| Background: Pancreatic cancer is the most malignant tumor in digestive system.According to the data released by China National Cancer Center in 2018,the mortality rate of pancreatic cancer patients in China ranks the fifth among all tumors,and the 5-year survival rate of pancreatic cancer is the worst,less than 8%.Surgical treatment is the first choice for the treatment of pancreatic cancer.According to the related literature,the 5-year survival rate of some pancreatic cancer patients can reach 14.0%-35.5%.At the time of diagnosis,only 20 % of patients are deemed to be resectable as 50 % of patients have metastatic disease and 30 % are diagnosed with locally advanced pancreatic cancer(LAPC).National Comprehensive Cancer Network(NCCN)guidelines and the Americas Hepato Pancreato Biliary Association consensus statement define LAPC as >180° arterial involvement of either the celiac artery(CA)or superior mesenteric artery(SMA).Pancreatic body/tail cancer is usually diagnosed in its advanced stage,which is often considered unresectable because of the involvement of the celiac axis(CA)or the origin of the common hepatic artery(CHA).Chemo-and/or radiotherapies have been the only options for these locally advanced pancreatic cancers,but their effects have been dismal.Extended distal pancreatectomy with en bloc resection of the celiac artery(DP-CAR)may provide a chance for complete resection of locally advanced pancreatic cancer.However,data regarding DP-CAR are limited.It is unclear whether it is safe and effective,can provide survival benefits similar to DP,or can result in prolonged survival and better quality of life compared to supportive treatments.Celiac axis resection without vascular reconstruction for gastric cancer was initially reported for total gastrectomy by Appleby.Since then,celiac axis resection has been applied to distal pancreatectomy,a procedure referred to as DP-CAR.DPCAR is a difficult and complicated procedure that has been the subject of much debate.It is feasible in theory because the blood supply through the superior mesenteric artery,pancreatoduodenal arcades,and gastroduodenal artery can support the hepatobiliary system and stomach.However,postoperative ischemic problems continue to be a concern.Although DP-CAR dramatically increases tumor resectability,the associated postoperative morbidity rate is high.The value of DP-CAR has no Most of existing reports regarding DP-CAR include small case numbers without comparable data,which make it hard to determine the actual value of this procedure.Meta-analysis is an effective way to pool data from different studies to generate more stable and consolidated results.Therefore,the objective of this study was to use a meta-analysis to determine whether DP-CAR is a safe,feasible,and beneficial procedure.Objective: A Cochrane system evaluation was used to evaluate the published clinical studies on DP-CAR and DP in the treatment of locally advanced pancreatic body and tail cancer,and to compare the operation time,bleeding volume,R0 resection rate,postoperative total complication rate and other related clinical efficacy indexes of the two operation methods,in order to provide objective reference for safety and efficacy of DP-CAR in the treatment of pancreatic body and tail cancer.Methods: A computerized search was conducted using Pub Med,Embase,Web of Science,the Cochrane Library,and Chinese electronic databases(VIP database,Wan Fang database,and CNKI database).Articles were selected according to predesigned inclusion and exclusion criteria,and data were extracted according to predesigned sheets.Clinical,oncologic,and survival outcomes of DP-CAR were systematically reviewed by hazard ratios(HRs)or odds ratio(OR)using fixed-or random-effects models.The data were collected and analyzed by Excel,and the data were meta analyzed by Revman 5.3.To systematically evaluate the research status and clinical efficacy of DP-CAR and pancreaticocerulectomy in the treatment of locally advanced pancreatic cancer,such as: R0 resection rate,median survival time,incidence of complications,bleeding,operation time,tumor size,portal vein resection rate,pancreatic leakage rate,delayed gastric emptying,hospital stay,etc.Results: Twelve studies were included.DP-CAR had a longer operating time and greater intraoperative blood loss compared to distal pancreatectomy(DP).The meta-analysis was finally included in 12 retrospective control studies,including 1124 patients,213 patients in the DP-CAR group and 911 patients in the DP group.The results of this meta-analysis showed that the operation time of DP-CAR group was longer than that of DP Group [MD =-73.69,95% CI:(-112.99,-34.38),P = 0.0002],the blood transfusion rate was higher [or = 0.29;95% CI:(0.10,0.87),P = 0.03],the portal vein resection rate was higher [or = 6.00,95% CI:(2.59,13.91),P < 0.0001],and the postoperative gastric emptying disorder rate was higher [or = 0.37,95% CI:(0.15,0.93),P = 0.03],R0 resection rate was low [or = 2.79,95% CI:(1.90,4.09),P < 0.00001].However,there was no significant difference between DP-CAR group and DP group in the incidence of pancreatic leakage [or = 1.15,95% CI:(0.79,1.66),P = 0.36],length of stay [MD = 1.33,95% CI:(-4.70,7.35),P = 0.67],tumor size [MD =-5.04,95% CI:(-15.18,-5.10),P = 0.33] and 90 day mortality [or = 0.40;95% CI:(0.15,1.06)P = 0.07].Conclusion: In light of improved neoadjuvant therapeutic regimens,the DP-CAR is a feasible and safe treatment option for patients with LAPC involving the CA,SMA or CHA,with morbidity and mortality similar to patients undergoing classic DP and an average median survival time of 17.7 months. |
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