Background
Pancreaticoduodenectomy, one of the most complex intra-abdominal operations, is widely used for benign and malignant disease located in the pancreatic head or periampullary region [
1,
2]. Despite developments in surgical techniques, pancreaticoduodenectomy is still accompanied by a high postoperative complication rate of 40–50% [
3]. Previous studies demonstrated that the most common complications after pancreaticoduodenectomy were postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE) [
3,
4]. Several methods of digestive tract reconstruction have been recommended to reduce the main postoperative complications, namely conventional pancreaticojejunostomy, isolated pancreaticojejunostomy [
5,
6], and isolated gastrojejunostomy [
7,
8]. Isolated pancreaticojejunostomy, first described in 1976, was proposed to reduce complications such as POPF, based on the theory of separating bile and pancreatic enzymes [
5]. In isolated gastrojejunostomy, a second loop is made to perform the gastroenteric anastomosis, which may favor digestive transit by separating the pancreatic enzymes and gastric sutures [
9]. However, the debate regarding these three reconstructions is on-going. Some studies demonstrated that isolated pancreaticojejunostomy and isolated gastrojejunostomy may be associated with less postoperative complications, such as POPF [
10] and DGE [
11]. Kaman et al. suggested that morbidity and mortality could be reduced using isolated pancreaticojejunostomy to separate the bile from pancreatic secretions [
12]; however, other studies reached different conclusions. Furthermore, studies comparing isolated pancreaticojejunostomy versus conventional pancreaticojejunostomy and isolated gastrojejunostomy versus conventional pancreaticojejunostomy involved low numbers of patients or had retrospective designs. With the recent publication of several new studies, we performed this systematic review and meta-analysis to compare the surgical outcomes of isolated pancreaticojejunostomy, isolated gastrojejunostomy, and conventional pancreaticojejunostomy.
Discussion
This meta-analysis compared isolated pancreaticojejunostomy and isolated gastrojejunostomy with conventional pancreaticojejunostomy after pancreaticoduodenectomy. Our results showed that isolated pancreaticojejunostomy was associated with fewer major complications and lower reoperation rates, but required longer operation time versus conventional pancreaticojejunostomy. However, the rates for overall complications, POPF, CR-POPF, DGE, CR-DGE, bile leakage, and hemorrhage, and the length of postoperative hospital stay and mortality rates with isolated pancreaticojejunostomy versus isolated gastrojejunostomy were similar to rates for conventional pancreaticojejunostomy. Considering the limitations, future high-quality RCTs are required.
POPF, one of the most frequent complications after pancreaticoduodenectomy, is associated with intra-abdominal abscess, sepsis, and life-threatening hemorrhage. Many methods have been used to decrease the incidence of POPF such as using fibrin [
28] or pancreatic stenting [
29], and modifying the jejunal anastomosis [
30]; however, the optimal technique is still debated. Our study revealed no significant difference between isolated pancreaticojejunostomy and conventional pancreaticojejunostomy, which was consistent with most previous studies. However, some studies demonstrated that isolated pancreaticojejunostomy was associated with lower rates of POPF after pancreaticoduodenectomy compared with conventional pancreaticojejunostomy [
20,
31]. Several reasons were revealed in these studies, including the separation of bile acids and pancreatic enzymes [
5] and decreasing the reflux of bile into the pancreas [
32]; however, these advantages were theoretical, and comparative studies are lacking. Of note, adding jejunojejunal anastomosis in isolated pancreaticojejunostomy could increase intestinal intraluminal pressure, which may affect the pancreaticojejunostomy anastomosis [
19]. An RCT performed by Ke et al. showed that the rate of Grade B POPF in the isolated pancreaticojejunostomy group was higher than that in the conventional pancreaticojejunostomy group [
6]. In addition to the 13 studies involving 1942 patients, our study showed that isolated pancreaticojejunostomy provides no advantage over conventional pancreaticojejunostomy regarding CR-POPF. Similar to previous studies evaluating isolated gastrojejunostomy, the incidences of POPF and CR-POPF were similar to those with conventional pancreaticojejunostomy.
DGE is also one of the most frequent complications after pancreaticoduodenectomy, with rates ranging from 13.5 to 40% [
14,
33]. Several surgical reconstruction procedures have been proposed to decrease the incidence of DGE, namely the Billroth I procedure, Braun enteroenterostomy, and isolated gastrojejunostomy. However, few studies have compared isolated gastrojejunostomy and conventional pancreaticojejunostomy. The debate regarding isolated gastrojejunostomy versus conventional pancreaticojejunostomy is on-going. Regarding DGE and CR-DGE, our results revealed no significant difference between isolated gastrojejunostomy and conventional pancreaticojejunostomy, and we found similar results when comparing isolated pancreaticojejunostomy and conventional pancreaticojejunostomy. A previous meta-analysis involving three studies revealed that conventional pancreaticojejunostomy was associated with lower rates of DGE versus isolated gastrojejunostomy [
34]; however, the sample size in the study was small. In the current meta-analysis, we showed that the incidences of DGE and CR-DGE were similar for both isolated pancreaticojejunostomy and conventional pancreaticojejunostomy, indicating that the activation of pancreatic enzymes does not influence the occurrence of DGE.
Regarding major complications, our meta-analysis demonstrated that isolated pancreaticojejunostomy has comparable with conventional pancreaticojejunostomy. The definition of major complications in our included studies varied. Applied with Clavin-Dindo grade, there were three studies provided the data of major complications. Our study showed that there was no significantly difference between isolated pancreaticojejunostomy and conventional pancreaticojejunostomy. Interestingly, isolated pancreaticojejunostomy decreases the incidence of reoperation in this study. The study conducted by Aghalarov et al and Chhaidar et al showed that isolated pancreaticojejunostomy has less reoperation [
10,
20]. They showed that the reoperation was largely because of POPF-related complications. Nevertheless, there are many factors that affect the occurrence of reoperation after surgery, such as bleeding, gastrointestinal anastomotic leakage. Additionally, with the development of percutaneous drainage and other procedures, there was fewer reoperation. However, there was lack of enough data about the detail of reoperations which may lead to bias in this present study.
Conclusion
In conclusion, isolated pancreaticojejunostomy was associated with lower reoperation rates, but required longer operation times versus conventional pancreaticojejunostomy. The rate of major complications, overall complications, POPF, CR-POPF, DGE, CR-DGE, bile leakage, and hemorrhage, and the length of postoperative hospital stay and mortality rates with isolated pancreaticojejunostomy and isolated gastrojejunostomy were similar to the respective rates with conventional pancreaticojejunostomy. However, further randomized controlled trials are needed.
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