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The Pylorus: Take It or Leave It? Systematic Review and Meta-Analysis of Pylorus-Preserving versus Standard Whipple Pancreaticoduodenectomy for Pancreatic or Periampullary Cancer

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Abstract

Background

Our objective was to determine the relative effects of pylorus-preserving pancreaticoduodenectomy (PPPD) and standard Whipple pancreaticoduodenectomy (SWPD) in patients with pancreatic or periampullary cancer.

Methods

We searched seven bibliographic databases, conference proceedings, and reference lists of articles and textbooks, and we contacted experts in the field of hepatobiliary surgery. We included published and unpublished randomized controlled trials. We evaluated the methodological quality of trials and, in duplicate, extracted data regarding operative, perioperative, and long-term outcomes. We contacted all authors and asked them to provide additional information regarding the trials. We pooled results from the studies by using a random-effects model, evaluated the degree of heterogeneity, and explored potential explanations for heterogeneity.

Results

Six trials that included a total of 574 patients met eligibility criteria. In the pooled analysis, PPPD was 72 minutes faster (P < .001, 95% confidence interval [95% CI], 53–92), with 284 mL less blood loss (P < .001, 95% CI, 176–391) and .66 fewer units of blood transfused (P = .002, 95% CI, .25–1.16). Other perioperative and long-term outcomes did not statistically differ, although the confidence intervals include important differences.

Conclusions

Moderate-quality evidence suggests PPPD is a faster procedure with less blood loss compared with SWPD. Large absolute differences in other key outcomes are unlikely; excluding relatively small differences will, however, require larger, methodologically stronger trials.

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Acknowledgments

P.K. holds a Canada Graduate Scholarship from the Canadian Institutes of Health Research. M.B. is a scholar of the Swiss National Science Foundation.

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Authors and Affiliations

  1. Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main St. W, Hamilton, Ontario, L85 3Z5, Canada

    Paul J. Karanicolas MD, Matthias Briel MD, H. Pavan Koka MD, Darrin M. Payne MD & Gordon H. Guyatt MD, MSc

  2. Department of Medicine, McMaster University, Hamilton, Canada

    Gordon H. Guyatt MD, MSc

  3. Department of Surgery, University of Western Ontario, University Hospital, London Health Sciences Centre, Room C8-114, 339 Windermere Road, London, Ontario, N6A 5A5, Canada

    Paul J. Karanicolas MD, Edward Davies MD, H. Pavan Koka MD, Darrin M. Payne MD & Shona E. Smith MD

  4. Basel Institute for Clinical Epidemiology, University Hospital Basel, Habelstasse 10, 3rd floor, Basel, Ch-4031, Switzerland

    Regina Kunz MD, MSc & Matthias Briel MD

  5. Department of Surgery, National Cheng Kung University Hospital, No. 138, Sheng-Li road, Tainan, 704, Taiwan

    Hui-Ping Hsu MD & Pin-Wen Lin MD

  6. Department of Surgery, University Hospital Eppendorf, Martinistrasse 52, Hamburg, D-20246, Germany

    Christian Bloechle MD

  7. Department of Surgery, Heinz Kalk-Hospital, Bad Kissingen, D-8730, Germany

    Karl-Joseph Paquet MD

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  1. Paul J. Karanicolas MD
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  2. Edward Davies MD
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  3. Regina Kunz MD, MSc
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  9. Pin-Wen Lin MD
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  10. Christian Bloechle MD
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  12. Gordon H. Guyatt MD, MSc
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Correspondence to Paul J. Karanicolas MD.

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Karanicolas, P.J., Davies, E., Kunz, R. et al. The Pylorus: Take It or Leave It? Systematic Review and Meta-Analysis of Pylorus-Preserving versus Standard Whipple Pancreaticoduodenectomy for Pancreatic or Periampullary Cancer. Ann Surg Oncol 14, 1825–1834 (2007). https://doi.org/10.1245/s10434-006-9330-3

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