Abstract
Background
Pancreaticoduodenectomy/PD is a technically demanding pancreatic resection. Options of surgical reconstruction include (1) the child reconstruction defined as pancreatojejunostomy/PJ followed by hepaticojejunostomy/HJ and the gastrojejunostomy/GJ “the standard/s-Child,” (2) the s-child reconstruction with an additional Braun enteroenterostomy “BE-Child,” or (3) Isolated-Roux-En-Y-pancreaticojejunostomy “Iso-Roux-En-Y,” in which the pancreas anastomosis is reconstructed in a separate loop after the GJ. Yet, the impact of these reconstruction methods on patients’ outcome has not been sufficiently compared in a systematic manner.
Methods
A systematic review and meta-analysis were conducted according to the Preferred-Reporting-Items-for-Systematic-review-and-Meta-Analysis/PRISMA-guidelines by screening Pubmed/Medline, Scopus, Cochrane Library and Web-of-Science. Articles meeting predefined criteria were extracted and meta-analysis was performed.
Results
Nineteen studies were identified comparing BE-Child or Isolated-Roux-En-Y vs. s-Child. Compared to s-Child neither BE-Child (p = 0.43) nor Iso-Roux-En-Y (p = 0.94) displayed an impact on postoperative mortality, whereas BE-Child showed less postoperative complications (p = 0.02). BE-Child (p = 0.15) and Iso-Roux-En-Y (p = 0.61) did not affect postoperative pancreatic fistula/POPF in general, but BE-Child was associated with a decrease of clinically relevant POPF (p = 0.005), clinically relevant delayed gastric emptying/DGE B/C (p = 0.004), bile leaks (p = 0.01), and hospital stay (p = 0.06). BE-Child entailed also an increased operation time (p = 0.0002) with no impact on DGE A/B/C, hemorrhage, surgical site infections and pulmonary complications.
Conclusion
BE-Child is associated with a decreased risk for postoperative complications, particularly a decreased risk for clinically relevant DGE, POPF, and bile leaks, whereas Iso-Roux-En-Y does not seem to affect the clinical course after PD. Therefore, BE seems to be a valuable surgical method to improve patients’ outcome after PD.
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Acknowledgements
The authors are grateful to Dr. John Moir (The Newcastle upon Tyne Hospitals NHS Foundation Trust) for his contributions and the corrections of the manuscript.
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Study conception and design: SS, IED, DW, GOC, and HF. Acquisition of data: SS, IED, TV, RS, TV, LK, and DR. Analysis and interpretation of data: SS, IED, and DW. Drafting of manuscript: SS and IED. Critical revision of manuscript: SS, IED; TV, RS, DR, DW, HF, and GOC.
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Supplementary Fig. 1a-f
Sensitivity analysis of patients’ age and gender for postoperative complications, clinically relevant POPF and DGE of meta-analysis comparing BE-Child vs. s-Child. Studies, which provided sufficient information for the comparison of patients’ age and gender between BE-Child vs. s-Child, were eligible to be included in sensitivity analysis of postoperative complications, clinically relevant POPF and clinically relevant DGE. Only meta-analysis including more than 1 study were performed. Data were pooled using the Mantel–Haenszel random effects models and expressed as risk ratio with their corresponding 95%-CI and p value. M-H: Mantel–Haenszel model; CI: confidence interval (PNG 3388 kb)
Supplementary Fig. 2a-d
Sensitivity analysis of patients’ BMI and histology for postoperative complications, clinically relevant POPF and DGE of meta-analysis comparing BE-Child vs. s-Child. Studies, which provided sufficient information for the comparison of patients’ BMI and histology between BEChild vs. s-Child, were eligible to be included in sensitivity analysis of postoperative complications, clinically relevant POPF and clinically relevant DGE. Only meta-analysis including more than 1 study were performed. Data were pooled using the Mantel–Haenszel random effects models and expressed as risk ratio with their corresponding 95%-CI and p value. M-H: Mantel–Haenszel model; CI: confidence interval (PNG 2250 kb)
Supplementary Fig. 3a-g
Sensitivity analysis of pancreatic duct diameter, pancreas texture and type of anastomosis for postoperative complications, clinically relevant POPF and DGE of meta-analysis comparing BE-Child vs. s-Child. Studies, which provided sufficient information for the comparison of the mean pancreatic duct diameter, pancreatic duct diameter < 3 mm, soft pancreatic tissue and type of anastomosis of the pancreaticojejunostomy between BEChild vs. s-Child, were eligible to be included in sensitivity analysis of postoperative complications, clinically relevant POPF and clinically relevant DGE. Only meta-analysis including more than 1 study were performed. Data were pooled using the Mantel–Haenszel random effects models and expressed as risk ratio with their corresponding 95%-CI and p value. M-H: Mantel–Haenszel model; CI: confidence interval (PNG 3362 kb)
Supplementary Fig. 4a-c
Sensitivity analysis of age, BMI, biliary stenting, pancreatic duct diameter, pancreas texture, pathology and type of anastomosis for postoperative complications, clinically relevant POPF and DGE of meta-analysis comparing Iso-Roux-En-Y vs. s-Child. Studies, which provided sufficient information for patients’ age, BMI, biliary stenting, pancreatic duct diameter, pancreas texture, pathology and the type of anastomosis of the pancreaticojejunostomy between Iso-Roux-En-Y vs. s-Child, were eligible to be included in sensitivity analysis of postoperative complications, clinically relevant POPF and clinically relevant DGE. Only meta-analysis including more than 1 study were performed. Data were pooled using the Mantel–Haenszel random effects models and expressed as risk ratio with their corresponding 95%-CI and p value. M-H: Mantel–Haenszel model; CI: confidence interval (PNG 4064 kb)
Supplementary Fig. 5
BE as an independent protective factor for DGE. Multivariate odds ratio were extracted and pooled in meta-analyses using the Inverse Variance random effects model with their corresponding 95%-CI and p values. DGE: delayed gastric emptying; IV: inverse variance model; CI: confidence interval (PNG 748 kb)
Supplementary Fig. 6a-b
The effect of BE on mortality and postoperative complications in patients after PD and PPPD. Forrest plot of quantitative data comparing the incidence of mortality (a.) and postoperative complications (b.) between patients with BE-Child and s-Child. In this meta-analysis subgroup were introduced depending on PPPD or PD were performed. Data were pooled using the Mantel–Haenszel random effects models and expressed as risk ratio with their corresponding 95%-CI and p value. M-H: Mantel–Haenszel model; CI: confidence interval, PD: pancreaticoduodenectomy; PPPD: pylorus-preserving pancreaticoduodenectomy (PNG 1392 kb)
Supplementary Fig. 7
The effect of BE on POPF and DGE in patients after PD and PPPD. Forest plot of all kind of POPF (a.) and clinically relevant POPF according to ISGPS (b.) in patients after BEChild or s-Child depending on a PD or PPPD were performed. Data of DGE (c.) and clinically relevant DGE according to ISGPS (d) were pooled in comparative meta-analysis with patients undergoing BE-Child or s-Child. All data were pooled as risk ratio with their corresponding 95%-CI and p value using the Mantel–Haenszel model for random effects. POPF: postoperative pancreatic fistula; DGE; delayed gastric emptying; ISPGS: International Study Group for Pancreatic Surgery; M-H: Mantel–Haenszel model; CI: confidence interval, PD: pancreaticoduodenectomy; PPPD: pylorus-preserving pancreaticoduodenectomy (PNG 3768 kb)
Supplementary Fig. 8
The effect of Iso-Roux-En-Y on mortality and postoperative complications in patients after PD and PPPD. Forrest plot of quantitative data comparing the incidence of mortality (a.) and postoperative complications (b.) between patients with Iso-Roux-En-Y and s-Child. In this meta-analysis subgroup were introduced depending on PPPD or PD were performed. Data were pooled using the Mantel–Haenszel random effects models and expressed as risk ratio with their corresponding 95%-CI and p value. M-H: Mantel–Haenszel model; CI: confidence interval, PD: pancreaticoduodenectomy; PPPD: pylorus-preserving pancreaticoduodenectomy (PNG 1395 kb)
Supplementary Fig. 9
The effect of Iso-Roux-En-Y on POPF and DGE in patients after PD and PPPD. Forest plot of all kind of POPF (a.) and clinically relevant POPF according to ISGPS (b.) in patients after Iso- Roux-En-Y or s-Child depending on a PD or PPPD were performed. Data of DGE (c.) and clinically relevant DGE according to ISGPS (d) were pooled in comparative meta-analysis with patients undergoing Iso-Roux-En-Y or s- Child. All data were pooled as risk ratio with their corresponding 95%-CI and p value using the Mantel–Haenszel model for random effects. POPF: postoperative pancreatic fistula; DGE; delayed gastric emptying; ISPGS: International Study Group for Pancreatic Surgery; M-H: Mantel–Haenszel model; CI: confidence interval, PD: pancreaticoduodenectomy; PPPD: pylorus-preserving pancreaticoduodenectomy (PNG 3434 kb)
Supplemental Figure 10
Publication bias. According to the recommendation of the Cochrane Network, publication bias was analyzed in each meta-analysis containing at least 10 studies. Here, the Funnel plot as well as the Egger’s test could not detect any publication bias in the meta-analysis comparing postoperative mortality between BE-Child vs. Iso-Roux-En-Y. (PNG 384 kb)
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Schorn, S., Demir, I.E., Vogel, T. et al. Mortality and postoperative complications after different types of surgical reconstruction following pancreaticoduodenectomy—a systematic review with meta-analysis. Langenbecks Arch Surg 404, 141–157 (2019). https://doi.org/10.1007/s00423-019-01762-5
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DOI: https://doi.org/10.1007/s00423-019-01762-5