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. 2026 Aug 22;10(4):zrag091. doi: 10.1093/bjsopen/zrag091

Pancreatic surgery and length of hospital stay: meta-analysis of randomized clinical trials

Laetitia Z Hampe 1, Klaudia Narbekovas 2, Chenchen Li 3, Amila Cizmic 4, Anas A Preukschas 5, Anna Nießen 6, Jan Bardenhagen 7, Faik G Uzunoglu 8, Ulla Klaiber 9, Oliver Strobel 10, Pascal Probst 11, Thilo Hackert 12, Felix Nickel 13,✉, Carl-Stephan Leonhardt 14
PMCID: PMC13499424  PMID: 42631915

Abstract

Background

Length of hospital stay (LOS) is a commonly reported postoperative outcome measure in pancreatic surgery. However, LOS may be influenced by various factors, including healthcare systems, cultural traditions, and readmission rate. This systematic review and meta-analysis investigated LOS in pancreatic surgery.

Methods

A meta-analysis was conducted to identify all randomized clinical trials (RCTs) of pancreatic surgery reporting LOS. Analyses were conducted using a random-effects model with mean differences as the effect estimator for the continuous outcome LOS.

Results

In all, 186 RCTs published between 1994 and 2025, comprising 28 381 patients, were included. The mean LOS differed significantly by type of resection (P = 0.003) and by country (P < 0.001). Country remained a statistically significant factor after adjusting for readmission rate, year of study, and type of resection. The shortest LOS was observed in the USA, with a pooled value of 11 days (95% confidence interval (c.i.) 9.93 to 12.32) and the longest was seen in Japan, with a pooled value of 28 days (95% c.i. 25.60 to 31.67). Subgroup analysis of studies comparing minimally invasive and open surgery showed a mean LOS difference of 2 days (95% c.i. −2.79 to −0.85; prediction interval −7.70 to 4.06). However, this effect varied across countries, with mean LOS differences ranging from 1 to 6 days.

Conclusion

LOS after pancreatic surgery exhibited substantial statistical heterogeneity based on country, the type of operation, and access. This highlights the importance of considering contextual factors when evaluating and comparing LOS as an outcome measure in pancreatic surgery.

This systematic review and meta-analysis of 186 randomized clinical trials of pancreatic surgery reporting length of hospital stay (LOS) found significant heterogeneity in LOS by resection type, surgical approach, and country. These results provide a comprehensive overview of LOS and factors influencing it, highlighting the need to consider them when using LOS as an outcome measure in pancreatic surgery.

Introduction

Pancreatic surgery is technically demanding and anatomically complex, with a high complication rate1–4. The length of hospital stay (LOS) is commonly used as a postoperative outcome measure in pancreatic surgery, indicating treatment success and effectiveness of perioperative management strategies1–9. A shorter LOS is commonly directly associated with a favourable postoperative outcome5,6. Nonetheless, consideration of other factors that may affect LOS is frequently lacking. This is particularly evident in studies that compare minimally invasive surgery (MIS) with open pancreatic surgery, where LOS is reported as a clinically relevant outcome measure7–10. The results of these studies have implications for everyday clinical practice.

Various factors can influence the readmission rate, including the LOS of the index operation. A more rapid discharge could potentially be associated with a higher readmission rate11. Some studies indicate that LOS alone may not be a reliable marker of postoperative outcomes and advocate for a composite outcome measure that includes both LOS and readmission rate12–14. In addition, research shows that in addition to medical factors, such as postoperative complications, LOS may influenced by external factors, such as travel distance and the healthcare system, which can vary widely across regions15–17. For example, countries with a bundled payment model (for example, the USA) often prioritize shorter LOS to control expenses, whereas in some parts of Asia healthcare systems and discharge criteria may allow for or even favor extended LOS18,19. Resource availability, healthcare system constraints, and national regulations further contribute to variations in LOS20. Variations in MIS experience, surgical practice, and institutional management of complications may also contribute to country-specific differences in LOS. These non-medical factors can profoundly affect reported LOS, introducing variability that may not reflect the true differences in surgical outcomes. Potential differences in underlying discharge criteria may challenge the validity of LOS as an outcome measure and may necessitate adaptation for comparison and benchmarking21–23. To address this issue, a meta-analysis was conducted to investigate differences in LOS in pancreatic surgery, with and without adjustment for potential confounding factors.

Methods

This systematic review and meta-analysis was conducted in accordance with the recommendations of the Cochrane Handbook for Systematic Reviews and Interventions24 and is reported in accordance with the PRISMA guidelines25. The study protocol was preregistered in the PROSPERO international prospective register of systematic reviews (CRD42024601296).

Systematic literature search

A systematic literature search was conducted on December 9, 2025 using the International Study Group of Pancreatic Surgery (ISGPS) Evidence Map of Pancreatic Surgery (https://map.eviglance.com/maps/8?view=map), which compiles all up-to-date randomized clinical trials (RCTs) and systematic reviews on pancreatic surgery, based on systematic literature searches in PubMed, Cochrane CENTRAL, and Web of Science26. Using the ISGPS evidence map allows a curated and searchable overview of RCTs, simplifying the literature search compared with traditional database queries. Search strategies were formulated in line with the PICO framework27 (Table 1).

Table 1.

PICO framework

PICO element Description
Population Patients with pancreatic diseases undergoing pancreatic surgery
Intervention Inclusion: all types of interventions aiming to affect the surgical outcome, including medical devices, perioperative management, surgical strategy, drugs, and nutrition
Control/comparators Controls: any other kind of control compared with the abovementioned intervention
Comparators: region of RCTs, type of resection, surgical approach (MIS and open surgery)
Outcomes Primary outcome: LOS
Secondary outcome: readmission rate
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PICO, Patient Intervention Comparator Outcome; RCTs, randomized clinical trials; MIS, minimally invasive surgery; LOS, length of hospital stay.

Inclusion and exclusion criteria

All RCTs identified through the Evidence Map of Pancreatic Surgery were independently screened by three authors (LH, KN, and CSL) up until 9 December 2025. The inclusion criterion was the reporting of LOS. Studies were excluded if they were not published in English or did not involve pancreatic resection (for example, studies focusing on other interventions, such as endoscopic or radiological procedures). Studies not published in English were excluded to ensure consistent data extraction and to avoid potential misclassification due to translation inaccuracies. Multinational studies were not considered because they did not permit country-specific analysis. Similarly, for the regression analysis, studies from countries with only a single eligible study were excluded. Furthermore, studies lacking a clearly defined statistical measure for LOS were excluded. One study investigating only patients with postoperative pancreatic fistula and another analysing early discharge as an intervention following pancreatic surgery were excluded due to potential bias in the results28,29. The PRISMA flow chart exemplifies the selection process25 (Fig. 1). Any disagreements regarding eligibility were resolved through discussion among the three authors until a consensus was reached.

Fig. 1.

For image description, please refer to the figure legend and surrounding text.

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PRISMA diagram

*For some studies, more than one exclusion criterion applied. RCT, randomized clinical trial; LOS, length of hospital stay; POPF, postoperative pancreatic fistula.

Data extraction and analysis

The following data were extracted from the included studies: first author, publication year and country in which the study was conducted, sample size, number of patients in the intervention and control groups, type of intervention, type of pancreatic resection, surgical approach, primary study endpoint, data on LOS and readmission, American Society of Anesthesiologists classification30, enhanced recovery after surgery protocol, age, sex, and major complications (Clavien–Dindo grade ≥ III)31. LOS was extracted as reported in each study, regardless of whether a definition was provided.

Subgroup analysis: surgical approach

Subgroup analysis on MIS and open surgery was performed. An additional literature search for observational comparative studies was conducted. The search strategy is provided in the supplementary methods.

Risk of bias

Quality assessment was performed according to the Cochrane Handbook for Systematic Reviews of Interventions for RCTs, evaluating the risk of bias arising from the randomization process, deviations from intended interventions, missing outcome data, outcome measurements, and selection of reported results, as well as an overall risk of bias judgement32. The quality of the included observational studies was assessed using the ROBINS-I tool33.

Meta-regression

To assess the influence of certain study characteristics on LOS, meta-regression was conducted. The following study characteristics were used as moderator variables: readmission rate, year of study publication, type of resection, and country. The moderator variables considered were based on clinical expertise and no interactions were considered. The test of moderators was used to assess whether the moderator variable had a significant influence.

Statistical analysis

For LOS, in days, as a continuous and readily interpretable outcome, a random-effects meta-analysis of mean differences was conducted using the DerSimonian Laird estimator34. To reflect the expected range of effects in a future study, accounting for between-study heterogeneity35, the 95% prediction interval (p.i.) was calculated for pooled random-effects estimates. Sensitivity analysis, with or without Hartung–Knapp adjustment, was performed to assess type I error36. Heterogeneity was assessed using I2 and τ2 statistics. I2 ≥ 50% was considered large heterogeneity, and I2 ≥ 75% was considered very large heterogeneity37. Absolute between-study variability was quantified using τ2. For the purpose of analysis, the median and interquartile range were transformed to the mean and standard deviation according to McGrath et al.38. All analysis was conducted using R programming language (R Foundation for Statistical Computing, Austria, Vienna), primarily using the metafor, metamedian, and meta packages39,40. Two-sided P < 0.05 was considered statistically significant. Considerations of clinical relevance were made separately, taking into account the magnitude of the observed effects, and are discussed in the Discussion. All figures were created using Flourish® (Canva UK Operations Limited brand, London, UK).

Results

Study characteristics

In all, 385 RCTs were identified, of which 186 reported on LOS. These studies were published between 1994 and 2025, comprising a total of 28 381 patients (Table S1).

The overall mean age of the patients was 62 years, with 56.0% being male (15 903). Most studies focused on pancreatoduodenectomy (PD; 161 studies, 86.6%) and left-sided pancreatectomy (LP; 22 studies, 11.8%). Most RCTs were conducted in Asia (82, 44.1%), Europe (69, 37.1%), and North America (30, 16.1%) (Fig. 2). Quality assessment showed that most studies had some concern of bias (74, 39.4%), with 44 studies (23.4%) classified as being at low risk of bias and 70 (37.2%) classified as being at high risk of bias (Fig. S1).

Fig. 2.

For image description, please refer to the figure legend and surrounding text.

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Geographic distribution of included RCTs (n = 186)

Length of hospital stay

In 18 studies (9.7%), LOS was the primary endpoint. Across all studies, mean LOS was 17 days (95% confidence interval (c.i.) 16.16 to 18.56 days). LOS differed significantly according to the country in which the study was conducted (P < 0.001). Japan had the longest mean LOS at 28 (95% c.i. 25.60 to 31.67) days, while the USA and Egypt had the shortest LOS, both with 11 (95% c.i. 9.93 to 12.32 and 9.57 to 11.88) days (Fig. 3a, Table S2).

Fig. 3.

For image description, please refer to the figure legend and surrounding text.

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Radar chart of mean LOS by country

Mean LOS by country for a all pancreatic resections, b pancreatoduodenectomy, and c left-sided pancreatectomy. LOS, length of hospital stay.

Mean LOS by type of resection

A statistically significant difference in LOS was observed according to type of pancreatic resection (P = 0.003; Table S3). Studies (161) that investigated PD reported a mean LOS of 18 (95% c.i. 16.86 to 19.55) days, whereas the mean LOS in studies (22) including LP was 12 (95% c.i. 9.63 to 15.67) days. In subgroup analyses, LOS varied significantly by country for both LP (P < 0.001) and PD (P < 0.001; Fig. 3b,c).

LOS and readmission rate

To investigate the association between LOS and readmission rates, only RCTs reporting values for both variables were considered. Of the 186 RCTs reporting LOS, 72 (38.7%) also reported readmission rates (Table S4). These studies were published between 1995 and 2024 and included a total of 12 678 patients. Most studies originated from Asia (33, 46%), followed by Europe (29, 40%) and North America (10, 14%; Fig. S2). The longest mean LOS was observed in Japan with 22 (95% c.i. 17.48 to 26.90) days, and the shortest was observed in the USA with 9 (95% c.i. 7.39 to 11.69) days (Figs S3 and S4).

In meta-regression with LOS as the outcome and country as a moderator variable, LOS was on average, 12 days shorter in the USA than in Japan (95% c.i. 8.98 to 15.74 days). Among other countries, the mean difference in LOS compared with the USA ranged from 5 to 8 days. For Finland, India, Italy, the Netherlands, and Sweden the analyses did not provide evidence of a statistically significant difference (Table S5). After adjusting for readmission rate, type of resection, and publication year, the country in which the study was conducted remained significantly associated with differences in LOS (I2 = 96.7%; τ2 = 11.2; Table S6).

In meta-regression with readmission rate as the outcome and LOS as the moderator, the readmission rate was not significantly associated with LOS (data not shown).

Minimally invasive versus open surgery

Of the 72 included RCTs, nine compared MIS to open surgery. Due to the limited number of RCTs, an additional literature search was conducted, which identified 301 observational studies, of which 34 met the inclusion criteria and were included in the analysis. Overall, 43 studies9,10,41–81 (9 RCTs, 34 observational studies) published between 2013 and 2024 were included in the subgroup analysis, representing a total of 69 919 patients (Table S7). Most studies (20, 59%) had a moderate risk of bias (Fig. S5). Twelve studies (35%) had a low risk of bias, and two (6%) were classified as having a high risk of bias. Most studies focused on PD (21, 49%), followed by LP (16, 37%). Two studies (5%) included all types of pancreatic resections, one study (2%) focused on total pancreatectomy (TP), and one study (2%) investigated both LP and PD. Most studies originated from Asia (18, 42%), followed by Europe (15, 35%) and North America (10, 23%; Fig. S6).

The overall mean LOS was 13 (95% c.i. 11.40 to 15.22; 95% p.i. 4.97 to 34.89) days (Figs S7 and S8). Meta-regression of the subgroup cohort showed that the country in which the study was conducted was a significant factor for LOS, and remained significant after adjusting for readmission rate, type of resection, and year of publication (Tables S8 and S9).

The mean difference in LOS between the intervention and control groups was analysed, with the intervention group consistently representing MIS (Fig. 4). Overall, the mean LOS differed by 2 (95% c.i. −2.79 to −0.85; 95% p.i. −7.70 to 4.06) days between the groups and varied substantially between countries. In the USA, Germany, the Netherlands, and Italy, the mean difference of LOS between the intervention and control groups was 1 day.2.790.857.70

Fig. 4.

For image description, please refer to the figure legend and surrounding text.

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Forest plot of mean differences in length of stay by country and surgical approach

All included studies focused on the surgical. Values in parentheses are 95% confidence intervals. s.d., standard deviation.

Discussion

This study demonstrated substantial statistical heterogeneity in LOS after pancreatic surgery based on the country in which a study was conducted. This suggests that in addition to being a reflection of postoperative outcomes, LOS is also influenced by external factors, challenging its validity as a stand-alone measure for surgical outcomes.

LOS is a common outcome measure in surgical research, particularly in studies comparing MIS to open pancreatic surgery10,41,42,82–84. LOS is easily measured and linked to outcomes, because patients with complications usually stay longer than those with a textbook outcome85,86. LOS has also been proposed as a component of an ideal composite outcome after PD by a transatlantic study group87, as well as part of a composite endpoints, and their validation after hepatopancreatic surgery88,89. Because LOS may not solely reflect surgical outcomes and may be influenced by the country in which a study is conducted, other authors have excluded LOS from the definition of textbook outcome for PD and LP90. Recent studies have shown that LOS is also influenced by patient factors (age and co-morbidities) and external factors such as travel distance, hospital location, and healthcare system15–17. The present study showed a statistically significant association between LOS and the country in which a study was conducted. For example, LOS was a mean of 12 days longer for patients in Japan than in the USA. These variations in LOS across different countries may reflect differences in healthcare systems, reimbursement models, and cultural norms16,17,91,92. Implementation of enhanced recovery after surgery protocols may also have influenced LOS over time and may have contributed to the intercountry differences in LOS observed in the present study93. Differences in surgical practice, MIS experience, and institutional complication management may have further contributed to differences in LOS. This is supported by Golinelli et al.92, who analysed LOS trends across 25 European countries over two decades and demonstrated that specific healthcare system types and reimbursement models are independently associated with LOS. Mackay et al.94 compared national registries of pancreatic surgery from the USA, Germany, the Netherlands, and Sweden and found that median LOS ranged from 8 to 16 days, which aligns with the findings of the present study. The present study provides a comprehensive overview of LOS reporting in pancreatic surgery in studies from Europe, the USA, Asia, Africa, and Australia, finding an even broader range in LOS, with pooled mean values between 11 and 30 days. These findings highlight the limitations of LOS and the need to account for regional differences when comparing studies across countries. Benchmarking studies often overlook these factors, which may result in biased conclusions21–23.

Previous studies reported an association between LOS and readmission rates11. However, the present study did not demonstrate a statistically significant association between LOS and readmission rate. This suggests that the relationship may not be consistent across different settings. The readmission rate may also be influenced by country, reflecting differences in discharge policies and healthcare systems.

Subgroup analysis revealed high heterogeneity in the mean differences in LOS within individual countries between the investigated groups (MIS versus open surgery). In countries such as the USA, Germany, the Netherlands, and Italy, the mean difference between MIS and open pancreatic surgery was merely 1 day. In contrast, in other countries, like Japan and Singapore, larger mean differences of 2–8 days were seen. This indicates that studies using LOS as an endpoint may not be comparable across different countries. It remains unclear whether such variations are clinically meaningful to patients, because a 1-day shorter hospital stay may not lead to a better perceived outcome for the patient. Evaluation of postoperative outcomes should focus on patient well being and quality of life next to optimal oncological outcomes and the absence of major complications. Given these limitations, alternative outcomes such as time to functional recovery may be more suitable and avoid some of the contextual biases inherent to LOS. Patient-centred outcomes, such as time to recovery or quality-adjusted life years may add value95,96. However, their limitation is feasibility, because where LOS is easy to measure, more patient-centred parameters are more difficult to quantify. LOS may still remain a relevant parameter for assessing postoperative outcomes and surgical success in pancreatic surgery because it may serve as a simple but imprecise surrogate parameter for postoperative morbidity and mortality85,86. The present study highlights the need to consider contextual factors when comparing research from different countries. To address the complexity of LOS as an outcome parameter, influencing factors should be consistently addressed in the discussion or incorporated into composite outcomes that consider a broader range of relevant parameters, thereby creating a more comprehensive picture of postoperative outcomes14,87,97.

This study has several limitations. There was considerable heterogeneity among the included studies regarding study design, patient characteristics, study period, and methodology. Regional and hospital-level differences within countries were not accounted for. Data on travel distance, interhospital differences, and discharge criteria were inconsistently reported and could not be analysed. The exclusion of studies not published in English may have introduced language bias, and the exclusion of countries represented by only one study may also have introduced selection bias. Small-study bias may have influenced the results of the meta-analysis98. Variations in LOS definitions across studies represent an additional limitation. The p.i. estimates rely on assumptions regarding effect distribution that may not always be met. Differences between laparoscopic and robotic approaches could not be evaluated due to the limited number of studies reporting these subgroups.

In conclusion, this study demonstrates substantial heterogeneity in LOS after pancreatic surgery across countries. This indicates that in addition to postoperative outcomes and surgical success, LOS reflects external factors, limiting its validity as a stand-alone outcome measure.

Supplementary Material

zrag091_Supplementary_Data
zrag091_supplementary_data.docx (829.9KB, docx)

Contributor Information

Laetitia Z Hampe, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Klaudia Narbekovas, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.

Chenchen Li, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Amila Cizmic, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Anas A Preukschas, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Anna Nießen, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Jan Bardenhagen, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Faik G Uzunoglu, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Ulla Klaiber, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.

Oliver Strobel, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.

Pascal Probst, Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland.

Thilo Hackert, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Felix Nickel, Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Carl-Stephan Leonhardt, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.

Funding

The authors have no funding to declare.

Author contributions

Laetitia Zoe Hampe (Methodology, Data Extraction, Data Interpretation, Visualization, Writing—Original Draft) Klaudia Narbekovas (Data Extraction, Review & Editing), Chenchen Li (Data Extraction, Review & Editing), Amila Cizmic (Review & Editing), Anas Amin Preukschas (Review & Editing), Anna Nießen (Review & Editing), Jan Bardenhagen (Review & Editing), Faik Güntac Uzunoglu (Review & Editing), Ulla Klaiber (Review & Editing), Oliver Strobel (Review & Editing), Pascal Probst (Design, Methodology, Review & Editing), Thilo Hackert (Supervision, Review & Editing), Felix Nickel (Conceptualization, Methodology, Supervision, Review & Editing), Carl-Stephan Leonhardt (Conceptualization, Methodology, Data Extraction, Data Curation, Formal Analysis, Data Interpretation, Review & Editing).

Disclosure

The authors declare no conflicts of interest.

Supplementary material

Supplementary material is available at BJS Open online.

Data availability

All data analysed in this study were derived from previously published studies. The data set generated from these data is not publicly available. The generated data set and statistical code used for the meta-analysis are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

zrag091_Supplementary_Data
zrag091_supplementary_data.docx (829.9KB, docx)

Data Availability Statement

All data analysed in this study were derived from previously published studies. The data set generated from these data is not publicly available. The generated data set and statistical code used for the meta-analysis are available from the corresponding author upon reasonable request.

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