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Optimal intraoperative management in pancreatic surgery: a systematic review of randomized controlled trials
Belkacem Acidi1, Alain Sauvanet2, Giovanni Marchegianni3
1Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.
Background:
Despite major advances in pancreatic surgery and reduced mortality, intraoperative management remains poorly standardized and largely dependent on surgeon expertise. This systematic review aimed to synthesise randomized controlled trials evaluating intraoperative surgical techniques in pancreatic surgery and their impact on predefined postoperative outcomes (POPF, DGE, SSI, and length of stay).
Methods:
Following PRISMA guidelines, a comprehensive search of PubMed, EMBASE, and the Cochrane Database (2013-2024) identified RCTs assessing intraoperative management in pancreatic surgery. Studies focusing on oncologic outcomes or including fewer than 60 patients were excluded. Quality and risk of bias were assessed using the Jadad Scale and the Cochrane RoB-2 tool.
Results:
Of 818 articles screened, 47 RCTs met inclusion criteria (Jadad ≥3). Postoperative pancreatic fistula (POPF) was the primary endpoint in 19 studies. Significant POPF reductions were associated with specific techniques such as end-to-side anastomosis, pancreaticogastrostomy, and polyethylene glycol-coated patches. Minimally invasive distal pancreatectomy showed reduced blood loss, hospital stay, and faster recovery. Selective or no-drain policies in distal pancreatectomy were supported by RCTs to reduce clinically relevant POPF.
Conclusion:
Intraoperative management in pancreatic surgery remains heterogeneous. Standardized, evidence-based protocols and additional high-quality RCTs are required to optimize surgical techniques and outcomes.
