), 2013. https://doi.org/10.3390/jcm12052013