Safety and Efficacy for Robot-Assisted Versus Open Pancreaticoduodenectomy: A Meta-Analysis of Multiple Worldwide Centers

Objectives: To compare the efficacy of robot-assisted pancreaticoduodenectomy with that of laparotomy. Methods: The PubMed, EMBASE, Cochrane Library, and other databases were searched for literature available from their respective inception dates up to May 2020 to find studies comparing robot-assisted pancreaticoduodenectomy (RPD) with open pancreaticoduodenectomy (OPD). The RevMan 5.3 statistical software was used for analysis to evaluate surgical outcome and oncology safety. The combination ratio ( RR ) and weighted mean difference ( WMD ) and their 95% confidence intervals ( CIs ) were calculated using fixed effect or random effect models. Results: 18 cohort studies from 16 medical centers were eligible with a total of 5795 patients including 1420 RPD group patients and 4375 OPD group patients. The RPD group fared better than the OPD group in terms of estimated blood loss (EBL) ( WMD =-175.65, 95% CI (-251.85, -99.44), P<0.00001), wound infection rate ( RR =0.60, 95% CI (0.44,0.81), P= 0.001), reoperation rate (RR=0.61, 95% CI (0.41,0.91), P=0.02), hospital day ( WMD = -2.95, 95% CI (-5.33,-0.56), P = 0.02), intraoperative blood transfusion ( RR = 0.56, 95% CI (0.42, 0.76), P=0.0001), overall complication ( RR = 0.78, 95% CI (0.64,0.95), P = 0.01), and clinical pancreatic fistula (PF) (RR = 0.54, 95% CI (0.41,0.70), P < 0.0001). In terms of lymph node clearance ( WMD = 0.48, 95% CI (-2.05,3.02), P = 0.71), R0 rate ( RR = 1.05, 95% CI (1.00,1.11), P = 0.05), postoperative pancreatic fistula (POPF) ( RR =1, 95% CI (0.85,1.19), P = 0.97), bile leakage ( RR = 0.99, 95% CI (0.54,1.83), P = 0.98), delayed gastric emptying (DGE) ( RR = 0.79, 95% CI (0.60,1.03), P = 0.08), mortality ( RR = 0.82, 95% CI (0.62,1.10), P=0.19), and severe complication ( RR = 0.98, 95% CI (0.71,1.36), P = 0.91), there were no significant differences between the two groups. Laparoscopic surgery was inferior to open surgery in terms of operational time ( WMD = 80.85, 95% CI (16.09,145.61), P=0.01). Conclusions: RPD is not inferior to OPD, and it is even more advantageous for DGE, wound infection rate, reoperation rate, hospital stay, transfusion, overall complication and clinical PF. However, these findings need to be further verified by high-quality randomized controlled trials.