This systematic review was conducted using PubMed and EMBASE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline[7]. Two authors (Li and Zhen) independently screened the articles after removing duplicates. Our search algorithm combined the terms: (1) “Pancreatic surgery” OR “pancreatoduodenectomy” OR “duodenum-preserving pancreatic head resection” OR “distal pancreatectomy” OR “central pancreatectomy” OR “total pancreatectomy”; and (2) “Quality of life”. Only articles written in English were included. The references of retrieved articles were screened for any relevant articles.

Inclusion criteria: Articles involving the QOL of patients who underwent PD, DPPHR, DP, CP, and TP were included. The exclusion criteria were as follows: (1) Articles not within the scope of interest of this review; (2) Overlapping patient data; (3) Articles not published in English; and (4) Articles published before January 1, 2012.

The search results are shown in Figure 1. A total of 1515 potential studies were identified: 1313 from PubMed, 190 from EMABASE, and 12 additional references through a manual search. After excluding duplicates, 1453 articles were left. However, after screening titles and abstracts, 872 articles were excluded because they were outside the scope of this review. We also excluded article that were inaccessible (n = 127). A total of 454 full-text articles were collected, of which 312 were excluded for language (n = 11), not addressing the QOL after PD, DPPHR, DP, CP, or TP (n = 301), or being published before January 1, 2012 (n = 97). After the selection process, 45 clinical studies were included. The 45 articles included 13 on PD, seven on DPPHR, nine on DP, two on CP, and 14 on TP.

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Figure 1 PRISMA flow diagram. QOL: Quality of life; PD: Pancreaticoduodenectomy; DPPHR: Duodenum-preserving pancreatic head resection; DP: Distal pancreatectomy; CP: Central pancreatectomy; TP: Total pancreatectomy.

Thirteen studies, including three randomized controlled trials (RCTs), four prospective observational studies, and six retrospective studies on PD were assessed. Six studies focused on perioperative QOL in patients with PD. Two RCTs and one retrospective study reported postoperative QOL changes after two years (Table 1). Some studies demonstrated that patients’ QOL significantly diminished within one month post-operatively and nearly recovered to preoperative or baseline levels at three months after PD regardless of the pathology type[8-11], others reported that six months even one year was a more accurate period[12-14]. For long-term survivors, gastrointestinal symptoms such as bloating and indigestion are factors that affect their long-term QOL, and some of these symptoms are caused by pancreatic exocrine insufficiency after PD instead of post-operative complications[15,16]. Studies have reported that nearly half of the survivors required pancrelipase after PD[9,17,18]. Pancrelipase can improve nutritional status; however, its capacity to improve QOL is controversial[9,13,19].

Most studies have demonstrated that no differences between pylorus-preserving PD (PPPD) and conventional PD overall mortality, morbidity, survival, and QOL[20-24]. Studies have also shown that preoperative body weight loss, impaired preoperative pancreatic exocrine function, longer operative time, intraoperative radiotherapy, pancreatic carcinoma, and postoperative diarrhea may result in delayed QOL recovery[25].

Laparoscopic PD (LPD) could provide better QOL for patients with better functional status within six months postoperatively[26]. However, this advantage disappears after six months[27].

Table 2 summarizes the results of the included articles on DPPHR. The sample sizes of the seven studies were 74, 80, 25, 40, 85, 17, and 16. Only one study examined the change in QOL within one year. One group of researchers reported that DPPHR and PD were comparatively effective in improving long-term QOL postoperatively[28-30]. Another group held that DPPHR could bring about better outcomes in the form of less frequent nausea, pain, and diarrhea, better physical status, working ability, and global QOL[31].

Studies have found that the Frey and the Berne approach had the advantages of shorter operation time and hospital stay duration compared to the Beger’s. However, none showed any obvious difference in improving the patients’ postoperative QOL[32-35].

Nine studies included patients who underwent DP (Table 3). Two studies reported the perioperative QOL of patients who underwent DP, and seven mainly compared the differences between open and minimally invasive methods. Studies have shown that minimally invasive DP (MIDP) results in shorter hospital stays and functional recovery time compared to open DP (ODP)[36,37]. The MIDP group had better short-term QOL than the ODP group for up to 30 d postoperatively[38,39]. However, which is better for long-term QOL of > 1 year is controversial. During this period, some studies demonstrated no difference between MIDP and ODP[38,40], while others reported that MIDP could bring about better QOL for patients regarding physical, cognitive, social, and role functions, and symptoms, such as nausea, vomiting, and insomnia[41,42].

Laparoscopic spleen-preserving DP (LSPDP) and laparoscopic DP with splenectomy (LDPS) had similar perioperative outcomes[43]. Patients who underwent LSPDP had significantly better vitality than those who underwent LDPS, and were less likely to contract the common cold and flu[44,45].

The modified Appleby improved the ratio of R0 resection, relieved pain and improved patients’ overall QOL[46].

Details of the two studies on CP with sample sizes of 36 and 42 are included in Table 3. Laparoscopic CP can help patients maintain better working and living conditions than open CP[47]. While comparing DP and PD, some researchers thought that CP showed a significant benefit in specific symptoms, such as loss of appetite, insomnia, nausea, and vomiting[48]. Others held different opinions that CP was associated with better pancreatic function but the same or even worse long-term QOL and significantly increased post-operative morbidity and risk than DP or PD[49,50].

The two studies on TP were prospective observational studies (Table 4). Two articles showed the results of QOL within one year. It has been extensively verified that the perioperative and long-term outcomes of TP are comparable to those of PD regarding morbidity, mortality, survival rates, and QOL, regardless of patient age or tumor pathology[51-55]. One study demonstrated that the long-term post-operative QOL of patients who underwent TP was lower than that of the general population[56], however, more studies reported no significant differences[57,58]. Regarding pain relief, especially for most patients with narcotic-dependent, TP could alleviate pain largely such that half of the patients with chronic pancreatitis patients could be relieve from narcotics and return to normal life a year after surgery. However, it is a continuous improvement process. Over time, an increasing number of patients no longer required narcotics to control their abdominal pain[59-63]. More than half of the patients reported that their bowel habits had changed; therefore, they needed to take pancreatin[64-66]. A quarter to more than half of the patients, especially children, achieved insulin independence after islet cell autotransplantation (IAT)[67]. Although the insulin independence rate could decline over time, most patients could almost control their glycemic stability with an acceptable dose of insulin[60,61,68-70]. The stable control of glucose provides a more enjoyable life with better QOL for patients to have a normal social, work and study life[71].

PD, developed by Kausch[72] and Whipple et al[73], is a major surgical procedure used to treat middle and lower-segment cancers of the common bile duct and the periampullary region. The safety of PD has improved significantly in recent years. The mortality rate of PD has decreased from > 50% to < 5%, and the incidence of surgical complications has also decreased significantly[74]. Under these circumstances, attention gradually shifted from safe hospital discharge to the recovery of QOL. Therefore, an increasing number of studies have assessed the changes in patients’ QOL after PD. However, these studies came from different countries with different demographic characteristics and almost always had small sample sizes, especially prospective studies. As shown in Table 1, seven of the studies had a sample size of < 100 participants, and only one had a sample size of more than 300.

PPPD was first performed in 1943 by Watson[75] and was popularized by Traverso and Longmire[76]. Although the merits of PPPD versus classic PD are still debated, especially regarding perioperative risk, PPPD provides surgeons with another option[77]. Most studies have demonstrated that PPPD and PD have similar effects on patients’ QOL. Factors leading to the delayed recovery of QOL, such as preoperative body weight loss and impaired preoperative pancreatic exocrine function, are currently being explored.

Traditionally, PD was performed openly. Since the first case described by Gagner and Pomp[78] in 1994, many surgeons have explored the advantages of LPD and open PD (OPD). Our previous multi-center, open-label, RCT proved that LPD was associated with a shorter length of stay, similar short-term morbidity, and mortality rates as OPD. Due to the better safety of LPD and the maturity of surgical techniques, an increasing number of surgeons are focusing on comparing the differences in QOL between LPD and OPD. LPD have a better QOL advantage than OPD in the first six months, however, our new study showed that this advantage disappears three years postoperatively[27]. However, owing to the difficulty in collecting data, most related research data are unrepresentative. Therefore, high-quality RCTs should be performed in the future.

PD was surgeons’ first choice for benign or low-grade malignant lesions of the pancreatic head until the emergence of DPPHR. For these patients, since Beger et al[79] developed DPPHR in the early 1970s, another choice has emerged; with DPPHR, more organs are preserved, which could result in better endocrine and exocrine function postoperatively. Therefore, many studies have focused on prioritizing PD and DPPHR. Except for the perioperative parameters, whether DPPHR is superior to PD regarding QOL is still controversial[80]. Most researchers believe that DPPHR and PD relieve obstruction of the pancreatic head, which was the cause of the symptoms. Therefore, they have no significant influence on long-term QOL postoperatively[28,29]. Another study also suggested that increased digestive tract reconstruction during PD surgery lead to lower exocrine function and worse QOL postoperatively[31]. However, this study had poor representativeness because of its smaller sample size and earlier publication time.

Modifications of the original Beger procedure appeared, such as those by Frey and Berne, as people realized its superiority[81,82]. Compared to the Beger, Frey and Berne were technically more straightforward. All patients maintained the same pancreatic volume and exocrine and endocrine functions. Therefore, they had advantages regarding operation time and duration of hospital stay but showed no noticeable difference in improving postoperative QOL[32-35]. In conclusion, surgeons can choose any of them based on their expertise and intraoperative findings. Owing to the shorter operation time and length of hospital stay, modifications to the original Beger procedure should be preferred.

DP is the standard surgical method for treating tumors of the pancreatic body or tail. Traditionally, it has been performed using an open approach. However, due to technological developments in laparoscopic and robotic instruments, MIDP is routinely performed by surgeons worldwide. Nearly all studies have demonstrated that MIDP can result in better QOL than ODP perioperatively. However, which is better in the long-term remains controversial. Larger sample sizes and more convincing studies have reported no long-term differences between MIDP and ODP[38,40].

While performing DP, the traditional approach is to remove the spleen because it is closely attached to the distal pancreas anatomically. As people realize the function of the spleen, an increasing number of surgeons are choosing to perform LSPDP for benign and low-malignancy tumors of the distal pancreas. Due to the preservation of the spleen in LSPDP, it is clear that LSPDP is superior to LDPS regarding QOL[44,45].

Appleby surgery was first performed in 1976 for the treatment of progressive carcinoma[83] of pancreatic body and tail. Owing to the difficulty of Appleby technology and the advent of neoadjuvant therapy, the number of Appleby surgeries is decreasing; therefore, there is a lack of relevant studies concerning QOL after Appleby.

Guillemin successfully performed CP by anastomosis to both pancreatic remnants with an omega-shaped jejunal loop in 1957[84]. Letton and Wilson[85] completed the procedure in two patients with pancreatic injury with a Roux-en-Y jejunal loop anastomosis to the tail and closure to the head remnant[85]. An increasing number of surgeons prefer to perform this procedure in cases where the lesion is limited to the pancreatic neck or body. A normal pancreas has significantly less parenchymal loss, which means that more pancreatic function can be retained. According to previous studies, functional recovery and mean QOL are comparable to those of a standard control population[48]. It is generally believed that patients who underwent CP have a better QOL, but a higher perioperative risk[47-50]. However, studies on the QOL after CP are lacking.

Since Rockey[86] performed the first TP in a patient with pancreatic cancer in 1942, some surgeons have attempted to perform the same procedure. However, owing to poor perioperative outcomes and QOL in the beginning, the feasibility of TP has been questioned. Many studies have been conducted to answer this question. The safety of TP has improved dramatically owing to mature surgical techniques and other factors. Impaired exocrine function is also one of the reasons why the feasibility of TP has been questioned. However, the optimization of pancreatin improved the patients’ exocrine function. Another reason is the high risk of brittle diabetes. Many factors are associated with insulin independence, such as non-hereditary chronic pancreatitis, younger age, lower body surface area, and higher total islet equivalents. The pancreas is the only organ that produces insulin. Due to the removal of the entire pancreas, TP causes great damage to patients’ ability to maintain stable blood sugar levels. To solve this problem, a new technology, the IAT, was first described in 1977. In IAT, islet cells are isolated from patients and transplanted into the portal vein. With the advent of pancreatin and IAT, the endocrine and exocrine functions of patients after TP have significantly improved[64-66]. It seems unlikely that TP can maintain or improve patients’ QOL. However, this was only possible if the patient had preoperative endocrine and exocrine pancreatic dysfunction or chronic pain. TP improved the QOL of these patients to some extent. In conclusion, TP can be considered in selected patients with neoplasms involving the entire pancreas or refractory chronic pancreatitis, regardless of the age of patients and pathology of the neoplasms.

Pancreatic surgery is challenging because of the anatomical characteristics of pancreas. With the progress of medical standards, the perioperative outcomes have been greatly improved these years. More and more attention has been paid to the changes of quality of life (QOL) after pancreatic surgery. There is a lack of summary of QOL after various kinds of pancreatic surgery. With the purpose of describing the results of existing researches concerning QOL of pancreatic surgery we conducted this study.

Understanding which kind of pancreatic surgery has better QOL can provide some basis for clinical surgical decision.

This review aimed to summarize and analyze current research results on QOL after pancreatic surgery including pancreaticoduodenectomy, duodenum-preserving pancreatic head resection, distal pancreatectomy, central pancreatectomy and total pancreatectomy after January 1, 2012. It provides some directions for future researches based on the results of the controversy over patients' QOL after surgery. And it also provides some basis for clinical surgical decision-making.

A systematic review was conducted in PubMed and EMBASE Database, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. And references of the retrieved articles were screened for any relevant articles. We extracted the results of these articles and summarized them.

This review summarizes and analyzes current research results on QOL after pancreatic surgery. The article covers the discussion and analysis of the QOL of various pancreatic surgery. Which kind of surgical procedure has better QOL is controversial. The long-term benefits on QOL of minimally invasive surgery over open surgery are controversial.

Comparison and summary of QOL in patients with different types of pancreatic surgery. We included not only the results of the same surgical procedure, but also the results between different procedures.

More well-designed prospective analyses of patients' QOL after pancreatic surgery are needed.