Key messages
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Duct-to-mucosa pancreaticojejunostomy (attachment of the excretory duct of the pancreas to the bowel) may have little to no effect on leakage of juice from the pancreas to the abdominal tissues compared with invagination pancreaticojejunostomy (insertion of the pancreatic stump within the bowel), but we are very uncertain about the results. No studies looked at unwanted or harmful effects.
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We do not know whether a modified duct-to-mucosa pancreaticojejunostomy is better, equal to, or worse than the traditional duct-to-mucosa pancreaticojejunostomy.
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Future research is needed looking at the benefits and harms of duct-to-mucosa pancreaticojejunostomy compared to other types of pancreaticojejunostomy.
What is a postoperative pancreatic fistula?
The pancreas is a digestive gland located at the back of the upper abdomen that controls blood sugar. The standard surgical treatment for cancer or inflammation of the pancreas is partial removal of the head of the pancreas, together with the nearby gut, through an operation known as the Whipple procedure. The Whipple procedure involves pancreaticojejunostomy (reconnecting the pancreas and the bowel) to allow pancreatic juice containing digestive enzymes to enter the digestive system. A postoperative pancreatic fistula occurs when the reconnection does not heal properly, creating a leakage of pancreatic juice from the pancreas to the abdominal tissues. Postoperative pancreatic fistula is a complication that delays recovery from surgery and often requires further surgery to ensure complete healing.
What can we do to reduce postoperative pancreatic fistula?
Methods of reconnecting the pancreas and the bowel for people undergoing the Whipple procedure include:
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duct-to-mucosa pancreaticojejunostomy (attachment of the excretory duct of the pancreas to the bowel);
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invagination pancreaticojejunostomy (insertion of the pancreatic stump within the bowel);
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binding the pancreas and the bowel.
Duct-to-mucosa pancreaticojejunostomy is a method commonly used worldwide to reduce leakage of juice from the pancreas to the abdominal tissues after the Whipple procedure. However, the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy are still uncertain.
What did we want to find out?
We wanted to find out whether duct-to-mucosa pancreaticojejunostomy for people undergoing Whipple procedure is better than any other types of pancreaticojejunostomy to reduce:
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leakage of juice from the pancreas to the abdominal tissues;
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death rate;
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unwanted effects;
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re-operation rate;
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bleeding rate after surgery;
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overall complication rate; and
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length of hospital stay.
What did we do?
We searched for studies that compared duct-to-mucosa pancreaticojejunostomy against any other types of pancreaticojejunostomy or different types of duct-to-mucosa pancreaticojejunostomy after Whipple procedure. We compared and summarized the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found 14 studies (3 new to this update) involving 2140 adults undergoing open Whipple procedure. The studies ranged in size from 64 to 308 people and were conducted in countries around the world; most were done in China (four studies). Most studies lasted for approximately two years; only four studies lasted for four years or more. Five studies were funded by non-commercial grants.
Main results
We found 12 studies involving 1678 adults in which duct-to-mucosa pancreaticojejunostomy was compared with invagination pancreaticojejunostomy in people undergoing open Whipple procedure. Duct-to-mucosa pancreaticojejunostomy may have little to no effect on leakage of juice from the pancreas to the abdominal tissues, death rate, re-operation rate, bleeding rate after surgery, overall complication rate, and length of hospital stay compared with invagination pancreaticojejunostomy, but we are very uncertain about the results. No studies reported on unwanted effects.
We found two studies involving 462 adults in which a modified duct-to-mucosa pancreaticojejunostomy was compared with the traditional duct-to-mucosa pancreaticojejunostomy in people undergoing open Whipple procedure. We do not know whether a modified method reduces leakage of juice from the pancreas to the abdominal tissues, death rate, unwanted events, re-operation rate, bleeding rate after surgery, overall complication rate, or length of hospital stay.
What are the limitations of the evidence?
We have very little confidence in the evidence because most studies had problems with how they were conducted or reported.
How up-to-date is this evidence?
This review updates our previous review. The evidence is current to June 2024.
Vollständige Zusammenfassung lesen
Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain.
Zielsetzungen
To evaluate the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in people undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques.
Suchstrategie
We searched CENTRAL, MEDLINE, two other databases and three trials registers, together with reference checking, and contacted study authors to identify studies for inclusion in the review. The latest search date was 8 June 2024.
Auswahlkriterien
We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy.
Datensammlung und ‐analyse
Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes.
Hauptergebnisse
We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias.
Duct-to-mucosa versus any other type of pancreaticojejunostomy
We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes.
One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy
We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes.
Schlussfolgerungen der Autoren
For the comparison of duct-to-mucosa versus invagination pancreaticojejunostomy for adult participants undergoing open pancreaticoduodenectomy, duct-to-mucosa pancreaticojejunostomy may have little to no effect on any of the outcomes compared with invagination pancreaticojejunostomy, including rate of POPF (grade B or C), postoperative mortality, rate of surgical re-intervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay, but the evidence is very uncertain.
For the comparison of duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique versus duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique for adult participants undergoing open pancreaticoduodenectomy, data for all outcomes were sparse, and the certainty of the evidence is very low. We are thus unable to draw any conclusions about the effects of duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique.
The benefit of duct-to-mucosa pancreaticojejunostomy over other types of pancreaticojejunostomy remains unclear. From a clinical perspective, there is no high-certainty evidence of one type of duct-to-mucosa pancreaticojejunostomy being superior to other types of pancreaticojejunostomy, and hence surgeons should use their preferred techniques. Patients must be informed regarding this uncertainty and the experience of surgeons in the different methods, and be involved in decision-making.
Finanzierung
This Cochrane review was funded by the National Natural Science Foundation of China (Grant No. 81701950, 82172135), Natural Science Foundation of Chongqing (Grant No. CSTB2025NSCQ-GPX1128), Suitable Technology Promotion Project of Chongqing (Grant No. 2024jstg028), Joint Project of Pinnacle Disciplinary Group, and the Kuanren Talents Program of the second affiliated hospital of Chongqing Medical University.
Registrierung
Registration (2019): CRD42020169007
Protocol (2019): DOI 10.1002/14651858.CD013462
Original review (2022): DOI 10.1002/14651858.CD013462.pub2
