title: WITHDRAWN: Pancreaticoduodenectomy (classic Whipple) versus pylorus-preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma.
abstract: BACKGROUND
  Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours is either a classic Whipple operation or a pylorus-preserving pancreaticoduodenectomy. It is unclear which of the procedures is more favourable in terms of survival, mortality, complications and quality of life.
  
  
  OBJECTIVE
  Several publications have highlighted advantages and disadvantages of the two techniques and the current basis of evidence remains unclear. The objective of this systematic review is to compare the effectiveness of each operation.
  
  
  METHODS
  We conducted a search on 28/03/2006 to identify all RCTs, applying no language restriction.We searched the following electronic databases: CENTRAL, CDSR and DARE from The Cochrane Library (2006, issue 2), MEDLINE (1966 to 2006) and EMBASE (1980 to 2006). We handsearched abstracts from 1995 to 2006 from the American Digestive Disease Week (DDW), published in Gastroenterology, and the United European Gastroenterology Week (UEGW), published in Gut.
  
  
  METHODS
  We considered randomised controlled trials comparing the classic Whipple operation with pylorus-preserving pancreaticoduodenectomy to be eligible if they included patients with periampullary or pancreatic carcinoma.
  
  
  METHODS
  Two authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (OR), pooled continuous outcomes using weighted mean differences (WMD), and used hazard ratios (HR) for meta-analysis of survival. Two authors independently evaluated the methodological quality of included studies according to quality standards and by using a questionnaire.
  
  
  RESULTS
  We retrieved 1235 abstracts and checked these for eligibility, including seven randomised controlled trials. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. Our comparisons of in-hospital mortality (OR 0.49; 95% confidence interval (CI) 0.17 to 1.40; P = 0.18), overall survival (HR 0.84; 95% CI 0.61 to 1.16; P = 0.29) and morbidity showed no significant differences. However, we noted that operating time (WMD -68.26 minutes; 95% CI -105.70 to -30.83; P = 0.0004) and intra-operative blood loss (WMD -0.76 millilitres; 95% CI -0.96 to -0.56; P < 0.00001) were significantly reduced in the pylorus-preserving pancreaticoduodenectomy group.
  
  
  CONCLUSIONS
  There is no evidence of relevant differences in mortality, morbidity and survival between the two operations. Given obvious clinical and methodological heterogeneity, future research must be undertaken to perform high-quality randomised controlled trials of complex surgical interventions on the basis of well-defined outcome parameters.
authors.affiliation: Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, Germany, 69120.
authors.forename: Markus K
authors.initials: MK
authors.lastname: Diener
authors.forename: Christina
authors.initials: C
authors.lastname: Heukaeufer
authors.forename: Guido
authors.initials: G
authors.lastname: Schwarzer
authors.forename: Christoph M
authors.initials: CM
authors.lastname: Seiler
authors.forename: Gerd
authors.initials: G
authors.lastname: Antes
authors.forename: Hanns-Peter
authors.initials: HP
authors.lastname: Knaebel
authors.forename: Markus W
authors.initials: MW
authors.lastname: Büchler
mesh_terms: D014670:Ampulla of Vater / Q000601:surgery*; D003138:Common Bile Duct Neoplasms / Q000401:mortality / Q000601:surgery*; D005746:Gastric Emptying; D006801:Humans; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods* / Q000401:mortality; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic