Duct-to-Mucosa Versus Invagination Pancreaticojejunostomy Following Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis

Abstract

Background: Postoperative pancreatic fistula (POPF) is one of the most common complications after pancreaticoduodenectomy (PD). The ideal choice of pancreaticojejunostomy (PJ) anastomosis remains a matter of debate.

Methods: A meta-analysis of randomized controlled trials (RCTs) comparing duct-to-mucosa with invagination PJ following PD was performed. Pooled odds ratio (OR) with 95 % confidence intervals (CI) were calculated using fixed-effects or random-effects models.

Results: In total, five RCTs involving 654 patients were included. Meta-analysis revealed no significant difference in POPF rate between the duct-to-mucosa and invagination PJ techniques (OR = 1.23, 95 % CI = 0.78-1.93; P = 0.38). Two of five trials applied the POPF definition proposed by the International Study Group of Pancreatic Surgery (ISGPS). Using this definition, the incidence of clinically relevant POPF was lower in patients undergoing invagination PJ than in those undergoing duct-to-mucosa PJ (OR = 2.94, 95 % CI = 1.31-6.60; P = 0.009). There was no significant difference in terms of delayed gastric emptying, intra-abdominal collection, overall morbidity and mortality, reoperation rate, and length of hospital stay between the two groups.

Conclusion: Invagination PJ is not superior to duct-to-mucosa PJ in terms of POPF and other complications but appears to reduce clinically relevant POPF. Further well-designed RCTs that use ISGPS definition are still required before strong evidence-based recommendations can be formulated.

Keywords: Duct-to-mucosa; Invagination; Pancreatic fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy.