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Meta-Analysis
. 2017 Sep 12;9(9):CD012257.
doi: 10.1002/14651858.CD012257.pub2.

Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy

Yao Cheng  1 , Marta Briarava, Mingliang Lai, Xiaomei Wang, Bing Tu, Nansheng Cheng, Jianping Gong, Yuhong Yuan, Pierluigi Pilati, Simone Mocellin
Affiliations
Meta-Analysis

Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy

Yao Cheng et al. Cochrane Database Syst Rev. .

Abstract

Background: Pancreatoduodenectomy is a surgical procedure used to treat diseases of the pancreatic head and, less often, the duodenum. The most common disease treated is cancer, but pancreatoduodenectomy is also used for people with traumatic lesions and chronic pancreatitis. Following pancreatoduodenectomy, the pancreatic stump must be connected with the small bowel where pancreatic juice can play its role in food digestion. Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are surgical procedures commonly used to reconstruct the pancreatic stump after pancreatoduodenectomy. Both of these procedures have a non-negligible rate of postoperative complications. Since it is unclear which procedure is better, there are currently no international guidelines on how to reconstruct the pancreatic stump after pancreatoduodenectomy, and the choice is based on the surgeon's personal preference.

Objectives: To assess the effects of pancreaticogastrostomy compared to pancreaticojejunostomy on postoperative pancreatic fistula in participants undergoing pancreaticoduodenectomy.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9), Ovid MEDLINE (1946 to 30 September 2016), Ovid Embase (1974 to 30 September 2016) and CINAHL (1982 to 30 September 2016). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) and screened references of eligible articles and systematic reviews on this subject. There were no language or publication date restrictions.

Selection criteria: We included all randomized controlled trials (RCTs) assessing the clinical outcomes of PJ compared to PG in people undergoing pancreatoduodenectomy.

Data collection and analysis: We used standard methodological procedures expected by The Cochrane Collaboration. We performed descriptive analyses of the included RCTs for the primary (rate of postoperative pancreatic fistula and mortality) and secondary outcomes (length of hospital stay, rate of surgical re-intervention, overall rate of surgical complications, rate of postoperative bleeding, rate of intra-abdominal abscess, quality of life, cost analysis). We used a random-effects model for all analyses. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes (using PG as the reference) with 95% confidence intervals (CI) as a measure of variability.

Main results: We included 10 RCTs that enrolled a total of 1629 participants. The characteristics of all studies matched the requirements to compare the two types of surgical reconstruction following pancreatoduodenectomy. All studies reported incidence of postoperative pancreatic fistula (the main complication) and postoperative mortality.Overall, the risk of bias in included studies was high; only one included study was assessed at low risk of bias.There was little or no difference between PJ and PG in overall risk of postoperative pancreatic fistula (PJ 24.3%; PG 21.4%; RR 1.19, 95% CI 0.88 to 1.62; 7 studies; low-quality evidence). Inclusion of studies that clearly distinguished clinically significant pancreatic fistula resulted in us being uncertain whether PJ improved the risk of pancreatic fistula when compared with PG (19.3% versus 12.8%; RR 1.51, 95% CI 0.92 to 2.47; very low-quality evidence). PJ probably has little or no difference from PG in risk of postoperative mortality (3.9% versus 4.8%; RR 0.84, 95% CI 0.53 to 1.34; moderate-quality evidence).We found low-quality evidence that PJ may differ little from PG in length of hospital stay (MD 1.04 days, 95% CI -1.18 to 3.27; 4 studies, N = 502) or risk of surgical re-intervention (11.6% versus 10.3%; RR 1.18, 95% CI 0.86 to 1.61; 7 studies, N = 1263). We found moderate-quality evidence suggesting little difference between PJ and PG in terms of risk of any surgical complication (46.5% versus 44.5%; RR 1.03, 95% CI 0.90 to 1.18; 9 studies, N = 1513). PJ may slightly improve the risk of postoperative bleeding (9.3% versus 13.8%; RR 0.69, 95% CI: 0.51 to 0.93; low-quality evidence; 8 studies, N = 1386), but may slightly worsen the risk of developing intra-abdominal abscess (14.7% versus 8.0%; RR 1.77, 95% CI 1.11 to 2.81; 7 studies, N = 1121; low quality evidence). Only one study reported quality of life (N = 320); PG may improve some quality of life parameters over PJ (low-quality evidence). No studies reported cost analysis data.

Authors' conclusions: There is no reliable evidence to support the use of pancreatojejunostomy over pancreatogastrostomy. Future large international studies may shed new light on this field of investigation.

PubMed Disclaimer

Conflict of interest statement

The review authors declare no conflicts of interest of any type.

SM: none known. YC: none known. MB: none known. ML: none known. XW: none known. BT: none known. NC: none known. JG: none known. YY: none known. PP: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Pancreaticojejunostomy versus pancreaticogastrostomy, Outcome 1 Postoperative pancreatic fistula (Grade A, B or C).
1.2
1.2. Analysis
Comparison 1 Pancreaticojejunostomy versus pancreaticogastrostomy, Outcome 2 Clinically significant pancreatic fistula (Grade B or C).
1.3
1.3. Analysis
Comparison 1 Pancreaticojejunostomy versus pancreaticogastrostomy, Outcome 3 Postoperative mortality.
1.4
1.4. Analysis
Comparison 1 Pancreaticojejunostomy versus pancreaticogastrostomy, Outcome 4 Length of hospital stay.
1.5
1.5. Analysis
Comparison 1 Pancreaticojejunostomy versus pancreaticogastrostomy, Outcome 5 Surgical re‐intervention.
1.6
1.6. Analysis
Comparison 1 Pancreaticojejunostomy versus pancreaticogastrostomy, Outcome 6 Surgical complications.
1.7
1.7. Analysis
Comparison 1 Pancreaticojejunostomy versus pancreaticogastrostomy, Outcome 7 Postoperative bleeding.
1.8
1.8. Analysis
Comparison 1 Pancreaticojejunostomy versus pancreaticogastrostomy, Outcome 8 Intra‐abdominal abscess.
2.1
2.1. Analysis
Comparison 2 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by Western versus Eastern countries), Outcome 1 Postoperative pancreatic fistula (Grade A, B or C).
2.2
2.2. Analysis
Comparison 2 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by Western versus Eastern countries), Outcome 2 Clinically significant pancreatic fistula (Grade B or C).
2.3
2.3. Analysis
Comparison 2 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by Western versus Eastern countries), Outcome 3 Postoperative mortality.
3.1
3.1. Analysis
Comparison 3 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by pancreaticojejunostomy techniques), Outcome 1 Postoperative pancreatic fistula (Grade A, B or C).
3.2
3.2. Analysis
Comparison 3 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by pancreaticojejunostomy techniques), Outcome 2 Clinically significant pancreatic fistula (Grade B or C).
3.3
3.3. Analysis
Comparison 3 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by pancreaticojejunostomy techniques), Outcome 3 Postoperative mortality.
4.1
4.1. Analysis
Comparison 4 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by pancreaticogastrostomy techniques), Outcome 1 Postoperative pancreatic fistula (Grade A, B or C).
4.2
4.2. Analysis
Comparison 4 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by pancreaticogastrostomy techniques), Outcome 2 Clinically significant pancreatic fistula (Grade B or C).
4.3
4.3. Analysis
Comparison 4 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by pancreaticogastrostomy techniques), Outcome 3 Postoperative mortality.
5.1
5.1. Analysis
Comparison 5 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by risk of postoperative pancreatic fistula), Outcome 1 Postoperative pancreatic fistula (Grade A, B or C).
5.2
5.2. Analysis
Comparison 5 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by risk of postoperative pancreatic fistula), Outcome 2 Clinically significant pancreatic fistula (Grade B or C).
5.3
5.3. Analysis
Comparison 5 Pancreaticojejunostomy versus pancreaticogastrostomy (stratified by risk of postoperative pancreatic fistula), Outcome 3 Postoperative mortality.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD012257

References

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References to other published versions of this review

Cheng 2016
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