Evidence-Based Analysis For Clinical Application Of Pylorus-Preserved Pancreaticoduodenectomy

Background:Pancreatic cancer is a common malignancy which ranks the 5th cancer-related death in western countries, and in China its morbidity has an increasing trend. It has high degree of malignancy and is difficult to be early diagnosed. The surgery is complicated and has a poor prognosis. Up to now, for the early diagnosed patients, surgical resection is still the best treatment. Since the first case of pancreaticoduodenectomy was conducted by Whipple in 1935, a variety of extended radical mastectomy or modified surgical came into being, such as pylorus-preserving pancreaticoduodenectomy(PPPD), expanding Whipple's, extended lymph node dissection and resection combined with vascular. But only two operation techniques are performed worldwide in the treatment of pancreatic and periampullary cancer: classic Whipple's and PPPD. They two are still controversial in terms of their radical effects and postoperative complications. As in recent years, the continuous improvement of the status of evidence-based medicine, it is necessary to carry out a Meta-analysis between the CW and PPPD to provide a reference for clinical selection of operative techniques.Objective:Comparison of effectiveness between CW and PPPD.Methods:We searched the database (CNKI, CBM, PUBMED and Cochrane Central Register of Controlled Trials database) to gather all the randomized controlled trials comparing classical Whipple's and PPPD.Two investigators eliminated sub-standard literatures, evaluated the included RCTs based on Jadad scale,and extracted the relevant data for meta-analysis.Result:Seven RCTs were selected finally and 492 patients were involved (CW 249 and PPPD 243). The results show there's no significant difference between CW and PPPD in mortality (OR=0.70,95%CI=[0.29,1.67]), blood loss(SMD=-0.67,95% CI=[-1.42,0.08]), hospital stay (SMD=0.08,95% CI=[-0.30,0.47]):Overall morbidity (OR=0.84,95%CI=[0.51,1.38]), postoperative complications (pancreatic fistula:OR=0.85,95%CI=[0.45,1.61],P=0.61>0.05; biliary leakage:OR=2.19, 95%CI=[0.48,10.02],P=0.31>0.05; postoperation bleeding:OR=0.75,95%CI =[0.31,1.79], P=0.51>0.05; wound infection:OR=0.85,95%CI=[0.35,2.03], P=0.71>0.05; abdominal abscess:OR=0.97,95% CI=[0.41,2.32], P=0.95>0.05; DGE:OR=3.04,95%CI=[0.96,9.61],P=0.06>0.05) and long-term survival (HR=0.82,95%CI=[0.63,1.06],P=0.13>0.05). The operation time and blood transfusion of PPPD were significantly less than that of CW.Conclusions:The meta analysis shows that, PPPD can shorten the operation time and reduce the volume of blood transfusion, but it is no different than CW in mortality, hospital stay, blood loss, overall morbidity, postoperative complications (especially for DGE) and long-term survival. Although, in view of the poor quality of included studies, more large-scale, multi-center clinical trials are needed to prove which of PPPD and CW is more effective.