The Pylorus: Take It or Leave It? Systematic Review and Meta-Analysis of Pylorus-Preserving versus Standard Whipple Pancreaticoduodenectomy for Pancreatic or Periampullary Cancer
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.
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 We included published and unpublished randomized controlled trials.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.
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.
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.
KeywordsPancreatic cancer Pancreaticoduodenectomy Whipple procedure Pylorus Systematic review Meta-analysis
- 5.Kausch W. Das Carcinom der Papilla duodeni und seine radikale Entfernung. Bruns Beitr Klin Chir 1912; 78:439–86Google Scholar
- 6.Whipple AO, al. e. Treatment of carcinoma of the ampulla of Vater. Ann Surg 1935; 102:763–79Google Scholar
- 9.Carter D, Russell R, Pitt H (eds). Rob and Smith’s Operative Surgery: Hepatobiliary and Pancreatic Surgery. 5th ed. London: Chapman & Hall, 1996Google Scholar
- 10.Howard J, Idezuki Y, Ihse I, Prinz R (eds). Surgical Diseases of the Pancreas. 3rd ed. Baltimore: Williams & Wilkins, 1998Google Scholar
- 18.Breslow N, Day N. Combination of results from a series of 2 × 2 tables; control of confounding. In: Statistical Methods in Cancer Research, vol. 1, The Analysis of Case-Control Studies. Lyon, France: International Agency for Research on Cancer, 1980:136–46Google Scholar
- 20.Sackett D, Haynes R, Guyatt G, Tugwell P. Clinincal Epidemiology: A Basic Science for Clinical Medicine. 2nd ed. Boston: Little, Brown, 1991:30Google Scholar
- 28.Wenger FA, Jacobi CA, Haubold K, Zieren HU, Muller JM. Gastrointestinal quality of life after duodenopancreatectomy in pancreatic carcinoma. Preliminary results of a prospective randomized study: pancreatoduodenectomy or pylorus-preserving pancreatoduodenectomy. Chirurg 1999; 70:1454–9PubMedCrossRefGoogle Scholar
- 33.Bloechle C, Broering DC, Latuske C, Latuske M, v Schrenck T, Izbicki JR. Prospective randomized study to evaluate quality of life after partial pancreatoduodenectomy according to whipple versus pylorus preserving pancreatoduodenectomy according to longmire-traverso for periampullary carcinoma. Deutsche Gesellschaft Chir 1999; (Suppl 1):661–4Google Scholar
- 34.Sharp KW, Ross CB, Halter SA, Morrison JG, Richards WO. Pancreaticoduodenectomy with pyloric preservation for carcinoma of the pancreas: a cautionary note. Surgery 1988; 105:645–53Google Scholar
- 35.Moosa AR. Pancreatic cancer. Approach to diagnosis, selection for surgery and choice of operation. Cancer 1982; 50:2689–98Google Scholar