Attachment to the jejunum versus stomach for the reconstruction of pancreatic stump following pancreaticoduodenectomy (‘Whipple’ operation)

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Authors: 
Cheng Y, Briarava M, Lai M, Wang X, Tu B, Cheng N, Gong J, Yuan Y, Pilati P, Mocellin S

Review question

Is pancreaticogastrostomy (PG, a surgery to join the pancreas to the stomach) better than pancreaticojejunostomy (PJ, a surgery to join the pancreas to the bowel) in terms of postoperative pancreatic fistula after a 'Whipple' operation (a major surgical operation involving the pancreas, duodenum, and other organs)?

Background

Pancreatoduodenectomy ('Whipple' operation) is a surgical procedure to treat diseases (most often cancer) of the pancreatic head, and sometimes, the duodenum. In a Whipple operation, the pancreas is detached from the gut then reconnected to enable pancreatic juice containing digestive enzymes to enter the digestive system. A common complication following Whipple surgery is pancreatic fistula, which occurs when the reconnection does not heal properly, leading to pancreatic juice leaking from the pancreas to abdominal tissues. This delays recovery from surgery and often requires further treatment to ensure complete healing. PJ and PG are surgical procedures often used to reconstruct the pancreatic stump after Whipple surgery and both procedures are burdened by a non-negligible rate of postoperative pancreatic fistula. It is unclear which procedure is better.

Search date

We searched up to September 2016.

Study characteristics

We included 10 randomized controlled studies (1629 participants) that compared PJ and PG in people undergoing Whipple surgery. The studies' features were adequate to make feasible and the planned comparison between the two surgical techniques. The primary outcomes were pancreatic fistula and death. Secondary outcomes were duration of hospitalization, surgical re-intervention, overall complications, bleeding, abdominal abscess, quality of life, and costs.

Key results

We could not demonstrate that one surgical procedure is better than the other. PJ may have little or no difference from PG in overall postoperative pancreatic fistula rate (PJ 24.3%; PG 21.4%), duration of hospitalization, or need for surgical re-intervention (11.6% versus 10.3%). Only seven studies clearly distinguished clinically significant pancreatic fistula which required a change in the patient's management. We are uncertain whether PJ improves the risk of clinically significant pancreatic fistula when compared with PG (19.3% versus 12.8%). PJ probably has little or no difference from PG in rates of death (3.9% versus 4.8%) or complications (46.5% versus 44.5%). The risk of postoperative bleeding in participants undergoing PJ was slightly lower than those undergoing PG (9.3% versus 13.8%), but this benefit appeared to be balanced with a higher risk of developing an abdominal abscess in PJ participants (14.7% versus 8.0%). Only one study reported quality of life; PG may be better than PJ in some quality of life parameters. Cost data were not reported in any studies.

Quality of the evidence

Most studies had flaws in methodological quality, reporting or both. Overall, the quality of evidence was low.

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