Does minimally invasive pylorus-preserving pancreaticoduodenectomy (MI-PPPD) triumph over open pylorus-preserving pancreaticoduodenectomy (O-PPPD)? A systematic review and meta-analysis

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BACKGROUND: PPPD is purported to be better than the Whipple procedure as it preserves full gastric capacity. Approaching this surgery using the MIS technique [minimally invasive pylorus-preserving pancreaticoduodenectomy (MI-PPPD)] may confer additional advantages compared to the open method. However, literature comparing MI-PPPD to open pylorus-preserving pancreaticoduodenectomy (O-PPPD) is scarce. This study seeks to review the efficacy and long-term outcomes of MI-PPPD against O-PPPD. MATERIALS AND METHODS: This PRISMA-adherent review involved a systematic search of PubMed, Scopus, Cochrane, and Embase for studies evaluating the outcomes of MI-PPPD compared to O-PPPD. Two independent reviewers extracted the summary data from included studies. Random effects meta-analyses were used for analysis. All analyses were performed in RStudio (Posit Software, PBC, Boston, Massachusetts) Version 4.3.2. Artificial intelligence was not used for research and manuscript development. RESULTS: Nine articles with 682 patients (391 in the MI-PPPD group and 291 in the O-PPPD group) were included. Postoperatively, there was no statistically significant differences in postoperative complications [risk ratio (RR) = 1.00, 95% CI: 0.69; 1.46], length of hospital stay [mean difference (MD) = -0.21, 95% CI: -0.53; 0.11], postoperative pancreatic fistula formation (RR = 0.78, 95% CI: 0.59; 1.05), delayed gastric emptying (RR = 0.63, 95% CI: 0.35; 1.14), postpancreatectomy hemorrhage (RR = 1.38, 95% CI: 0.77; 2.46), and 90-day mortality (RR = 2.42, 95% CI: 0.92; 6.34). Perioperatively, MI-PPPD had nonsignificant reduction in estimated blood loss (MD = -129.07, 95% CI: -579.35; -312.20) and nonsignificant difference in operative time (MD = 0.38 min, 95% CI: -0.18; 0.95). Oncological outcomes revealed equivalent outcomes in R0 resection (MD = 0.50%, 95% CI: 0.07; 3.82) and lymph node yield (MD = -1.31, 95% CI: -2.83; 0.22). CONCLUSION: MI-PPPD is noninferior to O-PPPD. Whilst MI-PPPD outcomes have been influenced by its high complexity and steep learning curve, this approach is believed to be on an upwards trajectory with the potential to surpass O-PPPD. Investment toward MI-PPPD training is recommended given the potential benefits it brings to patients.

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