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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

¹ Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main St. W, Hamilton, Ontario, L85 3Z5, Canada
² Department of Medicine, McMaster University, Hamilton, Canada
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
⁴ Basel Institute for Clinical Epidemiology, University Hospital Basel, Habelstasse 10, 3rd floor, Basel, Ch-4031, Switzerland
⁵ Department of Surgery, National Cheng Kung University Hospital, No. 138, Sheng-Li road, Tainan, 704, Taiwan
⁶ Department of Surgery, University Hospital Eppendorf, Martinistrasse 52, Hamburg, D-20246, Germany
⁷ Department of Surgery, Heinz Kalk-Hospital, Bad Kissingen, D-8730, Germany

Correspondence: Address correspondence and reprint requests to: Paul J. Karanicolas, MD; E-mail: pjkarani{at}uwo.ca

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 We included published and unpublished randomized controlled trials.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.

Key Words: Pancreatic cancer • Pancreaticoduodenectomy • Whipple procedure • Pylorus • Systematic review • Meta-analysis

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