Pancreaticojejunostomy is comparable to pancreaticogastrostomy after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials.
OBJECTIVE
To perform an up-to-date meta-analysis of randomized controlled trials (RCTs) comparing pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) in order to determine the safer anastomotic technique. Compared to existing meta-analysis, new RCTs were evaluated and subgroup analyses of different anastomotic techniques were carried out.


METHODS
We conducted a bibliographic research using the National Library of Medicine's PubMed database from January 1990 to July 2015 of RCTs. Only RCTs, in English, that compared PG versus all types of PJ were selected. Data were independently extracted by two authors. We performed a quantitative systematic review following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A random-effect model was applied. Statistical heterogeneity was assessed using the I (2) and χ (2) tests. Primary outcomes were rate of overall and clinically significant pancreatic fistula (POPF).


RESULTS
Ten RCTs were identified including 1629 patients, 826 undergoing PG and 803 undergoing PJ. RCTs showed significant heterogeneity regarding definitions of POPF, perioperative management, and characteristics of pancreatic gland. No significant differences were found in the rate of overall and clinically significant POPF, morbidity, mortality, reoperation, and intra-abdominal sepsis when PG was compared with all types PJ or when subgroup analysis (double-layer PG with or without anterior gastrotomy versus duct to mucosa PJ and single-layer PG versus single-layer end-to-end/end-to-side PJ) were analyzed.


CONCLUSIONS
PG is not superior to PJ in the prevention of POPF. Current RCTs have major methodological limitations with significant heterogeneity in regard to surgical techniques, definition of POPF/complications, and perioperative management.
Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Vita e Salute University, Via Olgettina 60, 20132, Milan, Italy.
Stefano
S
Crippa
Department of General and Oncologic Surgery, St. Maria Hospital, University of Perugia, Terni, Italy.
Roberto
R
Cirocchi
Mercer University, Tift College of Education, Atlanta, GA, USA.
Justus
J
Randolph
Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Vita e Salute University, Via Olgettina 60, 20132, Milan, Italy.
Stefano
S
Partelli
Department of Surgery, Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy.
Giulio
G
Belfiori
Department of Surgery, Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy.
Alessandra
A
Piccioli
Department of Digestive and Liver Surgery Unit, St. Maria Hospital, Terni, Italy.
Amilcare
A
Parisi
Department of Surgery, Division of Pancreatic Surgery, San Raffaele Scientific Institute, Vita e Salute University, Via Olgettina 60, 20132, Milan, Italy. falconi.massimo@hsr.it.
Massimo
M
Falconi
D005774:Gastrostomy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D010185:Pancreatic Fistula / Q000453:epidemiology*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000379:methods; D010193:Pancreaticojejunostomy / Q000009:adverse effects* / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology*; D016032:Randomized Controlled Trials as Topic
Meta-analysis; Pancreatic fistula; Pancreaticogastrostomy; Pancreaticojejunostomy; Randomized trial