title: Is antisecretory therapy after pancreatoduodenectomy necessary? Meta-analysis and contemporary practices of pancreatic surgeons.
abstract: BACKGROUND
  Marginal ulcer (MU) is a well-described complication of pancreatoduodenectomy (PD) whose incidence remains unclear. Gastric antisecretory medications likely attenuate the risk of marginal ulceration after PD; however, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known. The aims of this study were to document the incidence of MU after PD, identify any relationship between MU and gastric antisecretory medication, and survey current practice of MU prophylaxis among experienced pancreatic surgeons.
  
  
  METHODS
  the MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials, and Cochrane Database of Systematic Reviews databases were searched from their inception to May 2014 for abstracts documenting ulceration after pancreatoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Contemporary practice was assessed through a four-question survey distributed globally to 200 established pancreatic surgeons.
  
  
  RESULTS
  After a review of 208 abstracts, 54 studies were graded as relevant. These represented a cohort of 212 patients with marginal ulcer after PD (n = 4794). A meta-analysis of the included references shows mean incidence of ulceration after PD of 2.5% (confidence interval (CI) 1.8-3.2%) with a median time to diagnosis of 15.5 months. Pylorus preservation was associated with a MU rate of 2.0% (CI 1.0-2.9%), while "classic" PD procedures report an overall rate of 2.6% (CI 1.6-3.6%). Documented use of postoperative antisecretory medication was associated with a reduced rate of 1.4% (CI 0.1-1.7%). One hundred forty-four of 200 (72%) surveys were returned, from which it was determined that 92% of pancreatic surgeons have dealt with this complication, and 86% routinely prescribe prophylactic antisecretory medication after PD.
  
  
  CONCLUSIONS
  The incidence of MU after PD is 2.5% with a median time to occurrence of 15.5 months postoperatively. Gastric antisecretory medication prescription may affect the incidence of MU. The majority of pancreatic surgeons surveyed have encountered MU after PD; most (86%) routinely prescribe prophylactic gastric antisecretory medication.
authors.affiliation: Department of Surgery, Indiana University School of Medicine-IU Health University Hospital, 550 N University Blvd #1295, Indianapolis, IN, 46202, USA.
authors.forename: James R
authors.initials: JR
authors.lastname: Butler
authors.forename: Tyrone
authors.initials: T
authors.lastname: Rogers
authors.forename: George
authors.initials: G
authors.lastname: Eckart
authors.forename: Gregory R
authors.initials: GR
authors.lastname: Martens
authors.forename: Eugene P
authors.initials: EP
authors.lastname: Ceppa
authors.forename: Michael G
authors.initials: MG
authors.lastname: House
authors.forename: Attila
authors.initials: A
authors.lastname: Nakeeb
authors.forename: C Max
authors.initials: CM
authors.lastname: Schmidt
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Zyromski
mesh_terms: D000897:Anti-Ulcer Agents / Q000627:therapeutic use*; D006635:Histamine H2 Antagonists / Q000627:therapeutic use; D006801:Humans; D015994:Incidence; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D010437:Peptic Ulcer / Q000453:epidemiology* / Q000517:prevention & control*; D010818:Practice Patterns, Physicians'; D054328:Proton Pump Inhibitors / Q000627:therapeutic use
chemical_list: D000897:Anti-Ulcer Agents; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors