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Systematc Review and Meta-analysis Comparing Laparoscopic and Open Cystogastrostomy for Pancrestic Pseudocyst

There are various treatment modalities for managing symptomatic pancreatic pseudocysts. For those cysts densely adherent to the posterior wall of the stomach surgical internal drainage by cystogastrostomy is the preferred option. It can be performed by open and by laparoscopic surgery. Laparoscopic cystogastrostomy has been proposed to have several advantages in comparison to open surgery, but there is no clear consensus about that. Of 67 studies 52 studies met the inclusion criteria, representing 3140 patients. There were 14 LCG studies (240 patients), and 40 studies (2900 patients) about OCG. According to levels of evidence there were: three individual cohort studies (level of evidence 2b), 21 outcomes research studies (level of evidence 2c), four systematic reviews of case control studies (level of evidence 3a), three individual case control studies (level of evidence 3b) and 23 case series (level of evidence 4). LCG showed statistically significant more anastomotic bleeding (3.85% vs. 0.83%, p<0.001) but significantly less other perioperative bleeding complication (0% vs. 2.88%, p=0.014). There were more reinterventions due to complications in the open cystogastrostomy group, but not significantly (1.92% vs. 2.63%, p=0.558). There was no mortality in the group of patients operated laparoscopically, and there was 4.26% mortality in the open cystogastrostomy group (p=0.003). Although laparoscopic cystogastrostomy took significantly more operating time (160 min vs. 120 min, p<0.001) the length of hospital stay was four times shorter then in open cystogastrostomy group (6.16 vs. 26.93 days, p<0.001. The study highlighted some deficiencies in details of reporting, particularly with relation to the type of pancreatic pseudocysts surgery. A systematic review and meta-analysis was conducted searching MEDLINE, EMBASE, CENTRAL, DARE and Current Contents from 1958. to January 2008. to identify clinical trials to compare laparoscopic cystogastrostomy (LCG) and open cystogastrostomy (OCG). Because two comparative studies were included, meta-analysis could be performed. Frequencies of outcomes were compared using chi-square test (STATISTICA v6, STATsoft, USA). Meta-analysis was performed in line with recommendations from the Cochrane Collaboration and The Quality of Reporting of Meta-analysis (QUORUM) guidelines. Statistical analysis for categorical variables was carried out using the odds ratio (OR) at the summary statistic. The Mantel-Haenszel method was used to combine the OR for outcomes of interest using a random-effect meta-analytical technique. Meta-analysis was performed using Review Manager Software (RevMan 5, Cochrane Collaboration). Quantitative variables from cohort studies (age, pseudocyst size, duration of surgery, length of hospital stay and length of follow up) were compared by using student's t-test, after calculating group mean and variance (i.e. for laparoscopic and open cystogastrostomy) from available study parameters (means, variances, medians and ranges) using methods described by Hozo et al. Laparoscopic cystogastrostomy appears to have clinically important advantages comparing to open surgery in patients with retrogastric pancreatic pseudocyst. This is particularly evident in regard to the length of hospital stay and mortality. Certain complications were characteristically related to laparoscopic surgery but these could be associated due to adopting technical challenges of minimally invasive approach. Therefore further clinical trials of laparoscopic pseudocystogastrostomy should demonstrate the full benefits or drawbacks of laparoscopic surgery.

pancreatic pseudocyst; laparoscopic cystogastrostomy

DOI: 10.1007/s00464-009-0402-x