Impact of perioperative corticosteroids on postoperative morbidity after pancreaticoduodenectomy: A systematic review, meta-analysis, and trial sequential analysis

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• Picked for Surgery (top studies of the week, 8 November 2026): Evaluates perioperative morbidity after pancreaticoduodenectomy

Abstract

BACKGROUND: Postoperative morbidity after pancreaticoduodenectomy remains clinically relevant despite improvements in perioperative care and surgical technique. Perioperative systemic corticosteroids have been proposed to attenuate the inflammatory response after pancreatic surgery, but the certainty of the randomized evidence remains unclear. METHODS: We performed a systematic review, meta-analysis, and trial sequential analysis of randomized controlled trials evaluating perioperative systemic corticosteroids in adults undergoing pancreaticoduodenectomy. Eligible studies compared hydrocortisone, dexamethasone, or analogous systemic corticosteroids with placebo, no corticosteroids, or active pharmacologic comparators; trials with a placebo or no-treatment control constituted the primary analysis, and the trial with an active pharmacologic comparator was included in a sensitivity analysis. The main outcomes were mortality, major morbidity, and clinically relevant postoperative pancreatic fistula. Secondary outcomes included postpancreatectomy hemorrhage, delayed gastric emptying, reoperation, readmission, corticosteroid-related adverse events, and length of hospital stay. Trial sequential analysis was performed under a range of prespecified anticipated effects, and the certainty of the evidence for the critical outcomes was rated using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: Three randomized controlled trials with a placebo or no-treatment control (397 patients) constituted the primary analysis; a fourth trial with an active comparator (pasireotide) was added in a sensitivity analysis, for a total of 4 randomized controlled trials and 454 patients. Corticosteroid use was not associated with a significant reduction in mortality (primary analysis: risk difference, -0.00; 95% confidence interval, -0.03 to 0.03; sensitivity analysis: risk difference, -0.01; 95% confidence interval, -0.03 to 0.02). Major morbidity was numerically lower with corticosteroids, but the difference was not statistically significant (risk difference, -0.04; 95% confidence interval, -0.11 to 0.02 in both analyses). Clinically relevant postoperative pancreatic fistula was significantly reduced with corticosteroids (primary analysis: risk difference, -0.09; 95% confidence interval, -0.17 to -0.01; number needed to treat, 11; sensitivity analysis: risk difference, -0.08; 95% confidence interval, -0.16 to 0.00; number needed to treat, 12). Trial sequential analysis showed that the required information size was not reached for any of the critical end points under any prespecified anticipated effect (20%-30% relative risk reduction) or under the observed effect, in either analysis, suggesting that the current evidence remains underpowered. No significant differences were observed for delayed gastric emptying, postpancreatectomy hemorrhage, readmission, or length of stay in the primary analysis, whereas reoperation (risk difference, -0.04; 95% confidence interval, -0.08 to -0.01; number needed to treat, 23) was less frequent in the corticosteroid group. No trial reported an increase in corticosteroid-related adverse events (infections, hyperglycemia) with corticosteroids compared with controls. CONCLUSION: Perioperative systemic corticosteroids may reduce the incidence of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy, but the certainty of the randomized evidence is low to moderate, and the current data are insufficient to support their routine clinical use.

Abstract as published, via PubMed.