Randomized clinical trial of pylorus-preserving duodenopancreatectomy <i>versus</i> classical Whipple resection—long term results

Seiler, Ch.; Wagner, Markus; Bachmann, T.; Redaelli, C.; Schmied, Bruno M.; Uhl, Waldemar; Frieß, Helmut; Büchler, M.

doi:10.1002/bjs.4881

Cited by 246 publications

(168 citation statements)

References 34 publications

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“…Overall quality of life was shown to be similar in patients undergoing pylorus-preserving PD and classic Whipple procedure (34,35,37). Moreover, appetite and weight were better preserved in the pylorus-preserving group (34,35).…”

Section: Limitations Of Evidencementioning

confidence: 96%

“…With the growing recognition of evidence-based surgery, randomized controlled trials (RCTs) comparing both procedures emerged, followed by systematic reviews and meta-analyses summarizing the existing literature (31)(32)(33). Between 1998 and 2015, eight RCTs comparing both procedures in patients with pancreatic and periampullary carcinoma were published ( Table 1) (20)(21)(22)(34)(35)(36)(37)(38). A currently updated Cochrane review, gives an excellent summary and critical appraisal of the existing evidence (39).…”

Section: Postoperative Morbidity Mortality and Survivalmentioning

confidence: 99%

“…This is of particular importance in relation to DGE which cannot be regarded as an objective outcome parameter and thus, its evaluation is highly prone to bias within a non-blinded study design (41). The two largest RCTs reported comparable incidences of DGE (36,37), whereas five other RCTs with smaller sample sizes favored the classic Whipple procedure (20)(21)(22)34,38). Considering that none of the trials was powered to test a difference in DGE rates, treatment effects may be wrongly estimated.…”

Section: Limitations Of Evidencementioning

confidence: 99%

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Pylorus preservation pancreatectomy or not

Klaiber

Probst

Büchler

et al. 2017

Transl. Gastroenterol. Hepatol.

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Pancreaticoduodenectomy (PD) is the treatment of choice for various benign and malignant tumors of the pancreatic head or the periampullary region, and the only hope for cure in patients with cancer at this side. While it has been associated with high morbidity and mortality rates in the last century, its centralization in specialized institutions together with refinements in the operative technique and better management of postoperative complications have made PD a standardized, safe procedure. Besides the classic Whipple procedure including distal gastrectomy, two variations of PD with or without pylorus resection, but preservation of the entire stomach in either procedure exist today. Pylorus-preserving PD has gained wide acceptance as standard procedure and is being performed by an increasing number of pancreatic surgeons.After its oncological adequacy was questioned initially, pylorus-preserving PD was shown to be equivalent to the classic Whipple procedure regarding tumor recurrence and long-term survival. Moreover, operation time and blood loss were shown to be reduced in the pylorus-preserving procedure and benefits in nutritional status and quality of life were observed. However, preservation of the pylorus has been suggested to result in an increased incidence of postoperative delayed gastric emptying (DGE). In this context, pylorus-resecting PD has become popular especially in Japan with the aim to prevent DGE by removal of the pylorus but preservation of the stomach. In contrast to positive results from early studies, latest high-quality randomized controlled trial (RCT) data show that pylorus resection does not reduce DGE compared to the pyloruspreserving operation. Non-superiority of pylorus resection was also confirmed in current meta-analysis on this topic. This article summarizes the existing evidence on PD with or without pylorus preservation and derives recommendations for daily practice.

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Section: Limitations Of Evidencementioning

confidence: 96%

Section: Postoperative Morbidity Mortality and Survivalmentioning

confidence: 99%

Section: Limitations Of Evidencementioning

confidence: 99%

See 1 more Smart Citation

Pylorus preservation pancreatectomy or not

Klaiber

Probst

Büchler

et al. 2017

Transl. Gastroenterol. Hepatol.

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“…Though some randomized controlled trials (RCTs) and meta-analyses have suggested that these two procedures are comparable in terms of postoperative complications, long-term survival rates and quality of life, other studies have reported that PPPD is superior to classic Whipple's pancreaticoduodenectomy as it results in less occurrence of dumping, diarrhoea and bile reflux gastritis. [3,4] Hence PPPD is claimed to provide the patients with an improved nutritional status. [5,6] However, during the last few decades, significant advances have been made in the understanding of the pathogenesis of periampullary neoplasms.…”

Section: Introductionmentioning

confidence: 99%

Pancreaticoduodenectomy Procedure - A Tertiary Care Centre Experience

Surendran¹,

Chisthi²,

Das³

2017

AIMDR

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Background: Pancreaticoduodenectomy, also referred to as Whipple's resection, refers to the en bloc surgical resection of the pancreatic head, uncinate process, duodenum, gall bladder, and common bile duct. Though generally done for oncologic indications, the procedure can be warranted in benign or pre-neoplastic conditions of the peri-ampullary region also. Pathologic assessment of surgical specimens from pancreaticoduodenectomy needs special attention in order to accurately evaluate many factors that are prognostically important. The objective of the study was to analyze the clinical as well as histopathological profile of patients who underwent Whipple's resection over a 3-year period at a tertiary level institution. Methods: This descriptive study included patients from the General Surgery and Surgical Gastroenterology wards of Medical College Trivandrum, who underwent pancreaticoduodenectomy from January 2012 to January 2015. Results: The mean age was 55.18 years, with the majority of patients being females. Jaundice was the most common symptom, followed by itching. Among tumour markers, CA 19-9 was elevated in majority of patients, followed by CEA. Majority of the patients underwent PPPD rather than classical Whipple's resection. Head of the pancreas was the most common primary site followed by bile duct, ampulla of Vater and duodenum respectively. Adenocarcinoma was the most common pathological type among all sites with the majority being well-differentiated tumours. Conclusion: Adenocarcinoma of the head of the pancreas is the most common tumour for which majority of the patients undergoes pancreaticoduodenectomy at this institution. Majority of surgeons prefer the pylorus preserving type over the classical Whipple's procedure.

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“…Postoperative mortality after PD has decreased to below 5% in the past 10 -15 years [6]- [8]. However, mortality is still high, and overall morbidity, including that from pancreatic fistula, delayed gastric emptying, intra-abdominal bleeding, and intra-abdominal abscess, has remained high, ranging from 30% -60% [9]- [11]. In particular, pancreatic fistula still occurs in 5% to 40% of patients [11]- [13], and delayed gastric emptying occurs in 22% to 52% of patients undergoing PD [14] [15] despite refinements in surgical techniques and methods of perioperative management.…”

Section: Introductionmentioning

confidence: 99%

Effect of Post-ERCP Pancreatitis on Perioperative Factors of Pancreaticoduodenectomy

Hirashita¹,

Matsumoto²,

Izumi³

et al. 2015

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Background: Endoscopic retrograde cholangiopancreatography (ERCP) is commonly performed for biliary drainage and examination of the biliary and pancreatic duct before pancreaticoduodenectomy (PD). The influence of preoperative post-ERCP pancreatitis on PD is unknown. The aim of this study was to evaluate the relation between post-ERCP pancreatitis before PD and surgical outcomes of PD. Methods: We examined 38 patients who underwent PD. The relations between post-ERCP pancreatitis before PD and perioperative factors of PD such as patient characteristics, operative findings, and postoperative course were evaluated with univariate and multivariate analyses. Results: Post-ERCP pancreatitis was observed in 12 (37.5%) of the 38 patients. Univariate analyses showed operative procedure (P = 0.034), operation time (P = 0.004), blood loss (P = 0.031), C-reactive protein (P = 0.043), and delayed gastric emptying (P = 0.035) to be significantly associated with post-ERCP pancreatitis. Multivariate analyses showed operation time (OR, 1.017; 95%CI, 1.000 -1.034; P = 0.049) and delayed gastric emptying (OR, 18.72; 95%CI, 1.139 -307.6; P = 0.040) to be significantly associated with post-ERCP pancreatitis. Conclusions: Post-ERCP pancreatitis was associated with prolonged operation time and delayed gastric emptying in patients undergoing PD.

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Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection—long term results

Abstract: Both procedures were equally effective for the treatment of pancreatic and periampullary cancer. Pylorus-preserving Whipple resection offers some minor advantages in the early postoperative period, but not in the long term.

Cited by 246 publications

References 34 publications

Pylorus preservation pancreatectomy or not

Pylorus preservation pancreatectomy or not

Pancreaticoduodenectomy Procedure - A Tertiary Care Centre Experience

Effect of Post-ERCP Pancreatitis on Perioperative Factors of Pancreaticoduodenectomy

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