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Meta-Analysis
. 2022 Jan 11;1(1):CD011862.
doi: 10.1002/14651858.CD011862.pub3.

Antecolic versus retrocolic reconstruction after partial pancreaticoduodenectomy

Felix J Hüttner  1 , Rosa Klotz  2 , Alexis Ulrich  3 , Markus W Büchler  2 , Pascal Probst  2   4 , Markus K Diener  5
Affiliations
Meta-Analysis

Antecolic versus retrocolic reconstruction after partial pancreaticoduodenectomy

Felix J Hüttner et al. Cochrane Database Syst Rev. .

Abstract

Background: Pancreatic cancer remains one of the five leading causes of cancer deaths in industrialised nations. For adenocarcinomas in the head of the gland and premalignant lesions, partial pancreaticoduodenectomy represents the standard treatment for resectable tumours. The gastro- or duodenojejunostomy after partial pancreaticoduodenectomy can be reestablished via either an antecolic or retrocolic route. The debate about the more favourable technique for bowel reconstruction is ongoing.

Objectives: To compare the effectiveness and safety of antecolic and retrocolic gastro- or duodenojejunostomy after partial pancreaticoduodenectomy.

Search methods: In this updated version, we conducted a systematic literature search up to 6 July 2021 to identify all randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Library 2021, Issue 6, MEDLINE (1946 to 6 July 2021), and Embase (1974 to 6 July 2021). We applied no language restrictions. We handsearched reference lists of identified trials to identify further relevant trials, and searched the trial registries clinicaltrials.govand World Health Organization International Clinical Trials Registry Platform for ongoing trials.

Selection criteria: We considered all RCTs comparing antecolic with retrocolic reconstruction of bowel continuity after partial pancreaticoduodenectomy for any given indication to be eligible.

Data collection and analysis: Two review authors independently screened the identified references and extracted data from the included trials. The same two review authors independently assessed risk of bias of included trials, according to standard Cochrane methodology. We used a random-effects model to pool the results of the individual trials in a meta-analysis. We used odds ratios (OR) to compare binary outcomes and mean differences (MD) for continuous outcomes.

Main results: Of a total of 287 citations identified by the systematic literature search, we included eight randomised controlled trials (reported in 11 publications), with a total of 818 participants. There was high risk of bias in all of the trials in regard to blinding of participants and/or outcome assessors and unclear risk for selective reporting in six of the trials. There was little or no difference in the frequency of delayed gastric emptying (OR 0.67; 95% confidence interval (CI) 0.41 to 1.09; eight trials, 818 participants, low-certainty evidence) with relevant heterogeneity between trials (I2=40%). There was little or no difference in postoperative mortality (risk difference (RD) -0.00; 95% CI -0.02 to 0.01; eight trials, 818 participants, high-certainty evidence); postoperative pancreatic fistula (OR 1.01; 95% CI 0.73 to 1.40; eight trials, 818 participants, low-certainty evidence); postoperative haemorrhage (OR 0.87; 95% CI 0.47 to 1.59; six trials, 742 participants, low-certainty evidence); intra-abdominal abscess (OR 1.11; 95% CI 0.71 to 1.74; seven trials, 788 participants, low-certainty evidence); bile leakage (OR 0.82; 95% CI 0.35 to 1.91; seven trials, 606 participants, low-certainty evidence); reoperation rate (OR 0.68; 95% CI 0.34 to 1.36; five trials, 682 participants, low-certainty evidence); and length of hospital stay (MD -0.21; 95% CI -1.41 to 0.99; eight trials, 818 participants, low-certainty evidence). Only one trial reported quality of life, on a subgroup of 73 participants, also without a relevant difference between the two groups at any time point. The overall certainty of the evidence was low to moderate, due to some degree of heterogeneity, inconsistency and risk of bias in the included trials.

Authors' conclusions: There was low- to moderate-certainty evidence suggesting that antecolic reconstruction after partial pancreaticoduodenectomy results in little to no difference in morbidity, mortality, length of hospital stay, or quality of life. Due to heterogeneity in definitions of the endpoints between trials, and differences in postoperative management, future research should be based on clearly defined endpoints and standardised perioperative management, to potentially elucidate differences between these two procedures. Novel strategies should be evaluated for prophylaxis and treatment of common complications, such as delayed gastric emptying.

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Conflict of interest statement

FH: none known. RK: none known. MKD: none known. MWB: none known. AU: none known. PP: none known.

Figures

1
1
Study flow diagram.
2
2
Funnel plot of comparison: 1 antecolic vs. retrocolic, outcome: 1.1 delayed gastric emptying (all definitions).
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.
4
4
Risk of bias summary: review authors' judgements about each risk of bias item for each included trial.
1.1
1.1. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 1: Delayed gastric emptying (all definitions)
1.2
1.2. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 2: Delayed gastric emptying (ISGPS definition)
1.3
1.3. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 3: Clinically relevant delayed gastric emptying (ISGPS grade B/C)
1.4
1.4. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 4: Postoperative mortality
1.5
1.5. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 5: Postoperative pancreatic fistula
1.6
1.6. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 6: Postoperative pancreatic fistula ISGPF definition
1.7
1.7. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 7: Clinically relevant postoperative pancreatic fistula ( ISGPF grade B/C)
1.8
1.8. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 8: Postoperative hemorrhage
1.9
1.9. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 9: Bile leakage
1.10
1.10. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 10: Intra‐abdominal fluid collection/abscess
1.11
1.11. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 11: Reoperation rate
1.12
1.12. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 12: Duration of operation
1.13
1.13. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 13: Intraoperative blood loss
1.14
1.14. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 14: Length of hospital stay
1.15
1.15. Analysis
Comparison 1: antecolic vs. retrocolic, Outcome 15: Length of postoperative NGT
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References

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