A Systematic Review and Network‐Meta‐Analysis of Gastro‐Enteric Reconstruction Techniques Following Pancreatoduodenectomy to Reduce Delayed Gastric Emptying

Abstract

Introduction This network meta-analysis aimed to identify the reconstruction technique associated with lowest rates of DGE following pancreatoduodenectomy (PD) from randomised controlled trials (RCTs). Methods A systematic literature search of PubMed, Embase and MEDLINE databases was carried out using the PRISMA framework to identify all RCTs comparing reconstruction techniques of gastrojejunostomy after PD, with overall DGE as the primary endpoint. The primary outcome measure was overall DGE. Secondary outcomes were grade B/C DGE, duration of nasogastric tube, time to solid food intake, overall and grade B/C pancreatic fistula, bile leaks, reoperation, length of hospital stay and in-hospital mortality. ResultsThe search strategy identified eight RCTs including 761 patients. Six RCTs compared antecolic (n = 291 patients) and retrocolic Billroth II (n = 289 patients) reconstruction (n = 6 studies), and two RCTs compared antecolic Billroth II (n = 92 patients) and Roux-en-Y (n = 89 patients) reconstruction. Overall, antecolic Billroth II ranked best for overall and grade B/C DGE, bile leak, surgical site infection, length of stay and in-hospital mortality. Roux-en-Y was best for overall and grade B/C pancreatic fistula. Conclusion Antecolic Billroth II gastroenteric reconstruction is associated with the lowest rates of delayed gastric emptying after PD amongst the currently available techniques of gastrojejunostomy reconstructions.

Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials

“…The route of gastro-or duodenojejunostomy (antecolic vs retrocolic), anastomotic reconfiguration method (Billroth II vs Roux-en-Y), and addition of Braun enteroenterostomy have been commonly investigated for their role in DGE 18,66 , but there is a paucity of physiological literature justifying specific mechanisms. Some hypothesise excess torsion or poor angulation of the gastro-enteric anastomosis may contribute to DGE through mechanical obstruction, but this requires further exploration in future studies 67 .…”

“…Previous literature has attempted to ascertain an approach at each step of PD that is optimal for minimising DGE. A few meta-analyses have suggested antecolic, Billroth II to be favourable for DGE 16–18 . Of meta-analyses that specifically investigated the resection of the pylorus; Klaiber et al found no difference between PR and PP PD in a subgroup analysis of RCTs 12 , further confirmed by this NMA.…”

“…Pylorus resecting PD has been suggested to be favourable to pylorus preservation in reducing DGE rates as retaining the pylorus is thought to retain the propulsive activity of the stomach, but comparisons between the CW, PP and PR are limited 3,12,15 . Previous meta-analyses also suggested antecolic gastro-jejunostomy to be the most effective route for minimising DGE 16–18 , however, the evidence is conflicting 19 . Similarly, it remains controversial whether Billroth II or Roux-en-Y reconstruction is favourable 18,20–23 .…”

“…Previous meta-analyses also suggested antecolic gastro-jejunostomy to be the most effective route for minimising DGE 16–18 , however, the evidence is conflicting 19 . Similarly, it remains controversial whether Billroth II or Roux-en-Y reconstruction is favourable 18,20–23 . The addition of a Braun enteroenterostomy, typically to prevent bilious reflux, has also been proposed to lower DGE rates 24 .…”

Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials

“…Previous meta-analyses have also suggested that antecolic gastrojejunostomy is the more effective route for minimizing DGE 14–16 , but again evidence is conflicting 17 . Similarly, it remains controversial whether a simple Billroth II or Roux-en-Y reconstruction makes a difference 16 , 18–21 and what value is gained from Braun enteroenterostomy, to prevent bile reflux, in terms of DGE rates 22 .…”