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

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.

Authors' conclusions: 

There is no reliable evidence to support the use of pancreatojejunostomy over pancreatogastrostomy. Future large international studies may shed new light on this field of investigation.

Read the full abstract...
Background: 

Pancreatoduodenectomy is a surgical procedure used to treat diseases of the pancreatic head and, less often, the duodenum. The most common disease treated is cancer, but pancreatoduodenectomy is also used for people with traumatic lesions and chronic pancreatitis. Following pancreatoduodenectomy, the pancreatic stump must be connected with the small bowel where pancreatic juice can play its role in food digestion. Pancreatojejunostomy (PJ) and pancreatogastrostomy (PG) are surgical procedures commonly used to reconstruct the pancreatic stump after pancreatoduodenectomy. Both of these procedures have a non-negligible rate of postoperative complications. Since it is unclear which procedure is better, there are currently no international guidelines on how to reconstruct the pancreatic stump after pancreatoduodenectomy, and the choice is based on the surgeon's personal preference.

Objectives: 

To assess the effects of pancreaticogastrostomy compared to pancreaticojejunostomy on postoperative pancreatic fistula in participants undergoing pancreaticoduodenectomy.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 9), Ovid MEDLINE (1946 to 30 September 2016), Ovid Embase (1974 to 30 September 2016) and CINAHL (1982 to 30 September 2016). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) and screened references of eligible articles and systematic reviews on this subject. There were no language or publication date restrictions.

Selection criteria: 

We included all randomized controlled trials (RCTs) assessing the clinical outcomes of PJ compared to PG in people undergoing pancreatoduodenectomy.

Data collection and analysis: 

We used standard methodological procedures expected by The Cochrane Collaboration. We performed descriptive analyses of the included RCTs for the primary (rate of postoperative pancreatic fistula and mortality) and secondary outcomes (length of hospital stay, rate of surgical re-intervention, overall rate of surgical complications, rate of postoperative bleeding, rate of intra-abdominal abscess, quality of life, cost analysis). We used a random-effects model for all analyses. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes (using PG as the reference) with 95% confidence intervals (CI) as a measure of variability.

Main results: 

We included 10 RCTs that enrolled a total of 1629 participants. The characteristics of all studies matched the requirements to compare the two types of surgical reconstruction following pancreatoduodenectomy. All studies reported incidence of postoperative pancreatic fistula (the main complication) and postoperative mortality.

Overall, the risk of bias in included studies was high; only one included study was assessed at low risk of bias.

There was little or no difference between PJ and PG in overall risk of postoperative pancreatic fistula (PJ 24.3%; PG 21.4%; RR 1.19, 95% CI 0.88 to 1.62; 7 studies; low-quality evidence). Inclusion of studies that clearly distinguished clinically significant pancreatic fistula resulted in us being uncertain whether PJ improved the risk of pancreatic fistula when compared with PG (19.3% versus 12.8%; RR 1.51, 95% CI 0.92 to 2.47; very low-quality evidence). PJ probably has little or no difference from PG in risk of postoperative mortality (3.9% versus 4.8%; RR 0.84, 95% CI 0.53 to 1.34; moderate-quality evidence).

We found low-quality evidence that PJ may differ little from PG in length of hospital stay (MD 1.04 days, 95% CI -1.18 to 3.27; 4 studies, N = 502) or risk of surgical re-intervention (11.6% versus 10.3%; RR 1.18, 95% CI 0.86 to 1.61; 7 studies, N = 1263). We found moderate-quality evidence suggesting little difference between PJ and PG in terms of risk of any surgical complication (46.5% versus 44.5%; RR 1.03, 95% CI 0.90 to 1.18; 9 studies, N = 1513). PJ may slightly improve the risk of postoperative bleeding (9.3% versus 13.8%; RR 0.69, 95% CI: 0.51 to 0.93; low-quality evidence; 8 studies, N = 1386), but may slightly worsen the risk of developing intra-abdominal abscess (14.7% versus 8.0%; RR 1.77, 95% CI 1.11 to 2.81; 7 studies, N = 1121; low quality evidence). Only one study reported quality of life (N = 320); PG may improve some quality of life parameters over PJ (low-quality evidence). No studies reported cost analysis data.

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