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Is Antisecretory Therapy After Pancreatoduodenectomy Necessary? Meta-analysis and Contemporary Practices of Pancreatic Surgeons

  • 2014 SSAT Poster Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Marginal ulcer (MU) is a well-described complication of pancreatoduodenectomy (PD) whose incidence remains unclear. Gastric antisecretory medications likely attenuate the risk of marginal ulceration after PD; however, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known. The aims of this study were to document the incidence of MU after PD, identify any relationship between MU and gastric antisecretory medication, and survey current practice of MU prophylaxis among experienced pancreatic surgeons.

Methods

the MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials, and Cochrane Database of Systematic Reviews databases were searched from their inception to May 2014 for abstracts documenting ulceration after pancreatoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Contemporary practice was assessed through a four-question survey distributed globally to 200 established pancreatic surgeons.

Results

After a review of 208 abstracts, 54 studies were graded as relevant. These represented a cohort of 212 patients with marginal ulcer after PD (n = 4794). A meta-analysis of the included references shows mean incidence of ulceration after PD of 2.5 % (confidence interval (CI) 1.8–3.2 %) with a median time to diagnosis of 15.5 months. Pylorus preservation was associated with a MU rate of 2.0 % (CI 1.0–2.9 %), while “classic” PD procedures report an overall rate of 2.6 % (CI 1.6–3.6 %). Documented use of postoperative antisecretory medication was associated with a reduced rate of 1.4 % (CI 0.1–1.7 %). One hundred forty-four of 200 (72 %) surveys were returned, from which it was determined that 92 % of pancreatic surgeons have dealt with this complication, and 86 % routinely prescribe prophylactic antisecretory medication after PD.

Conclusions

The incidence of MU after PD is 2.5 % with a median time to occurrence of 15.5 months postoperatively. Gastric antisecretory medication prescription may affect the incidence of MU. The majority of pancreatic surgeons surveyed have encountered MU after PD; most (86 %) routinely prescribe prophylactic gastric antisecretory medication.

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References

  1. Dragstedt, L.R., Some Physiologic Principles Involved in Surgical Treatment of Gastric and Duodenal Ulcer Ann. Surg, 1935. 102: p. 563-580

    CAS  Google Scholar 

  2. Owens, F., The Problem of Peptic Ulcer Following Pancreatic. Annals of Surgery, 1948. 128(1): p. 15-20.

    Article  PubMed Central  PubMed  Google Scholar 

  3. DerSimonian, R., Combining evidence from clinical trials. Anesth Analg., 1990. 70: p. 475-6.

    Article  CAS  PubMed  Google Scholar 

  4. Abdel-Wahab, M., et al., Modified pancreaticoduodenectomy: experience with 81 cases, Wahab modification. Hepatogastroenterology, 2001. 48(42): p. 1572-6.

    CAS  PubMed  Google Scholar 

  5. Bassi, C., et al., Open pancreaticogastrostomy after pancreaticoduodenectomy: a pilot study. J Gastrointest Surg, 2006. 10(7): p. 1072-80.

    Article  PubMed  Google Scholar 

  6. Basso, N., et al., Retained antral mucosa in pancreaticoduodenectomy patients. Am J Surg, 1977. 134(2): p. 259-62.

    Article  CAS  PubMed  Google Scholar 

  7. Braasch, J.W., et al., Pyloric and gastric preserving pancreatic resection. Experience with 87 patients. Ann Surg, 1986. 204(4): p. 411-8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  8. Cameron, J.L., et al., One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg, 1993. 217(5): p. 430-5; discussion 435-8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  9. Caronna, R., et al., Functional results of a personal technique of reconstruction after pancreaticoduodenectomy. J Exp Clin Cancer Res, 2003. 22(4 Suppl): p. 187-9.

    CAS  PubMed  Google Scholar 

  10. De Bernardinis, G., et al., An original reconstructive method after pylorus-preserving pancreatoduodenectomy. Surg Today, 1993. 23(6): p. 481-5.

    Article  PubMed  Google Scholar 

  11. Fink, A.S., et al., Long-term evaluation of pylorus preservation during pancreaticoduodenectomy. World J Surg, 1988. 12(5): p. 663-70.

    Article  CAS  PubMed  Google Scholar 

  12. Flautner, L., T. Tihanyi, and A. Szecseny, Pancreatogastrostomy: an ideal complement to pancreatic head resection with preservation of the pylorus in the treatment of chronic pancreatitis. Am J Surg, 1985. 150(5): p. 608-11.

    Article  CAS  PubMed  Google Scholar 

  13. Grant, C.S. and J.A. Van Heerden, Anastomotic ulceration following subtotal and total pancreatectomy. Ann Surg, 1979. 190(1): p. 1-5.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  14. Hayashibe, A. and M. Kameyama, The clinical results of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy in consecutive 55 cases. Pancreas, 2007. 35(3): p. 273-5.

    Article  PubMed  Google Scholar 

  15. Herter, F.P., et al., Surgical experience with pancreatic and periampullary cancer. Ann Surg, 1982. 195(3): p. 274-81.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  16. Hishinuma, S., et al., Complications after pylorus-preserving pancreatoduodenectomy with gastrointestinal reconstruction by the Imanaga method. J Am Coll Surg, 1998. 186(1): p. 10-6.

    Article  CAS  PubMed  Google Scholar 

  17. Holbrook, R.F., K. Hargrave, and L.W. Traverso, A prospective cost analysis of pancreatoduodenectomy. Am J Surg, 1996. 171(5): p. 508-11.

    Article  CAS  PubMed  Google Scholar 

  18. Hoshal, V.L., Jr., et al., Personal experience with the Whipple operation: outcomes and lessons learned. Am Surg, 2004. 70(2): p. 121-5; discussion 126.

    PubMed  Google Scholar 

  19. Itani, K.M., et al., Pylorus-preserving pancreatoduodenectomy. A clinical and physiologic appraisal. Ann Surg, 1986. 204(6): p. 655-64.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  20. Jimenez, R.E., et al., Outcome of pancreaticoduodenectomy with pylorus preservation or with antrectomy in the treatment of chronic pancreatitis. Ann Surg, 2000. 231(3): p. 293-300.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  21. Kim, H.C., et al., Exocrine and endocrine stomach after gastrobulbar preserving pancreatoduodenectomy. Ann Surg, 1987. 206(6): p. 717-27.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  22. Kim, K.H., et al., Effect of a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis in pancreaticoduodenectomy: a single surgeon's experiences. Hepatogastroenterology, 2007. 54(77): p. 1368-72.

    PubMed  Google Scholar 

  23. Kingsnorth, A.N., J.D. Berg, and M.R. Gray, A novel reconstructive technique for pylorus-preserving pancreaticoduodenectomy: avoidance of early postoperative gastric stasis. Ann R Coll Surg Engl, 1993. 75(1): p. 38-42.

    PubMed Central  CAS  PubMed  Google Scholar 

  24. Klinkenbijl, J.H., et al., The advantages of pylorus-preserving pancreatoduodenectomy in malignant disease of the pancreas and periampullary region. Ann Surg, 1992. 216(2): p. 142-5.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  25. Kozuschek, W., et al., A comparison of long term results of the standard Whipple procedure and the pylorus preserving pancreatoduodenectomy. J Am Coll Surg, 1994. 178(5): p. 443-53.

    CAS  PubMed  Google Scholar 

  26. Lerut, J., et al., Pylorus-preserving pancreatoduodenectomy. Experience in 20 patients. HPB Surg, 1991. 4(2): p. 109-17; discussion 117-9.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  27. Lupo, L.G., et al., Is pyloric function preserved in pylorus-preserving pancreaticoduodenectomy? Eur J Surg, 1998. 164(2): p. 127-32.

    Article  CAS  PubMed  Google Scholar 

  28. Lygidakis, N.J., et al., Reappraisal of a method of reconstruction after pancreatoduodenectomy. Hepatogastroenterology, 2005. 52(64): p. 1077-82.

    CAS  PubMed  Google Scholar 

  29. Ma, Y.G., et al., Pancreaticoduodenectomy with Roux-Y anastomosis in reconstructing the digestive tract: report of 26 patients. Hepatobiliary Pancreat Dis Int, 2002. 1(4): p. 611-3.

    PubMed  Google Scholar 

  30. Matsuno, S., et al., Pancreatic function and rehabilitation after pancreaticoduodenectomy. Jpn J Surg, 1988. 18(1): p. 23-30.

    Article  CAS  PubMed  Google Scholar 

  31. McAfee, M.K., J.A. van Heerden, and M.A. Adson, Is proximal pancreatoduodenectomy with pyloric preservation superior to total pancreatectomy? Surgery, 1989. 105(3): p. 347-51.

    CAS  PubMed  Google Scholar 

  32. Miedema, B.W., et al., Complications following pancreaticoduodenectomy. Current management. Arch Surg, 1992. 127(8): p. 945-9; discussion 949-50.

    Article  CAS  PubMed  Google Scholar 

  33. Mosca, F., et al., Pancreaticoduodenectomy with pylorus preservation. Ital J Surg Sci, 1984. 14(4): p. 313-20.

    CAS  PubMed  Google Scholar 

  34. Newman, K.D., et al., Pyloric and gastric preservation with pancreatoduodenectomy. Am J Surg, 1983. 145(1): p. 152-6.

    Article  CAS  PubMed  Google Scholar 

  35. Nishikawa, M., et al., Gastric pH monitoring after pylorus preserving pancreaticoduodenectomy with Billroth I type of reconstruction. J Am Coll Surg, 1994. 179(2): p. 129-34.

    CAS  PubMed  Google Scholar 

  36. Ohtsuka, T., et al., Postoperative pancreatic exocrine function influences body weight maintenance after pylorus-preserving pancreatoduodenectomy. Am J Surg, 2001. 182(5): p. 524-9.

    Article  CAS  PubMed  Google Scholar 

  37. Oida, T., et al., Gastric marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy due to delayed gastric emptying and Helicobacter pylori infection. Hepatogastroenterology, 2012. 59(115): p. 899-902.

    PubMed  Google Scholar 

  38. Pannala, R., et al., Afferent limb syndrome and delayed GI problems after pancreaticoduodenectomy for pancreatic cancer: single-center, 14-year experience. Gastrointest Endosc, 2011. 74(2): p. 295-302.

    Article  PubMed  Google Scholar 

  39. Patel, A.G., et al., Pylorus-preserving Whipple resection for pancreatic cancer. Is it any better? Arch Surg, 1995. 130(8): p. 838-42; discussion 842-3.

    Article  CAS  PubMed  Google Scholar 

  40. Pellegrini, C.A., et al., An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy. Arch Surg, 1989. 124(7): p. 778-81.

    Article  CAS  PubMed  Google Scholar 

  41. Porter, M.R., Carcinoma of the pancreatico-duodenal area; operability and choice of procedure. Ann Surg, 1958. 148(4): p. 711-23; discussion 723-4.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  42. Riediger, H., et al., Long-term outcome after resection for chronic pancreatitis in 224 patients. J Gastrointest Surg, 2007. 11(8): p. 949-59; discussion 959-60.

    Article  PubMed  Google Scholar 

  43. Roder, J.D., et al., Pylorus-preserving versus standard pancreatico-duodenectomy: an analysis of 110 pancreatic and periampullary carcinomas. Br J Surg, 1992. 79(2): p. 152-5.

    Article  CAS  PubMed  Google Scholar 

  44. Ruilova, L.A. and C.D. Hershey, Experience with 21 pancreaticoduodenectomies. Arch Surg, 1976. 111(1): p. 27-30.

    Article  CAS  PubMed  Google Scholar 

  45. Safioleas, M.C., et al., How necessary is vagotomy after pancreaticoduodenectomy and total pancreatectomy. Hepatogastroenterology, 2005. 52(61): p. 251-2.

    PubMed  Google Scholar 

  46. Sakaguchi, T., et al., Marginal ulceration after pylorus-preserving pancreaticoduodenectomy. J Hepatobiliary Pancreat Surg, 2000. 7(2): p. 193-7.

    Article  CAS  PubMed  Google Scholar 

  47. Sakorafas, G.H., et al., Long-term results after surgery for chronic pancreatitis. Int J Pancreatol, 2000. 27(2): p. 131-42.

    Article  CAS  PubMed  Google Scholar 

  48. Schmidt, U., et al., Quality of life and functional long-term outcome after partial pancreatoduodenectomy: pancreatogastrostomy versus pancreatojejunostomy. Ann Surg Oncol, 2005. 12(6): p. 467-72.

    Article  PubMed  Google Scholar 

  49. Scott, H.W., Jr., et al., The role of vagotomy in pancreaticoduodenectomy. Ann Surg, 1980. 191(6): p. 688-96.

    Article  PubMed Central  PubMed  Google Scholar 

  50. Shan, Y.S., et al., Reconsideration of delayed gastric emptying in pancreaticoduodenectomy. World J Surg, 2005. 29(7): p. 873-9; discussion 880.

    Article  PubMed  Google Scholar 

  51. Shinchi, H., et al., Gastric acidity following pancreaticogastrostomy with pylorus-preserving pancreaticoduodenectomy. World J Surg, 2000. 24(1): p. 86-90; discussion 90-1.

    Article  CAS  PubMed  Google Scholar 

  52. Shyr, Y.M., et al., Non-stented pancreaticogastrostomy after pylorus-preserving pancreaticoduodenectomy. Zhonghua Yi Xue Za Zhi (Taipei), 2002. 65(6): p. 254-9.

    Google Scholar 

  53. Tanaka, T., Y. Matsugu, and Y. Fukuda, Use of ultrasonically activated shears improves the safety of pancreaticojejunostomy after pancreaticoduodenectomy. Arch Surg, 2002. 137(11): p. 1258-61.

    Article  PubMed  Google Scholar 

  54. Traverso, L.W. and R.A. Kozarek, Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis. Ann Surg, 1997. 226(4): p. 429-35; discussion 435-8.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  55. Walsh, D.B., et al., Adenocarcinoma of the ampulla of Vater. Diagnosis and treatment. Ann Surg, 1982. 195(2): p. 152-7.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  56. Wu, J.M., et al., Reflux esophagitis and marginal ulcer after pancreaticoduodenectomy. J Gastrointest Surg, 2011. 15(5): p. 824-8.

    Article  PubMed  Google Scholar 

  57. Yamaguchi, K., et al., ERT following IORT improves survival of patients with resectable pancreatic cancer. Hepatogastroenterology, 2005. 52(64): p. 1244-9.

    PubMed  Google Scholar 

  58. Elliott, D.W., Effect of lost pancreatic juice on gastric acid and peptic ulcer. Am J Surg, 1974. 127(6): p. 658-62.

    Article  CAS  PubMed  Google Scholar 

  59. Grace, P.A., et al., Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg, 1986. 151(1): p. 141-9.

    Article  CAS  PubMed  Google Scholar 

  60. Crist, D.W., J.V. Sitzmann, and J.L. Cameron, Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg, 1987. 206(3): p. 358-65.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  61. Traverso, L.W. and W.P. Longmire, Jr., Preservation of the pylorus in pancreaticoduodenectomy a follow-up evaluation. Ann Surg, 1980. 192(3): p. 306-10.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  62. Traverso, L.W. and W.P. Longmire, Jr., Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet, 1978. 146(6): p. 959-62.

    CAS  PubMed  Google Scholar 

  63. K, W., Carcinoma of the ampula of Vater: sucessful radical resection. Br J Surg, 1944. 31: p. 368-373.

  64. Pearlman, N.W., et al., Acid and gastrin levels following pyloric-preserving pancreaticoduodenectomy. Arch Surg, 1986. 121(6): p. 661-4.

    Article  CAS  PubMed  Google Scholar 

  65. Sudo, T., et al., Changes in plasma gastrin and secretin levels after pancreaticoduodenectomy. Surg Gynecol Obstet, 1984. 158(2): p. 133-6.

    CAS  PubMed  Google Scholar 

  66. Takada, T., et al., Postprandial plasma gastrin and secretin concentrations after a pancreatoduodenectomy. A comparison between a pylorus-preserving pancreatoduodenectomy and the Whipple procedure. Ann Surg, 1989. 210(1): p. 47-51.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  67. Gumbs, A.A., A.J. Duffy, and R.L. Bell, Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis, 2006. 2(4): p. 460-3.

    Article  PubMed  Google Scholar 

  68. Wilson, J.A., et al., Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol, 2006. 101(10): p. 2194-9.

    Article  PubMed  Google Scholar 

  69. Coblijn, U.K., et al., Development of Ulcer Disease After Roux-en-Y Gastric Bypass, Incidence, Risk Factors, and Patient Presentation: A Systematic Review. Obes Surg, 2013.

  70. Drepper, M.D., L. Spahr, and J.L. Frossard, Clopidogrel and proton pump inhibitors--where do we stand in 2012? World J Gastroenterol, 2012. 18(18): p. 2161-71.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  71. Katz, M.H., Failing the acid test: benefits of proton pump inhibitors may not justify the risks for many users. Arch Intern Med, 2010. 170(9): p. 747-8.

    Article  PubMed  Google Scholar 

  72. Lepage C, R.B., Jooste V et al., Continuing rapid increase in esophageal adenocarcinoma in England and Wales. The American Journal of Gastroenterology 2008. 103(11): p. 2694-9.

    Article  PubMed  Google Scholar 

  73. PJ, R., Could proton pump inhibitors cause cancer? Archives of Internal Medicine, 2010. 170(19): p. 1775-6.

  74. Brunner, G., C. Athmann, and A. Schneider, Long-term, open-label trial: safety and efficacy of continuous maintenance treatment with pantoprazole for up to 15 years in severe acid-peptic disease. Alimentary Pharmacology & Therapeutics, 2012. 36(1): p. 37-47.

    Article  CAS  Google Scholar 

  75. Fiocca, R., et al., Gastric exocrine and endocrine cell morphology under prolonged acid inhibition therapy: results of a 5-year follow-up in the LOTUS trial. Aliment Pharmacol Ther, 2012. 36(10): p. 959-71.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

We thank Kellie Kaneshiro of the Indiana University Ruth Lilly Medical Library for assistance with reference search and retrieval.

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Authors and Affiliations

  1. Department of Surgery, Indiana University School of Medicine—IU Health University Hospital, 550 N University Blvd #1295, Indianapolis, IN, 46202, USA

    James R. Butler, Tyrone Rogers, Gregory R. Martens, Eugene P. Ceppa, Michael G. House, Attila Nakeeb, C. Max Schmidt & Nicholas J. Zyromski

  2. Department of Biostatictics, Indiana University School of Medicine, Indianapolis, IN, USA

    George Eckart

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  1. James R. Butler
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Butler, J.R., Rogers, T., Eckart, G. et al. Is Antisecretory Therapy After Pancreatoduodenectomy Necessary? Meta-analysis and Contemporary Practices of Pancreatic Surgeons. J Gastrointest Surg 19, 604–612 (2015). https://doi.org/10.1007/s11605-015-2765-8

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