title: The impact of internal or external transanastomotic pancreatic duct stents following pancreaticojejunostomy. Which one is better? A meta-analysis.
abstract: BACKGROUND
  The use of pancreatic duct stent to improve postoperative outcomes of pancreatic anastomosis remains a matter of debate, and the value of stenting when performing anastomosis for normal pancreas (soft and duct less than 3 mm) needs further study. The aim of the present meta-analysis was to evaluate the perioperative outcomes of patients with stenting during pancreatic anastomosis and compare the effect of external stent with that of internal stent indirectly.
  
  
  METHODS
  A systematic literature search (EMBASE, MEDLINE, PubMed, The Cochrane Library, and Web of Science) was performed to identify studies evaluating external stent or internal stent. Included literature was assessed and extracted by two independent reviewers. A meta-analysis including comparative studies providing data on patients with and without external stenting or internal stenting during pancreaticojejunostomy anastomosis was performed.
  
  
  RESULTS
  Thirteen articles including 1,867 patients were identified for inclusion: five randomized controlled trials study and eight observational clinical studies. Meta-analyses revealed that use of external stent was associated with a significantly decreased risk for pancreatic fistula in total (odds ratio (OR) 0.47; 95 % confidence interval (CI) 0.31-0.71; P = 0.0004; I (2) = 3 %), pancreatic fistula in normal pancreas(OR 0.5; 95 % CI 0.30-0.82; P = 0.007; I (2) = 5 %), and overall morbidity(OR 0.64; 95 % CI 0.45-0.90; P = 0.01; I (2) = 0 %); however, the meta-analysis showed that there were no significant differences between internal stenting and non-stenting groups as regards perioperative outcomes and that in fact it may increase pancreatic fistula rate in normal pancreas(OR 1.97; 95 % CI 1.05-3.69; P = 0.03; I (2) = 0 %).
  
  
  CONCLUSIONS
  The results of this analysis demonstrate a trend toward reduced pancreatic fistula with the use of external pancreatic stents in pancreaticojejunostomy. An internal stent does not impact development of fistula and that in fact it was not useful in a soft pancreas. Our conclusion may be limited to stenting during the duct-to-mucosa pancreaticojejunostomy anastomosis, and the value of stenting during invagination anastomosis needs further study.
authors.affiliation: Department of Hepatobiliary Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan-Jiang Xi Road, GuangZhou, 510120, China.
authors.forename: Yu
authors.initials: Y
authors.lastname: Zhou
authors.forename: Quanbo
authors.initials: Q
authors.lastname: Zhou
authors.forename: Zhihua
authors.initials: Z
authors.lastname: Li
authors.forename: Qing
authors.initials: Q
authors.lastname: Lin
authors.forename: Yuanfeng
authors.initials: Y
authors.lastname: Gong
authors.forename: Rufu
authors.initials: R
authors.lastname: Chen
mesh_terms: D000714:Anastomosis, Surgical; D006801:Humans; D010183:Pancreatic Ducts / Q000601:surgery*; D010193:Pancreaticojejunostomy; D015607:Stents; D016896:Treatment Outcome