Surgical strategies in the treatment of chronic pancreatitis: An updated systematic review and meta-analysis of randomized controlled trials

Abstract

Background: Chronic pancreatitis (CP) is a common and frequently occurring disease. Pancreaticoduodenectomy (PD), pylorus-preserving pancreaticoduodenectomy (PPPD), and duodenum-preserving pancreatic head resection (DPPHR) are important treatment options for patients with chronic pancreatitis. The Beger and Frey procedures are 2 main duodenum-preserving techniques in duodenum-preserving pancreatic head resection (DPPHR) strategies. We conducted this systematic review and meta-analysis to compare the clinical efficacy of DPPHR versus PD, the Beger procedure versus PD, the Frey procedure versus PD, and the Beger procedure versus the Frey procedure in the treatment of pancreatitis. The optimal surgical option for chronic pancreatitis is still under debate. The aim of this systematic review and meta-analysis was to evaluate the clinical efficacy of different surgical strategies for chronic pancreatitis.

Methods: Five databases (PubMed, Medline, SinoMed, Embase, and Cochrane Library) were searched with the limitations of human subjects and randomized controlled trials (RCTs) text. Data were extracted by 2 of the coauthors independently and analyzed using the RevMan statistical software, version 5.3. Weighted mean differences (WMDs), risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration's Risk of Bias Tool was used to assess the risk of bias.

Results: Seven studies involving a total of 385 patients who underwent the surgical treatments were assessed. The methodological quality of the trials ranged from low to moderate and included PD (n = 134) and DPPHR (n = 251 [Beger procedure = 100; Frey procedure = 109; Beger or Frey procedure = 42]). There were no significant differences between DPPHR and PD in post-operation mortality (RR = 2.89, 95% CI = 0.31-26.87, P = 0.36), pain relief (RR = 1.09, 95% CI = 0.94-1.25, P = 0.26), exocrine insufficiency (follow-up time > 60 months: RR = 0.91, 95% CI = 0.72-1.15, P = 0.41), and endocrine insufficiency (RR = 0.75, 95% CI = 0.52-1.08, P = 0.12). Concerning the follow-up time < 60 months, the DPPHR group had better results of exocrine insufficiency (RR = 0.22, 95% CI = 0.08-0.62, P = 0.04). However, operation time (P < 0.0001), blood transfusion (P = 0.02), hospital stay (P = 0.0002), postoperation morbidity (P = 0.0007), weight gain (P < 0.00001), quality of life (P = 0.01), and occupational rehabilitation (P = 0.007) were significantly better for patients who underwent the DPPHR procedure compared with the PD procedure. The comparison results of the Frey procedure and PD showed that both procedures had an equal effect in the pain relief, postoperation mortality, exocrine and endocrine function, and quality of life (QoL) (P > 0.05), whereas patients who underwent the Frey procedure had significantly reduced operative times (P < 0.05) and less blood transfusions (P < 0.05). Comparing the Beger procedure to the PD procedure, there were no significant differences in hospital stay, blood transfusion, postoperation morbidity or mortality, pain relief, weight gain, exocrine insufficiency, and occupational rehabilitation (P > 0.05). Two studies comparing the Beger and Frey procedures showed no differences in postoperative morbidity, pain relief, exocrine insufficiency, and quality of life (P > 0.05). In terms of operative time, blood transfusion, hospital stay, postoperation morbidity, weight gain, quality of life, and occupational rehabilitation, the results also favored duodenum-preserving pancreatic head resection (DPPHR) strategies.

Conclusion: All procedures are equally effective for the management of pain, postoperation morbidity, exocrine insufficiency, and endocrine insufficiency for chronic pancreatitis. Improved short- and long-term outcomes, including operative time, blood transfusion, hospital stay, quality of life, weight gain, and occupational rehabilitation make DPPHR a more favorable surgical strategy for patients with chronic pancreatitis. Further, relevant trails are eager to prove these findings.

Figure 1

Flow diagram for the selection of randomized controlled trials included in the meta-analysis.

Figure 2

Risk of bias summary: this risk of bias tool incorporated the assessment of randomization (sequence generation and allocation concealment), blinding (participants and outcome assessors), incomplete outcome data, selective outcome reporting, and other risks of bias. The items were judged as “low risk,” “unclear risk,” or “high risk.” Red means “high risk,” green means “low risk,” and yellow means “unclear risk.”

Figure 3

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in operative time.

Figure 4

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in blood transfusion.

Figure 5

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in length of hospital stay.

Figure 6

Forest plot of randomized controlled trials of the Frey procedure versus pancreaticoduodenectomy in operative time.

Figure 7

Forest plot of randomized controlled trials of the Frey procedure versus pancreaticoduodenectomy in blood transfusion.

Figure 8

Forest plot of randomized controlled trials of the Beger procedure versus pancreaticoduodenectomy in blood transfusion.

Figure 9

Forest plot of randomized controlled trials of the Beger procedure versus pancreaticoduodenectomy in length of hospital stay.

Figure 10

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in postoperative mortality.

Figure 11

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in postoperative morbidity.

Figure 12

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in mortality.

Figure 13

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy for quality of life with the follow-up time < 60 months.

Figure 14

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy for quality of life with the follow-up time > 60 months.

Figure 15

Forest plot of randomized controlled trials of duodenum-preserving pancreatic head resection versus pancreaticoduodenectomy in occupational rehabilitation.

Figure 16

Forest plot of randomized controlled trials of the Beger procedure versus pancreaticoduodenectomy in occupational rehabilitation.