Comparison of the stomach-preserving versus classic 'Whipple' operation for people with cancer of the pancreas or the periampullary region

Review question

It is unclear whether the pylorus-preserving Whipple procedure results in a higher rate of recurrence of the tumour because it is less extensive and therefore may be less radical, but it is also unknown whether quality of life is decreased after removal of the lower portion of the stomach. Another uncertainty is whether the two methods are associated with different rates or types of complications.


Pancreatic cancer is a leading cause of cancer death. Two surgical procedures can lead to a cure: the classic Whipple operation, in which part of the pancreas, the gallbladder, the duodenum, the pylorus (outlet of the stomach), and the distal (lower) part of the stomach are removed, and the so-called pylorus-preserving pancreaticoduodenectomy, or pylorus-preserving Whipple operation, in which the stomach and the pylorus are not removed.

Study characteristics

We included eight randomised controlled trials with a total of 512 participants in this review. The included trials revealed vast differences in sample size as well as clinical and methodological quality.

Key results

We could identify no relevant differences in terms of main complications, long-term survival, or death due to complications after the operation, but operating time, intraoperative blood loss, and need for blood transfusion seem to be less frequent in the group treated with the pylorus-preserving Whipple operation. Our conclusion is that, at present, no relevant difference is evident between the two surgical procedures for the treatment of pancreatic or periampullary cancer.

Quality of the evidence

The quality of the body of evidence is still low since all trials revealed some shortcomings in terms of methodological quality or reporting.

Authors' conclusions: 

Current evidence suggests no relevant differences in mortality, morbidity, and survival between the two operations. However, some perioperative outcome measures significantly favour the PPW procedure. Given obvious clinical and methodological heterogeneity, future high-quality RCTs of complex surgical interventions based on well-defined outcome parameters are required.

Read the full abstract...

Pancreatic cancer is the fourth-leading cause of cancer death for both, men and women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, postoperative mortality, complications, and quality of life.


The objective of this systematic review was to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region.

Search strategy: 

We conducted searches on 28 March 2006, 11 January 2011, 9 January 2014, and 18 August 2015 to identify all randomised controlled trials (RCTs), while applying no language restrictions. We searched the following electronic databases on 18 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) from the Cochrane Library (2015, Issue 8); MEDLINE (1946 to August 2015); and EMBASE (1980 to August 2015). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010); we did not update this part of the search for the 2014 and 2015 updates because the prior searches did not contribute any additional information. We identified two additional trials through the updated search in 2015.

Selection criteria: 

RCTs comparing CW versus PPW including participants with periampullary or pancreatic carcinoma.

Data collection and analysis: 

Two review authors independently extracted data from the included trials. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs), and used hazard ratios (HRs) for meta-analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included trials according to the standards of The Cochrane Collaboration.

Main results: 

We included eight RCTs with a total of 512 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Postoperative mortality (OR 0.64, 95% confidence interval (CI) 0.26 to 1.54; P = 0.32), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P = 0.29), and morbidity showed no significant differences, except of delayed gastric emptying, which significantly favoured CW (OR 3.03, 95% CI 1.05 to 8.70; P = 0.04). Furthermore, we noted that operating time (MD -45.22 minutes, 95% CI -74.67 to -15.78; P = 0.003), intraoperative blood loss (MD -0.32 L, 95% CI -0.62 to -0.03; P = 0.03), and red blood cell transfusion (MD -0.47 units, 95% CI -0.86 to -0.07; P = 0.02) were significantly reduced in the PPW group. All significant results were associated with low-quality evidence based on GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria.