Clinical surgery–international
Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis

https://doi.org/10.1016/j.amjsurg.2006.10.010Get rights and content

Abstract

Objective

Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreaticoduodenectomy (PD). The ideal choice of anastomosis remains a matter of debate.

Data Sources

Articles published until end of March 2006 comparing PJ and PG after PD were searched.

Study Selection

Two reviewers independently assessed quality and eligibility of the studies and extracted data for further analysis. Meta-analysis was performed with a random-effects model by using weighted odds ratios.

Data Extraction and Synthesis

Sixteen articles were included; meta-analysis of 3 randomized controlled trials (RCT) revealed no significant difference between PJ and PG regarding overall postoperative complications, pancreatic fistula, intra-abdominal fluid collection, or mortality. On the contrary, analysis of 13 nonrandomized observational clinical studies (OCSs) showed significant results in favor of PG for the outcome parameters with a reduction of pancreatic fistula and mortality in favor of PG.

Conclusions

All OCSs reported superiority of PG over PJ, most likely influenced by publication bias. In contrast, all RCTs failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally good results. This meta-analysis yet again highlights the singular importance of performing well-designed RCTs and the role of evidence-based medicine in guiding modern surgical practice.

Section snippets

Search strategy

A systematic literature search was conducted independently by 2 authors (MNW, SVS) using the methods of the Cochrane collaboration [6]. The authors searched the National Library of Medicine (Medline; www.pubmed.org; 1966 to March Week 3 2006) and the Cochrane Database of Controlled Clinical Trials (www.cochrane.org). The search strategy was setup by using a combination of text words combined with a MeSH (Medical Subject Headings) database search (Table 1). In addition, the reference lists of

Excluded studies

The initial search strategy retrieved 1330 publications; after screening all titles and abstracts, overall 36 full papers were captured, of which 20 were excluded because of missing inclusion criteria and because they did not cover the comparison of the reconstruction methods following PD (Appendix 1). Thus, 16 full articles were retrieved for more detailed evaluation (Fig. 1).

Included studies

Overall, 16 articles with 2,150 patients (3 RCTs [13], [14], [15], n = 445 patients, Table 2,Appendix 2; 13 OCSs [16],

Comments

Management of the pancreatic remnant is perhaps the most difficult of tasks after a PD. To avoid complications after this demanding surgery, several methods and techniques of pancreatic anastomosis have been proposed. The variety of studies in the literature is a reflection of the lack of agreement over a particular method of management, and this only adds to the existing confusion. Therefore, the accumulated knowledge from this pool of information needed scientific evaluation to establish the

Addendum

While this article was in the review process in August 2006 a similar article by McKay et al [53] appeared in the British Journal of Surgery. However, this other meta-analysis did not take into account the most recently published randomized controlled trials and, therefore, came to different conclusions than this meta-analysis.

Acknowledgments

All authors had full access to all of the data in the study. The first 2 authors take responsibility for the integrity of the data and the accuracy of the data analysis.

References (53)

  • C. Fernandez-del Castillo et al.

    Standards for pancreatic resection in the 1990s

    Arch Surg

    (1995)
  • C.J. Yeo et al.

    Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes

    Ann Surg

    (1997)
  • M.W. Buchler et al.

    Pancreatic fistula after pancreatic head resection

    Br J Surg

    (2000)
  • R.B. Haynes et al.

    Developing optimal search strategies for detecting clinically sound studies in MEDLINE

    J Am Med Inform Assoc

    (1994)
  • D. Moher et al.

    Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement

    Br J Surg

    (2000)
  • D.F. Stroup et al.

    Meta-analysis of observational studies in epidemiology: a proposal for reportingMeta-analysis Of Observational Studies in Epidemiology (MOOSE) group

    JAMA

    (2000)
  • J.P. Higgins et al.

    Quantifiying heterogeneity in meta-analysis

    Stat Med

    (2002)
  • D.L. Demets

    Methods for combining randomized clinical trials: strengths and limitations

    Stat Med

    (1987)
  • J. Sterne et al.

    Investigating and dealing with publication and other biases in meta-analysis

    BMJ

    (2001)
  • C.J. Yeo et al.

    A prospective randomized trial of pancreaticogastrostomy versus pancreaticojejunostomy after pancreaticoduodenectomy

    Ann Surg

    (1995)
  • C. Bassi et al.

    Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study

    Ann Surg

    (2005)
  • H. Ramesh et al.

    Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy

    Aust N Z J Surg

    (1990)
  • S. Miyagawa et al.

    A retrospective comparative study of reconstructive methods following pancreaticoduodenectomy–pancreaticojejunostomy vs. pancreaticogastrostomy

    Hepatogastroenterology

    (1992)
  • A.K. Gvalani

    Pancreaticogastrostomy versus pancreaticojejunostomy following pancreaticoduodenectomy for periampullary carcinoma

    Indian J Gastroenterol

    (1996)
  • S.W. Kim et al.

    Comparison of pancreatogastrostomy and pancreatojejunostomy after pancreatoduodenectomy performed by one surgeon

    World J Surg

    (1997)
  • J.P. Arnaud et al.

    Pancreaticogastrostomy compared with pancreaticojejunostomy after pancreaticoduodenectomy

    Eur J Surg

    (1999)

    • Cited by (0)

    View full text
    Copyright © 2007 Excerpta Medica Inc. All rights reserved.