Annals of Surgical Oncology

, Volume 14, Issue 6, pp 1825–1834 | Cite as

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. Karanicolas
  • Edward Davies
  • Regina Kunz
  • Matthias Briel
  • H. Pavan Koka
  • Darrin M. Payne
  • Shona E. Smith
  • Hui-Ping Hsu
  • Pin-Wen Lin
  • Christian Bloechle
  • Karl-Joseph Paquet
  • Gordon H. Guyatt



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 We included published and unpublished randomized controlled trials.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.


Pancreatic cancer Pancreaticoduodenectomy Whipple procedure Pylorus Systematic review Meta-analysis 


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Copyright information

© Society of Surgical Oncology 2007

Authors and Affiliations

  • Paul J. Karanicolas
    • 1
    • 3
  • Edward Davies
    • 3
  • Regina Kunz
    • 4
  • Matthias Briel
    • 1
    • 4
  • H. Pavan Koka
    • 1
    • 3
  • Darrin M. Payne
    • 1
    • 3
  • Shona E. Smith
    • 3
  • Hui-Ping Hsu
    • 5
  • Pin-Wen Lin
    • 5
  • Christian Bloechle
    • 6
  • Karl-Joseph Paquet
    • 7
  • Gordon H. Guyatt
    • 1
    • 2
  1. 1.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamilton, OntarioCanada
  2. 2.Department of MedicineMcMaster UniversityHamiltonCanada
  3. 3.Department of SurgeryUniversity of Western Ontario, University HospitalLondonCanada
  4. 4.Basel Institute for Clinical EpidemiologyUniversity Hospital BaselBaselSwitzerland
  5. 5.Department of SurgeryNational Cheng Kung University HospitalTainanTaiwan
  6. 6.Department of SurgeryUniversity Hospital EppendorfHamburgGermany
  7. 7.Department of SurgeryHeinz Kalk-HospitalBad KissingenGermany

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