Meta-analysis of subtotal stomach-preserving pancreaticoduodenectomy vs pylorus preserving pancreaticoduodenectomy

Table 1 Characteristics of the included studies

Ref.	Country	Year	Design	Group	n	Sex (M/F)	Age1	Benign/malignant	Quality score
Hayashibe et al[17]	Japan	2007	Retro	PPPD	12	4/8	60.9 ± 8.5	0/12	1 (McKay)
				SSPPD	21	8/13	64.3 ± 9.5	1/20
Akizuki et al[27]	Japan	2008	PNR	PPPD	34	20/14 18/12	66 (28-78)	15/19	2 (McKay)
				SSPPD	30		65 (39-79)	4/26
Kurahara et al[28]	Japan	2010	Retro	PPPD	48	26/22 38/26	64.4	18/30	1 (McKay)
				SSPPD	64		66.8	11/53
Oida et al[30]	Japan	2011	Retro	PPPD	25	21/4	66.2 ± 4.7	0/25	1 (McKay)
				SSPPD	42	30/12	65.8 ± 5.8	0/42
Kawaiet al[29]	Japan	2011	RCT	PPPD	64	33/31 38/28	68 ± 9	12/52	3 (Jadad)
				SSPPD	66		67 ± 9	14/52
Fujii et al[31]	Japan	2012	Retro	PPPD	33	19/14	63.8 (35-83)	0/33	1 (McKay)
				SSPPD	56	28/28	64.6 (41-84)	0/56
Nanashima et al[33]	Japan	2013	Retro	PPPD	28	21/7	68 ± 8	7/21	1 (McKay)
				SSPPD	27	15/12	66 ± 12	5/22
Matsumoto et al[35]	Japan	2014	RCT	PPPD	50	29/21 35/15	66 ± 10	18/32	3 (Jadad)
				SSPPD	50		67 ± 9	21/29

¹Mean ± SD, standard deviation or Median and range. Retro: Retrospective observational study; PNR: Prospective nonrandomized observational study; RCT: Randomized controlled trial; SSPPD: Subtotal stomach-preserving pancreaticoduodenectomy; PPPD: Pylorus-preserving pancreaticoduodenectomy.

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

Ref.	Reconstruction	Definition of DGE	Indication for removing NGT	PPI	PA
Hayashibe et al[17]	Duct to mucosa and end-to-side pancreaticojejunostomy, end-to-side antecolic gastrojejunostomy, and side-to-side jejunojejunostomy (Braun anastomosis)	(1) NGT ≥ POD 10	Unknown	Unknown	Unknown
		(2) inability to tolerate a solid diet ≥ POD 14
Akizuki et al[27]	Duct-to-mucosa and end-to-side pancreaticojejunostomy,end duodenal (or stomach)-to-side jejunal, Braun anastomosis was made	(1) NGT ≥ POD 10	The fluid of NGT < 500 mL per night, generally removed on POD 1	Yes	Yes
		(2) inability to tolerate a solid diet ≥ POD 14
Kurahara et al[28]	End-to-side pancreaticogastrostomy with an internal stent, end-to-side duodenojejunostomy (PPPD) or gastrojejunostomy (SSPPD)	ISGPS	The fluid of NGT < 500 mL per night	Yes	Yes
Oida et al[30]	Pancreaticogastrostomy and end to end duodenojejunostomy (PPPD)	ISGPS	Unknown	Unknown	Unknown
	Pancreaticogastrostomy and end to end gastrojejunostomy (SSPPD)
Kawai et al[29]	Duct-to-mucosa, end-to-side pancreatojejunostomy with internal stent	ISGPS	All removed on POD 1	No	No
	Duodenojejunostomy (PPPD), gastrojejunostomy (SSPPD)
Fujii et al[31]	End-to-side pancreatojejunostomy and end-to-side antecolic gastrojejunostomy in SSPPD or a duodenojejunostomy in PPPD	ISGPS	Generally removed on POD 1, or on POD 2 if the fluid of NGT > 500 mL per night	Unknown	Unknown
Nanashima et al[33]	End-to-side with external stent pancreatojejunostomy	ISGPS	The fluid of the NGT < 300 mL per night	Yes	Unknown
Matsumoto et al[35]	End-to-side pancreatojejunostomy, end-to-side duodenojejunostomy (PPPD) and gastrojejunstomy (SSPPD)	ISGPS	The fluid of the NGT < 200 mL per night	Yes	Unknown

ISGPS: International Study Group on Pancreatic Surgery; SSPPD: Subtotal stomach-preserving pancreaticoduodenectomy; PPPD: Pylorus-preserving pancreaticoduodenectomy; POD: Postoperative day; DGE: Delayed gastric emptying; NGT: Nasogastric tube; SSA: Somatostatin analogues; PPI: Proton pump inhibitors; PA: Prokinetic agents.

Table 3 Summary results for studies comparing pylorus-preserving pancreaticoduodenectomy and subtotal stomach-preserving pancreaticoduodenectomy

Outcome of interest	No. ofstudies	No. ofpatients	OR/WMD = (95%CI)	P value	Heterogeneity P value	I2
Delayed gastric emptying	8	650	2.75 (1.75-4.30)	< 0.00001	0.10	43%
Operation time	8	650	-5.30 (-43.44-32.84)	0.79	0.0003	77%
Intraoperative blood loss	8	650	-217.70 [-429.77-(-5.63)]	0.04	0.004	68%
Pancreatic fistula	7	583	0.91 (0.56-1.49)	0.7	0.97	0%
Postoperative hemorrhage	5	461	0.51 (0.15-1.74)	0.29	0.95	0%
Intra-abdominal abscess	5	461	1.05 (0.54-2.05)	0.89	0.65	0%
Wound infection	5	394	0.88 (0.39-1.97)	0.75	0.88	0%
Time of start liquid diet	4	286	2.97 (-0.43-6.38)	0.09	0.001	82%
Time of start solid diet	4	316	3.69 (-0.46-7.83)	0.08	< 0.00001	91%
Time of nasogastric intubation	6	438	2.68 (0.77-4.58)	0.006	< 0.00001	96%
Reinsertion of nasogastric tube	4	349	1.90 (0.91-3.97)	0.09	0.58	0%
Mortality	6	471	0.31 (0.05-2.01)	0.22	1.00	0%
Hospital stay	4	255	3.92 (-0.37-8.22)	0.07	0.04	64%

WMD: Weight mean difference.

Table 4 Sensitivity analysis performed for studies comparing pylorus-preserving pancreaticoduodenectomy and subtotal stomach-preserving pancreaticoduodenectomy

Outcome of interest	No. of studies	No. of patients	OR (95%CI)	P value	HeterogeneityP value	I2
DGE with ISGPS definition
DGE (ISGPS B/C)	6	553	8.73 (2.09-36.56)	0.003	< 0.0001	82%
Operation time	6	553	6.50 (-35.02-48.02)	0.76	0.0005	80%
Intraoperative blood loss	6	553	0.78 (-81.90-83.46)	0.99	0.20	33%
Pancreatic fistula	5	486	0.92 (0.54-1.55)	0.75	0.93	0%
Postoperative hemorrhage	4	397	0.57 (0.15-2.16)	0.41	0.91	0%
Intraabdominal abscess	4	397	1.07 (0.53-2.18)	0.85	0.49	0%
Wound infection	3	297	1.18 (0.45-3.09)	0.74	0.98	0%
Time of start liquid diet	2	189	3.62 (-2.82-10.06)	0.27	0.03	80%
Time of start solid diet	3	252	4.77 (-0.11-9.64)	0.06	< 0.00001	94%
Time of nasogastric intubation	4	341	3.32 (0.31-6.32)	0.03	< 0.00001	97%
Reinsertion of nasogastric tube	3	285	2.15 (0.93-4.96)	0.07	0.44	0%
Mortality	4	374	0.32 (0.03-3.18)	0.33	0.97	0%
Hospital stay	3	222	5.96 (3.46-8.46)	< 0.00001	0.55	0%
DGE with other definition
DGE	2	97	2.29 (0.35-15.21)	0.39	0.11	61%
Operation time	2	97	-48.51 (-109. 22-12.20)	0.12	0.79	0%
Intraoperative blood loss	2	97	-588.29 [-898.10-(-278.49)]	0.0002	0.79	0%
Pancreatic fistula	2	97	0.86 (0.22-3.33)	0.83	-	-
Wound infection	2	97	0.44 (0.09-2.08)	0.30	0.88	0%
Time of start liquid diet	2	97	2.30 (-2.30-6.91)	0.33	0.006	87%
Time of NGD insertion	2	97	1.82 (-2.43-6.06)	0.40	0.02
Mortality	2	97	0.29 (0.01-7.26)	0.45	-	-
Hospital stay	2	97	0.17 (-2.77-3.11)	0.91	0.24	27%
Reconstruction with pancreaticojejunostomy
DGE	6	471	3.72 (2.12-6.56)	< 0.00001	0.18	35%
Operation time	6	471	-11.79 (-32.26-8.68)	0.26	0.21	30%
Intraoperative blood loss	6	471	-265.87 (-422.93-108.81)	0.0009	0.15	38%
Pancreatic fistula	6	471	0.90 (0.55-1.48)	0.67	0.94	0%
Postoperative hemorrhage	4	349	0.61 (0.16-2.38)	0.48	0.93	0%
Intra-abdominal abscess	4	349	1.06 (0.51-2.22)	0.88	0.48	0%
Wound infection	4	327	0.83 (0.34-2.03)	0.68	0.78	0%
Time of start solid diet	3	249	2.29 (-1.97-6.54)	0.29	0.06	64%
Time of nasogastric intubation	5	371	1.92 (0.38-3.47)	0.01	< 0.00001	89%
Hospital stay	3	188	1.23 (-1.64-4.09)	0.40	0.25	28%
Reconstruction with pancreaticogastrostomy
DGE	2	179	1.51 (0.70-3.26)	0.29	-	-
Operation time	2	179	49.00 (30.41-67.59)	< 0.00001	-	-
Intraoperative blood loss	2	179	41.00 (-51.78-133.78)	0.39	-	-
Randomized controlled trial
DGE	2	230	2.69 (1.17-6.17)	0.02	0.32	0%
Operation time	2	230	-16.69 (-42.68-9.30)	0.21	0.83	0%
Intraoperative blood loss	2	230	-120.23 (-364.94-124.48)	0.34	0.77	0%
Pancreatic fistula	2	230	1.08 (0.53-2.20)	0.82	0.91	0%
Postoperative hemorrhage	2	230	0.67 (0.11-4.11)	0.67	0.72	0%
Intra-abdominal abscess	2	230	0.75 (0.14-4.14)	0.75	0.15	51%
Wound infection	2	230	1.19 (0.38-3.70)	0.76	0.86	0%
Reinsertion of nasogastric tube	2	230	2.17 (0.84-5.59)	0.11	0.20	39%
Mortality	2	230	0.34 (0.01-8.46)	0.51	-	-
Non-randomized controlled trial
DGE	6	420	3.36 (1.25-9.08)	0.02	0.05	58%
Operation time	6	420	-0.56 (-47.55-46.43)	0.98	0.007	72%
Intraoperative blood loss	6	420	-283.77 (-593.42-25.87)	0.07	0.001	78%
Pancreatic fistula	5	353	0.77 (0.39-1.53)	0.46	0.93	0%
Postoperative hemorrhage	3	231	0.41 (0.08-2.22)	0.30	0.78	0%
Intra-abdominal abscess	3	231	1.21 (0.47-3.13)	0.70	0.83	0%
Wound infection	3	164	0.64 (0.19-2.08)	0.45	0.73	0%
Time of start liquid diet	3	186	3.68 (-0.30, 7.66)	0.07	0.0006	87%
Time of start solid diet	3	186	5.06 (0.39-9.73)	0.03	0.04	69%
Time of nasogastric intubation	5	308	3.49 (0.82-6.16)	0.01	< 0.00001	95%
Hospital stay	3	155	4.28 (-0.56-9.12)	0.08	0.02	76%
Mortality	4	240	0.30 (0.03-2.94)	0.30	0.97	0%
D1 lymph node dissection
DGE	2	57	0.32 (0.07-1.48)	0.14	0.90	0%
D2 lymph node dissection
DGE	2	119	3.07 (1.05-9.02)	0.04	0.53	0%

SSPPD: Subtotal stomach-preserving pancreaticoduodenectomy; PPPD: Pylorus-preserving pancreaticoduodenectomy; PD: Pancreaticoduodenectomy; WMD: Weighted mean difference.