Does antecolic reconstruction for duodenojejunostomy improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? A systematic review and meta-analysis

Table 1 General characteristics of the included studies

Ref.	Country	Study period	Design	Group	Patients	M/F	Mean age (yr)	Etiology of malignancy	Quality score
Kurosaki et al[16]	Japan	1996-2002	N-RCT	AG	25	13/12	651	25 (100)	1
				RG	19	10/9	611	17 (89.5)
Hartel et al[18]	Germany	1996-2003	N-RCT	AG	100	41/59	61 (53-71)2	70 (70)	2
				RG	100	46/54	65 (53-74)2	75 (75)
Murakami et al[17]	Japan	1994-2006	N-RCT	AG	78	46/32	67 ± 11	49 (62.8)	2
				RG	20	10/10	66.7 ± 12.2	16 (80)
Tani et al[19]	Japan	2002-2004	RCT	AG	20	11/9	63.1 ± 9.21	16 (80)	3
				RG	54	36/18	64 ± 12	39 (72.2)
Chijiiwa et al[20]	Japan	2005-2007	RCT	AG	17	11/6	69.7 ± 11.0	12 (70.6)	2
				RG	18	9/9	66.9 ± 12.9	16 (88.9)

¹Medians;

²medians with ranges in parentheses. RCT: Randomized controlled trial; N-RCT: Non-randomized controlled trial; AG: Antecolic group; RG: Retrocolic group; M/F: Male/female.

Table 2 Surgical reconstruction, definition of delayed gastric emptying and postoperative management

Ref.	Group	Reconstruction			Definition of DGE	Indication for removing NGT	SSA	Antacid	PA
Kurosaki et al[16]	AG	II	E-T-S PJ	E-T-S DJ	(1) NGT ≥ POD 10; (2) reinsertion of NGT	Aspiration < 200 mL/d	NM	NM	NM
	RG	I	E-T-S PJ or PG	E-T-E DJ
Hartel et al[18]	AG	II	E-T-S PG	E-T-S DJ	(1) NGT ≥ POD 10; (2) inability to tolerate a solid diet ≤ POD 14	Aspiration < 500 mL/d	No	H2 blocker	NM
	RG	I		E-T-E DJ
Murakami et al[17]	AG	II	E-T-S PJ	E-T-S DJ	(1) NGT ≥ POD 10; (2) inability to tolerate regular diet ≤ POD 10; (3) vomiting ≥ 3 consecutive days after POD 5; (4) radiographic passage with water-soluble contrast medium revealing a holdup of the contrast medium in the stomach	(1) After tracheal extubation; (2) Aspiration of reintubation < 200 mL/d	Yes	PPI	Yes
	RG
Tani et al[19]	AG	II	E-T-S PJ	E-T-S DJ	(1) aspiration > 500 mL/d from NGT left ≥POD 10; (2) reinsertion of NGT; (3) failure of unlimited oral intake by POD 14	Aspiration < 500 mL/d	No	H2 blocker	No
	RG
Chijiiwa et al[20]	AG	II	E-T-S PJ	E-T-S DJ	(1) NGT ≥ POD 10; (2) reinsertion of NGT; (3) inability to tolerate an appropriate amount solid food ≤ POD 14	NM	NM	H2 blocker	No
	RG

AG: Antecolic group; RG: Retrocolic group; I, II: Billroth I and Billroth II; E-T-S: End-to-side; E-T-E: End-to-end; PJ: Pancreaticojejunostomy; PG: Pancreaticogastrostomy; DJ: Duodenojejunostomy; POD: Postoperative day; DGE: Delayed gastric emptying; NGT: Nasogastric tube; NM: Not mentioned; SSA: Somatostatin analogues; PPI: Proton pump inhibitors; PA: Prokinetic agents.

Table 3 Postoperative complications and antecolic vs retrocolic reconstruction for duodenojejunostomy

Complications	Number of studies	Number of patients		OR	95% CI	P value	Heterogeneity (I2)
		AG	RG
Pancreatic fistula	5[14-17,19]	10/240	8/211	1.00	0.40, 2.50	0.99	0%
Hemorrhage	4[14,16,17,19]	3/162	5/157	0.63	0.18, 2.29	0.49	0%
Intra-abdominal abscesses	4[14,16,17,19]	11/162	14/157	0.72	0.30, 1.72	0.46	0%
Bile leakage	3[14,17,19]	0/62	2/57	0.28	0.03, 2.77	0.27	0%
The anastomotic leakage	3[16,17,19]	0/137	2/138	0.2	0.01, 4.14	0.29	_
Wound infection	3[14,17,19]	5/62	4/57	1.21	0.31, 4.72	0.78	0%
Reoperation	3[14,16,17]	2/145	6/139	0.33	0.07, 1.48	0.15	0%

AG: Antecolic group; RG: Retrocolic group; OR: Odds ratio.

Table 4 Sensitivity analysis performed for studies comparing antecolic and retrocolic reconstruction for duodenojejunostomy

Outcome	Number of studies	Number of patients		OR/MD	95% CI	P value	Heterogeneity (I2)
		AG	RG
Randomized controlled trials
Delayed gastric emptying	2[17,19]	2/37	14/38	0.1	0.02, 0.47	0.004	0%
Mortality	2[17,19]	0/37	1/38	0.32	0.01, 8.26	0.49	_
Postoperative hospital stay (d)	2[17,19]	37	38	-7.4	-27.2, 12.40	0.46	79%
Non-randomized controlled trials
Morbidity	2[15,16]	26/178	49/154	0.33	0.19, 0.57	< 0.00 001	0%
Delayed gastric emptying	3[14,15,16]	15/203	82/173	0.05	0.01, 0.20	< 0.00 001	72%
Reconstruction with Billroth II in the two groups
Morbidity	2[16,19]	20/117	30/118	0.85	0.16, 4.69	0.86	79%
Delayed gastric emptying	3[16,17,19]	7/137	38/138	0.15	0.06, 0.34	< 0.00 001	0%
Mortality	3[16,17,19]	0/137	1/138	0.32	0.01, 8.26	0.49	_
Postoperative hospital stay (d)	2[17,19]	37	38	-7.4	-27.2, 12.40	0.46	79%
Reconstruction with Billroth II in AG and Billroth I in RG
Delayed gastric emptying	2[14,15]	10/103	58/73	0.03	0.01, 0.06	< 0.00 001	0%

AG: Antecolic group; RG: Retrocolic group; OR: Odds ratio; MD: Mean difference.