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Pancreaticojejunostomy is comparable to pancreaticogastrostomy after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials

  • Systematic Reviews and Meta-analyses
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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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Acknowledgments

There are no sources of financial support.

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.

Author information

Authors and Affiliations

  1. Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Vita e Salute University, Via Olgettina 60, 20132, Milan, Italy

    Stefano Crippa, Stefano Partelli & Massimo Falconi

  2. Department of General and Oncologic Surgery, St. Maria Hospital, University of Perugia, Terni, Italy

    Roberto Cirocchi

  3. Mercer University, Tift College of Education, Atlanta, GA, USA

    Justus Randolph

  4. Department of Surgery, Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy

    Giulio Belfiori & Alessandra Piccioli

  5. Department of Digestive and Liver Surgery Unit, St. Maria Hospital, Terni, Italy

    Amilcare Parisi

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  1. Stefano Crippa
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Corresponding author

Correspondence to Massimo Falconi.

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Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Fig. 1

Risk of bias graph (GIF 31 kb)

High resolution (TIF 1839 kb)

Supplementary Fig. 2

Risk of bias summary (GIF 41 kb)

High resolution (TIF 1351 kb)

Supplementary Fig. 3

All types PG versus all types PJ, forest plot for postoperative mortality (GIF 17 kb)

High resolution (TIF 1771 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)

High resolution (TIF 1601 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)

High resolution (TIF 2503 kb)

Supplementary Fig. 6

All types PG versus all types PJ, forest plot for postoperative morbidity (GIF 19 kb)

High resolution (TIF 1469 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)

High resolution (TIF 1870 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)

High resolution (TIF 2430 kb)

Supplementary Fig. 9

All types PG versus all types PJ, forest plot for gastrointestinal (intra-luminal) bleeding (GIF 3 kb)

High resolution (TIF 3117 kb)

Supplementary Fig. 10

All types PG versus all types PJ, forest plot for intra-peritoneal bleeding (GIF 3 kb)

High resolution (TIF 3248 kb)

Supplementary Fig. 11

All types PG versus all types PJ, forest plot for intra-abdominal sepsis (GIF 3 kb)

High resolution (TIF 2796 kb)

Supplementary Fig. 12

All types PG versus all types PJ, forest plot for operative time (GIF 48 kb)

High resolution (TIF 7064 kb)

Supplementary Fig. 13

All types PG versus all types PJ, forest plot for reoperation (GIF 18 kb)

High resolution (TIF 1905 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

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