Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial

Topal, Baki; Fieuws, Steffen; Aerts, Raymond; Weerts, J; Feryn, T.; Roeyen, Geert; Bertrand, C.; Hubert, Catherine; Janssens, Marc; Closset, Jean

doi:10.1016/s1470-2045(13)70126-8

Cited by 260 publications

(241 citation statements)

References 17 publications

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“…[8][9][10][11][12][13][14][15] Some of these com parisons have been summarized in recent systematic reviews and metaanalyses. [16][17][18][19][20] Observational studies sug gested that PG is a safer reconstruction than PJ, resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality.…”

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confidence: 99%

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy

et al. 2015

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In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomyBackground: It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We com pared PJ and PG after pancreaticoduodenectomy (PD). Methods:A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the secondary outcomes were overall morbidity and mor tality. We used the Student t, Mann-Whitney U and χ 2 tests for intention to treat analysis. The effect of randomization, American Society of Anesthesiologists score, soft pancreatic texture and use of pancreatic stent on overall complications and fistula rates was calculated using logistic regression.Results: Our trial included 98 patients. The rate of pancreatic fistula formation was 18% in the PJ and 25% in the PG groups (p = 0.40). Postoperative complications occurred in 48% of patients in the PJ and 58% in the PG groups (p = 0.31). There were no significant predictors of overall complications in the multivariate analysis. Only soft pancreatic gland predicted the occurrence of pancreatic fistula (odds ratio 5.89, p = 0.003). Conclusion:There was no difference in the rates of pancreatic leak/fistula, overall complications or mortality between patients undergoing PG and and those under going PJ after PD.Contexte : Selon certains, la pancréatogastrostomie (PG) est une technique de recon struction plus sécuritaire que la pancréatojéjunostomie (PJ) et entraîne une morbidité moindre, y compris un taux moins élevé de fuites pancréatiques et une mortalité post opératoire diminuée. Nous avons comparé la PJ et la PG postpancréatoduodénectomie. Méthodes :Un essai clinique randomisé a été conçu et cessé à l'atteinte d'un taux de participation de 50 %. Les patients ont subi une reconstruction par PG ou par PJ. Le paramètre principal était le taux de fistules pancréatiques et les paramètres secondaires étaient la morbidité et la mortalité globales. Nous avons utilisé les tests t de Student, U de Mann-Whitney et du χ 2 carré pour l'analyse en intention de traiter. Nous avons cal culé l'effet de la randomisation, du score de l'American Society of Anesthesiologists, de la consistance molle du pancréas et du recours à l'endoprothèse pancréatique sur les com plications globales et les taux de fistules à l'aide d'une analyse de régression logistique.Résultats : Notre essai a regroupé 98 patients. Le taux de fistules pancréatiques a été de 18 % dans le groupe soumis à la PJ et de 25 % dans le groupe soumis à la PG (p = 0,40). Des complications postopératoires sont survenues chez 48 % des patients du groupe soumis à la PJ et chez 58 % du groupe soumis à la PG (p = 0,31). Aucun pré dicteur significatif des complications globales n'est ressorti à l'analyse multivariée. Seule l...

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In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy

et al. 2015

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“…Many studies have compared PJ with PG, and a consensus over the most effective technique remains to be determined; although several reports have shown similar outcomes between the 2 manoeuvres, [18][19][20][21] others have found that PG reduces the incidence of postoperative fistula. [22][23][24] Given the overwhelming preference for PJ over PG, quality evidence supporting a single technique has the potential to drastically change the postoperative course for patients undergoing PD.…”

Section: Discussionmentioning

confidence: 99%

Canadian practice patterns for pancreaticoduodenectomy

Cyr

Truong

Lam-McCulloch

et al. 2015

cjs

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Background: Discordant practice patterns may be a consequence of evidence-practice gaps or deficiencies in knowledge translation. We examined the current strategies used by hepato-pancreatico-biliary (HPB) surgeons in Canada for the perioperative management of pancreaticoduodenectomy (PD). Methods:We generated a web-based survey that focused on the perioperative measures surrounding PD. The survey was distributed to all members of the Canadian Hepato-Pancreatico-Biliary Association. Results:The survey was distributed to 74 surgeons and received a response rate of 50%. Many similarities in surgical techniques were reported; for example, most surgeons (86.5%) reconstruct the pancreas with pancreaticojejunostomy rather than pancreaticogastrostomy. In contrast, variable techniques regarding the use of peritoneal drainage tubes, anastomotic stents, octreotide and other intraoperative modalities were reported. Most surgeons (75.7%) reported that their patients frequently required preoperative biliary drainage, yet there was minimal agreement with the designated criteria. There was variability in postoperative care, including the use of epidural analgesia and timing of postoperative oral nutrition. Conclusion:We identified heterogeneity among Canadian HPB surgeons, suggesting a number of evidence-practice gaps within specific domains of pancreatic resections. Focused research in these areas may facilitate technical agreement and improve patient outcomes following PD.Contexte : La discordance entre les modes de pratique pourrait être due à des lacunes au plan des pratiques fondées sur des preuves ou à une déficience du transfert des connaissances. Nous avons étudié les stratégies actuellement utilisées par les chirurgiens hépato-pancréato-biliaires (HPB) au Canada pour la prise en charge périopératoire de la pancréatoduodénectomie (PD). Méthodes :Nous avons préparé un questionnaire électronique sur les mesures péri-opératoires entourant la PD. Le questionnaire a été distribué à tous les membres de l'Association hépato-pancréato-biliaire canadienne.Résultats : Le questionnaire a été distribué à 74 chirurgiens et a généré un taux de réponse de 50 %. De nombreuses similitudes dans les techniques chirurgicales ont été signalées : par exemple, la majorité des chirurgiens (86,5 %) reconstruisent le pancréas par pancréatojéjunostomie plutôt que par pancréatogastrostomie. En revanche, on a observé une variabilité dans les techniques d'utilisation des drains péritonéaux, des endoprothèses anastomotiques, des octréotides et autres modalités peropératoires. La majorité des chirurgiens (75,7 %) ont signalé que leurs patients avaient souvent besoin de drains biliaires préopératoires et pourtant, les critères désignés ne semblaient pas faire l'unanimité. On a aussi noté des différences dans les soins postopératoires, y compris en ce qui concerne le recours à l'analgésie péridurale et le moment de la reprise de l'alimentation orale après la chirurgie. Conclusion :Nous avons observé une hétérogénéité dans la pratique des chirurgiens HP...

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“…Differences in the definitions of these complications have led to a consensus of the International Study Group for Pancreatic Surgery (ISGPS) in 2006. Topal et al [56] included 329 patients and showed a lower incidence of PF after PG (OR = 2.86; 95%CI: 1.38-6.17; P = 0.02). Although there was heterogeneity between these studies, all were conducted in specialized centers by highly experienced surgeons and the surgical care was likely to be similar for all the studies.…”

Section: Definition Of Pancreatic Fistulamentioning

confidence: 99%

Reconstruction after pancreatoduodenectomy: Pancreatojejunostomyvspancreatogastrostomy

Gómez¹

2014

WJGO

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Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy (PD) in order to decrease postoperative complications, mainly pancreatic fistulas (PF). In this work, we compare the two most frequent techniques of reconstruction after PD, pancreatojejunostomy (PJ) and pancreatogastrostomy (PG), in order to determine which of the two is better. A systematic review of the literature was performed, including major meta-analysis articles, clinical randomized trials, systematic reviews, and retrospective studies. A total of 64 articles were finally included. PJ and PG are usually responsible for most of the postoperative morbidity, mainly due to the onset of PF, being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia. The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG. PF, delayed gastric emptying and mortality were not different. Although there was heterogeneity between these studies, all were conducted in specialized centers by highly experienced surgeons, and the surgical care was likely to be similar for all the studies. The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa. Exocrine function appears to be worse after PG than after PJ, resulting in severe atrophic changes in the remnant pancreas. Depending on the type of PJ or PG used, the PF rate and other complications can also be different. The best method to deal with the pancreatic stump after PD remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles such as good exposure and visualization. In conclusion, up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD. Core tip: Pancreatoduodenectomy is a technique with a high rate of morbidity and mortality. Surgeons try to find the best technique of reconstruction in order to decrease postoperative complications. We compare the two most frequent techniques of reconstruction after pancreatoduodenectomy, namely pancreatojejunostomy and pancreatogastrostomy, to determine which of the two is better. We offer a systematic review of the main papers published with all the pros and cons of each technique. The best method to deal with the pancreatic stump after pancreatoduodenectomy remains questionable. The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles, such as good exposure and visualization. TOPIC HIGHLIGHTSeptember 15, 2014|Volume 6|Issue 9|

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Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial

Cited by 260 publications

References 17 publications

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy

Canadian practice patterns for pancreaticoduodenectomy

Reconstruction after pancreatoduodenectomy: Pancreatojejunostomyvspancreatogastrostomy

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