Meta-analysis of subtotal stomach-preserving pancreaticoduodenectomy vs pylorus preserving pancreaticoduodenectomy

Abstract

Aim: To investigate the differences in outcome following pylorus preserving pancreaticoduodenectomy (PPPD) and subtotal stomach-preserving pancreaticoduodenectomy (SSPPD).

Methods: Major databases including PubMed (Medline), EMBASE and Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched for comparative studies between patients with PPPD and SSPPD published between January 1978 and July 2014. Studies were selected based on specific inclusion and exclusion criteria. The primary outcome was delayed gastric emptying (DGE). Secondary outcomes included operation time, intraoperative blood loss, pancreatic fistula, postoperative hemorrhage, intraabdominal abscess, wound infection, time to starting liquid diet, time to starting solid diet, period of nasogastric intubation, reinsertion of nasogastric tube, mortality and hospital stay. The pooled odds ratios (OR) or weighted mean difference (WMD) with 95% confidence intervals (95%CI) were calculated using either a fixed-effects or random-effects model.

Results: Eight comparative studies recruiting 650 patients were analyzed, which include two RCTs, one non-randomized prospective and 5 retrospective trial designs. Patients undergoing SSPPD experienced significantly lower rates of DGE (OR = 2.75; 95%CI: 1.75-4.30, P < 0.00001) and a shorter period of nasogastric intubation (OR = 2.68; 95%CI: 0.77-4.58, P < 0.00001), with a tendency towards shorter time to liquid (WMD = 2.97, 95%CI: -0.46-7.83; P = 0.09) and solid diets (WMD = 3.69, 95%CI: -0.46-7.83; P = 0.08) as well as shorter inpatient stay (WMD = 3.92, 95%CI: -0.37-8.22; P = 0.07), although these latter three did not reach statistical significance. PPPD, however, was associated with less intraoperative blood loss than SSPPD [WMD = -217.70, 95%CI: -429.77-(-5.63); P = 0.04]. There were no differences in other parameters between the two approaches, including operative time (WMD = -5.30, 95%CI: -43.44-32.84; P = 0.79), pancreatic fistula (OR = 0.91; 95%CI: 0.56-1.49; P = 0.70), postoperative hemorrhage (OR = 0.51; 95%CI: 0.15-1.74; P = 0.29), intraabdominal abscess (OR = 1.05; 95%CI: 0.54-2.05; P = 0.89), wound infection (OR = 0.88; 95%CI: 0.39-1.97; P = 0.75), reinsertion of nasogastric tube (OR = 1.90; 95%CI: 0.91-3.97; P = 0.09) and mortality (OR = 0.31; 95%CI: 0.05-2.01; P = 0.22).

Conclusion: SSPPD may improve intraoperative and short-term postoperative outcomes compared to PPPD, especially DGE. However, these findings need to be further ascertained by well-designed randomized controlled trials.

Keywords: Delayed gastric emptying; Meta-analysis; Pancreatic surgery; Pancreaticoduodenectomy; Pylorus preserving Subtotal stomach preserving pancreaticoduodenectomy.

Figure 1

Flow diagram depicting the study selection process in accordance with PRISMA guidelines.

Figure 2

Forest plots demonstrating primary outcome. Forest plots illustrating results of delayed gastric emptying in the form of meta-analysis comparing PPPD with SSPPD. Pooled odds ratios (ORs) with 95% confidence intervals (CI) were calculated using the fixed-effects model. PPPD: Pylorus preserving pancreaticoduodenectomy; SSPPD: Subtotal stomach-preserving pancreaticoduodenectomy.

Figure 3

Forest plots demonstrating secondary outcomes. Forest plots illustrating results of operation time (A), intraoperative blood loss (B), pancreatic fistula (C), postoperative hemorrhage (D), intraabdominal abscess (E), wound infection (F), time to starting liquid diet (G), time to starting solid diet (H), period of nasogastric intubation (I), reinsertion of nasogastric tube (J), mortality (K), hospital stay (L) in the form of meta-analysis comparing PPPD with SSPPD. Pooled odds ratios (ORs) or weighted mean difference (WMD) with 95% confidence intervals (CI) were calculated using the fixed effects model or the random-effects model. PPPD: Pylorus preserving pancreaticoduodenectomy; SSPPD: Subtotal stomach-preserving pancreaticoduodenectomy.

Figure 4

Funnel plot to investigate publication bias. Funnel plot on delayed gastric emptying basing on all studies. The funnel plot revealed no publication bias.