Meta-analysis of invagination and duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: An update.
OBJECTIVE
Duct-to-mucosa and invagination are two commonly used techniques of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy. Previously, we conducted a systematic review comparing the safety and efficacy of the two PJ techniques. Here, we added new evidence and updated our previous conclusion.


METHODS
We systematically searched multiple databases and included randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination techniques of PJ. The quality of evidence was assessed using Jadad score, and reporting bias was evaluated using funnel plots. Meta-analysis was performed using a random-effects model. Risk ratio (RR) and 95% confidence interval (CI) were calculated. The primary outcome was pancreatic fistula, and the secondary outcomes included mortality, reoperation, morbidity and postoperative hospital stay. Trial sequential analysis was performed to calculate the required information size.


RESULTS
Seven RCTs with 850 participants were included. No significant difference was detected in the rates of pancreatic fistula (RR 0.98, 95% CI 0.63 to 1.53), mortality (RR 0.94, 95% CI 0.40 to 2.18), reoperation (RR 1.23, 95% CI 0.69 to 2.20) and morbidity (RR 0.98, 95% CI 0.82 to 1.16) between the two groups. However, patients who underwent duct-to-mucosa PJ had a significantly shorter postoperative hospital stay (mean difference -2.80, 95% CI -5.08 to -0.52). Trial sequential analysis showed that another 279 participants were needed for conclusive results.


CONCLUSIONS
Given the current evidence, duct-to-mucosa PJ did not decrease the rates of pancreatic fistula and other adverse events as compared to invagination PJ; however, it did reduce postoperative hospital stay. Further RCTs are needed.
Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of General Surgery, Huzhou Central Hospital, Zhejiang University Huzhou Hospital, Huzhou, China.
Xu
X
Sun
Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
Qi
Q
Zhang
Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
JingYing
J
Zhang
Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
Yu
Y
Lou
Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
QiHan
Q
Fu
The Second Department of General Surgery, People's Hospital of Kaihua, Quzhou, China.
XingLong
X
Zhang
Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
TingBo
T
Liang
Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China. Electronic address: shirleybai57@hotmail.com.
XueLi
X
Bai
D000714:Anastomosis, Surgical / Q000379:methods; D006801:Humans; D007413:Intestinal Mucosa / Q000601:surgery*; D007902:Length of Stay; D009026:Mortality; D010183:Pancreatic Ducts / Q000601:surgery*; D010185:Pancreatic Fistula / Q000453:epidemiology*; D016577:Pancreaticoduodenectomy; D010193:Pancreaticojejunostomy / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology*; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation; D012449:Safety
Complications; Pancreatic fistula; Systematic review; Trial sequential analysis