Article

Annals of Surgical Oncology

, Volume 14, Issue 6, pp 1825-1834

First online:

The Pylorus: Take It or Leave It? Systematic Review and Meta-Analysis of Pylorus-Preserving versus Standard Whipple Pancreaticoduodenectomy for Pancreatic or Periampullary Cancer

  • Paul J. KaranicolasAffiliated withDepartment of Clinical Epidemiology and Biostatistics, McMaster UniversityDepartment of Surgery, University of Western Ontario, University Hospital Email author 
  • , Edward DaviesAffiliated withDepartment of Surgery, University of Western Ontario, University Hospital
  • , Regina KunzAffiliated withBasel Institute for Clinical Epidemiology, University Hospital Basel
  • , Matthias BrielAffiliated withDepartment of Clinical Epidemiology and Biostatistics, McMaster UniversityBasel Institute for Clinical Epidemiology, University Hospital Basel
  • , H. Pavan KokaAffiliated withDepartment of Clinical Epidemiology and Biostatistics, McMaster UniversityDepartment of Surgery, University of Western Ontario, University Hospital
  • , Darrin M. PayneAffiliated withDepartment of Clinical Epidemiology and Biostatistics, McMaster UniversityDepartment of Surgery, University of Western Ontario, University Hospital
  • , Shona E. SmithAffiliated withDepartment of Surgery, University of Western Ontario, University Hospital
  • , Hui-Ping HsuAffiliated withDepartment of Surgery, National Cheng Kung University Hospital
  • , Pin-Wen LinAffiliated withDepartment of Surgery, National Cheng Kung University Hospital
    • , Christian BloechleAffiliated withDepartment of Surgery, University Hospital Eppendorf
    • , Karl-Joseph PaquetAffiliated withDepartment of Surgery, Heinz Kalk-Hospital
    • , Gordon H. GuyattAffiliated withDepartment of Clinical Epidemiology and Biostatistics, McMaster UniversityDepartment of Medicine, McMaster University

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Abstract

Background

Our objective was to determine the relative effects of pylorus-preserving pancreaticoduodenectomy (PPPD) and standard Whipple pancreaticoduodenectomy (SWPD) in patients with pancreatic or periampullary cancer.

Methods

We searched seven bibliographic databases, conference proceedings, and reference lists of articles and textbooks, and we contacted experts in the field of hepatobiliary surgery. We included published and unpublished randomized controlled trials. We evaluated the methodological quality of trials and, in duplicate, extracted data regarding operative, perioperative, and long-term outcomes. We contacted all authors and asked them to provide additional information regarding the trials. We pooled results from the studies by using a random-effects model, evaluated the degree of heterogeneity, and explored potential explanations for heterogeneity.

Results

Six trials that included a total of 574 patients met eligibility criteria. In the pooled analysis, PPPD was 72 minutes faster (P < .001, 95% confidence interval [95% CI], 53–92), with 284 mL less blood loss (P < .001, 95% CI, 176–391) and .66 fewer units of blood transfused (P = .002, 95% CI, .25–1.16). Other perioperative and long-term outcomes did not statistically differ, although the confidence intervals include important differences.

Conclusions

Moderate-quality evidence suggests PPPD is a faster procedure with less blood loss compared with SWPD. Large absolute differences in other key outcomes are unlikely; excluding relatively small differences will, however, require larger, methodologically stronger trials.

Keywords

Pancreatic cancer Pancreaticoduodenectomy Whipple procedure Pylorus Systematic review Meta-analysis