MORBIDITY AND MORTALITY FOLLOWING SURGERY FOR PANCREAS CANCER IN LOW- AND MIDDLE-INCOME COUNTRIES: A SYSTEMATIC REVIEW AND META-ANALYSIS
Mustafa Ali Khan*1, Priya Ashok Kumar1, Javeria Tariq1, Maryam Sherwani1, Patrick B. Schwartz2, Mubeen Ali1, Kaleem S. Ahmed3, Syed Nabeel Zafar2
1Medical College, The Aga Khan University, Karachi, Sindh, Pakistan; 2University of Wisconsin-Madison, Madison, WI; 3Northwestern University Robert R McCormick School of Engineering and Applied Science, Evanston, IL
Background: Prior studies have shown worse outcomes after certain gastrointestinal surgeries in low- and middle-income countries (LMIC) when compared to high income countries (HIC). However, there is a dearth of information on outcomes after pancreatic cancer surgery in LMICs, making it difficult to plan quality improvement efforts for such complex cancers. The aim of this systematic review and meta-analysis was to describe postoperative mortality and morbidity after surgery for pancreas cancer in LMICs, and to identify research gaps.
Methods and Procedures: We searched PubMed, Web of Science, Embase, and Global Index Medicus for all published studies reporting outcomes after pancreatic cancer surgery from LMICs from January 1st 2001 to June 1st 2022. Studies were evaluated for quality using the NIH quality assessment tool. Random effects modelling was used to calculate pooled estimates of postoperative outcomes including pancreatic fistula, delayed gastric emptying, wound infection, re-operation, Clavien-Dindo grade 3 and 4 complications, mortality, and length of stay. Meta-regression analysis was performed to examine associations between outcomes and country level economic and health indicators. The review was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA). Sensitivity analysis by surgery type and study quality was performed.
Results: From a total of 18,342 titles and abstracts, 172 studies met our final inclusion criteria. Of these 72 studies were of ‘good' quality and were included in the meta-analysis. 33 were from upper middle income countries and 39 from lower middle income countries, while none were from low income countries. The studies included a total of 9930 patients. The pooled estimates were found to be 18.1% (95%CI 0.16–0.21, p <0.01, I2 = 83.8%) for pancreatic fistula, 12.6% (95%CI 0.10–0.16, p <0.01, I2 = 90.5%) for delayed gastric emptying, 11.8% (95%CI 0.09–0.15, p <0.01, I2 = 91.3%) for wound infection, 5.34% (95%CI 0.42–0.68, P <0.01, I2 = 77.7%) for re-operation, 17.1% (95%CI 0.12–0.23, p <0.01, I2 = 93.3%) for Clavien-Dindo grade 3 and 4 complications, and 3.94% (95%CI 0.03–0.05, p <0.01, I2 = 71.0%) for all post-operative mortality. The overall mean length of stay was 16.2 days (95%CI 14.2-18.0, p <0.01, I2 = 99.1%). Upon meta-regression for the selected studies, we found no significant association between short term outcomes and country income, human development index, or healthcare expenditure.
Conclusion: This is the first such systematic review and meta-analysis examining surgical complications of pancreatic surgery in low- and middle-income countries. This information can be used as a baseline to improve the quality and outcomes for pancreatic cancer surgery in LMICs.
PRISMA flowchart
Annotated Forest plot showing mortality after pancreatic cancer surgery in LMICs and UMICs
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