Abstract
Purpose
To perform an up-to-date meta-analysis of randomized controlled trials (RCTs) comparing pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) in order to determine the safer anastomotic technique. Compared to existing meta-analysis, new RCTs were evaluated and subgroup analyses of different anastomotic techniques were carried out.
Methods
We conducted a bibliographic research using the National Library of Medicine’s PubMed database from January 1990 to July 2015 of RCTs. Only RCTs, in English, that compared PG versus all types of PJ were selected. Data were independently extracted by two authors. We performed a quantitative systematic review following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A random-effect model was applied. Statistical heterogeneity was assessed using the I 2 and χ 2 tests. Primary outcomes were rate of overall and clinically significant pancreatic fistula (POPF).
Results
Ten RCTs were identified including 1629 patients, 826 undergoing PG and 803 undergoing PJ. RCTs showed significant heterogeneity regarding definitions of POPF, perioperative management, and characteristics of pancreatic gland. No significant differences were found in the rate of overall and clinically significant POPF, morbidity, mortality, reoperation, and intra-abdominal sepsis when PG was compared with all types PJ or when subgroup analysis (double-layer PG with or without anterior gastrotomy versus duct to mucosa PJ and single-layer PG versus single-layer end-to-end/end-to-side PJ) were analyzed.
Conclusions
PG is not superior to PJ in the prevention of POPF. Current RCTs have major methodological limitations with significant heterogeneity in regard to surgical techniques, definition of POPF/complications, and perioperative management.
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Author’s contribution
Stefano Crippa is responsible for the conception and design of the project, acquisition, analysis, and interpretation of the data and main author for drafting the manuscript.
Roberto Cirocchi contributed to the conception and design of the study; assisted in the acquisition of the data, interpretation of the results, drafting, and critical review of the paper; and performed the statistical analysis.
Justus Randolph assisted in the statistical analysis, drafting, and in the critical review of the paper.
Stefano Partelli, Giulio Belfiori, Alessandra Piccioli, and Amilcare Parisi assisted in the interpretations of the results and critical review of the paper.
Massimo Falconi contributed to the conception and design of the study and assisted in the interpretation of the results, drafting, and critical review of the paper.
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Supplementary Fig. 1
Risk of bias graph (GIF 31 kb)
Supplementary Fig. 2
Risk of bias summary (GIF 41 kb)
Supplementary Fig. 3
All types PG versus all types PJ, forest plot for postoperative mortality (GIF 17 kb)
Supplementary Fig. 4
Double-layer PG with or without anterior gastrotomy versus duct to mucosa PJ, forest plot for postoperative mortality (GIF 15 kb)
Supplementary Fig. 5
Single-layer PG versus single-layer end-to-end/end-to-side PJ, forest plot for postoperative mortality (GIF 3 kb)
Supplementary Fig. 6
All types PG versus all types PJ, forest plot for postoperative morbidity (GIF 19 kb)
Supplementary Fig. 7
Double-layer PG with or without anterior gastrotomy versus duct to mucosa PJ, forest plot for postoperative morbidity (GIF 15 kb)
Supplementary Fig. 8
Single-layer PG versus single-layer end-to-end/end-to-side PJ, forest plot for postoperative morbidity (GIF 3 kb)
Supplementary Fig. 9
All types PG versus all types PJ, forest plot for gastrointestinal (intra-luminal) bleeding (GIF 3 kb)
Supplementary Fig. 10
All types PG versus all types PJ, forest plot for intra-peritoneal bleeding (GIF 3 kb)
Supplementary Fig. 11
All types PG versus all types PJ, forest plot for intra-abdominal sepsis (GIF 3 kb)
Supplementary Fig. 12
All types PG versus all types PJ, forest plot for operative time (GIF 48 kb)
Supplementary Fig. 13
All types PG versus all types PJ, forest plot for reoperation (GIF 18 kb)
Supplementary Table 1
(DOC 40 kb)
Supplementary Table 2
(DOC 42 kb)
Supplementary Table 3
(DOC 52 kb)
Supplementary Table 4
(DOC 43 kb)
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Crippa, S., Cirocchi, R., Randolph, J. et al. Pancreaticojejunostomy is comparable to pancreaticogastrostomy after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials. Langenbecks Arch Surg 401, 427–437 (2016). https://doi.org/10.1007/s00423-016-1418-z
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DOI: https://doi.org/10.1007/s00423-016-1418-z