Comparison of bowel reconstruction routes after partial surgical removal of the pancreas and duodenum (first part of the small intestine)

Background

The pancreas is a digestive gland situated in the upper abdomen, which is also vital to normal control of blood sugar. Pancreatic cancer is one of the leading causes of cancer death in industrialized nations. The standard surgical treatment for cancer of the head of the gland and precancerous abnormalities is partial removal of the pancreas, together with the attached duodenum, known as a pancreaticoduodenectomy. Removal of the duodenum requires the restoration of the digestive pathway from the stomach to the rest of the gut. This can be accomplished by joining it to the jejunum (second part of the small intestine) either in front of (antecolic) or behind (retrocolic) the overlying large intestine (transverse colon).

Review question

It is unclear whether one of these two routes of reconstruction provides a benefit to the patient by reducing delayed gastric emptying (emptying of the stomach after ingestion of food); postoperative mortality (death); and other complications, such as pancreatic fistula (leakage of pancreatic juice), reoperation, perioperative measures (before, during, and after the operation), or length of hospital stay; and improving quality of life. Delayed gastric emptying was the primary outcome of this review because it is one of the most frequent complications after a pancreaticoduodenectomy; it can make it difficult to take anything by mouth and interferes with the patient’s quality of life, often resulting in a prolonged hospital stay and delay of further treatment.

Study characteristics

We included six randomised controlled trials (reported in nine publications), reporting data on a total of 576 adult participants, who underwent pancreaticoduodenectomy for any pancreatic disease. The evidence is current to September 2015.

Key results

We did not identify significant differences in delayed gastric emptying; postoperative mortality; postoperative pancreatic fistula, or other complications; reoperations; or length of hospital stay. Quality of life, only reported for a subset of participants in one trial, did not differ between the two groups. Our results do not suggest any relevant differences between antecolic and retrocolic reconstruction of the gastro- or duodenojejunostomy after partial pancreaticoduodenectomy.

Quality of evidence

The quality of the evidence was only low to moderate, due to clinical and statistical differences between individual trials, and risk of bias, due to shortcomings in the way the trials were conducted. Therefore, the results should be viewed with caution.

Authors' conclusions: 

There was low to moderate quality evidence suggesting no significant differences in morbidity, mortality, length of hospital stay, or quality of life between antecolic and retrocolic reconstruction routes for gastro- or duodenojejunostomy. Due to heterogeneity in definitions of the endpoints between trials, and differences in postoperative management, future research should be based on clearly defined endpoints and standardised perioperative management, to potentially elucidate differences between these two procedures. Novel strategies should be evaluated for prophylaxis and treatment of common complications, such as delayed gastric emptying.

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Background: 

Pancreatic cancer remains one of the five leading causes of cancer deaths in industrialized nations. For adenocarcinomas in the head of the gland and premalignant lesions, partial pancreaticoduodenectomy represents the standard treatment for resectable tumours. The gastro- or duodenojejunostomy after partial pancreaticoduodenectomy can be reestablished via either an antecolic or a retrocolic route. The debate about the more favourable technique for bowel reconstruction is ongoing.

Objectives: 

To compare the effectiveness and safety of antecolic and retrocolic gastro- or duodenojejunostomy after partial pancreaticoduodenectomy.

Search strategy: 

We conducted a systematic literature search on 29 September 2015 to identify all randomised controlled trials in the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library 2015, issue 9, MEDLINE (1946 to September 2015), and EMBASE (1974 to September 2015). We applied no language restrictions. We handsearched reference lists of identified trials to identify further relevant trials, and searched the trial registry clinicaltrials.gov for ongoing trials.

Selection criteria: 

We considered all randomised controlled trials that compared antecolic versus retrocolic reconstruction of bowel continuity after partial pancreaticoduodenectomy for any given indication to be eligible.

Data collection and analysis: 

Two review authors independently screened the identified references and extracted data from the included trials. The same two review authors independently assessed risk of bias of included trials, according to standard Cochrane methodology. We used a random-effects model to pool the results of the individual trials in a meta-analysis. We used odds ratios to compare binary outcomes and mean differences for continuous outcomes.

Main results: 

Of a total of 216 citations identified by the systematic literature search, we included six randomised controlled trials (reported in nine publications), with a total of 576 participants. We identified a moderate heterogeneity of methodological quality and risk of bias of the included trials. None of the pooled results for our main outcomes of interest showed significant differences: delayed gastric emptying (OR 0.60; 95% CI 0.31 to 1.18; P = 0.14), mortality (RD -0.01; 95% CI -0.03 to 0.02; P = 0.72), postoperative pancreatic fistula (OR 0.98; 95% CI 0.65 to 1.47; P = 0.92), postoperative haemorrhage (OR 0.79; 95% CI 0.38 to 1.65; P = 0.53), intra-abdominal abscess (OR 0.93; 95% CI 0.52 to 1.67; P = 0.82), bile leakage (OR 0.89; 95% CI 0.36 to 2.15; P = 0.79), reoperation rate (OR 0.59; 95% CI 0.27 to 1.31; P = 0.20), and length of hospital stay (MD -0.67; 95%CI -2.85 to 1.51; P = 0.55). Furthermore, the perioperative outcomes duration of operation, intraoperative blood loss and time to NGT removal showed no relevant differences. Only one trial reported quality of life, on a subgroup of participants, also without a significant difference between the two groups at any time point. The overall quality of the evidence was only low to moderate, due to heterogeneity, some inconsistency and risk of bias in the included trials.

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