Pylorus‐preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma
Abstract
Background
Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours consists of a classic Whipple (CW) operation or a pylorus‐preserving pancreaticoduodenectomy (PPW). It is unclear which of these procedures is more favourable in terms of survival, mortality, complications and quality of life.
Objectives
The objective of this systematic review is to compare the effectiveness of CW and PPW techniques for surgical treatment of cancer of the pancreatic head and the periampullary region.
Search methods
We conducted searches on 28 March 2006, 11 January 2011 and 9 January 2014 to identify all randomised controlled trials (RCTs), while applying no language restrictions. We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE) from The Cochrane Library (2013, Issue 4); MEDLINE (1946 to January 2014); and EMBASE (1980 to January 2014). We also searched abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010). We identified no additional studies upon updating the systematic review in 2014.
Selection criteria
We considered RCTs comparing CW versus PPW to be eligible if they included study participants with periampullary or pancreatic carcinoma.
Data collection and analysis
Two review authors independently extracted data from the included studies. We used a random‐effects model for pooling data. We compared binary outcomes using odds ratios (ORs), pooled continuous outcomes using mean differences (MDs) and used hazard ratios (HRs) for meta‐analysis of survival. Two review authors independently evaluated the methodological quality and risk of bias of included studies according to the standards of The Cochrane Collaboration.
Main results
We included six RCTs with a total of 465 participants. Our critical appraisal revealed vast heterogeneity with respect to methodological quality and outcome parameters. In‐hospital mortality (OR 0.49, 95% confidence interval (CI) 0.17 to 1.40; P value 0.18), overall survival (HR 0.84, 95% CI 0.61 to 1.16; P value 0.29) and morbidity showed no significant differences. However, we noted that operating time (MD ‐68.26 minutes, 95% CI ‐105.70 to ‐30.83; P value 0.0004) and intraoperative blood loss (MD ‐0.76 mL, 95% CI ‐0.96 to ‐0.56; P value < 0.00001) were significantly reduced in the PPW group. All significant results are associated with low quality of evidence as determined on the basis of GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria.
Authors' conclusions
No evidence suggests relevant differences in mortality, morbidity and survival between the two operations. Given obvious clinical and methodological heterogeneity, future research must be undertaken to perform high‐quality randomised controlled trials of complex surgical interventions on the basis of well‐defined outcome parameters.
PICOs
Plain language summary
Comparison of the stomach‐preserving 'Whipple' operation with the classic 'Whipple' operation for patients with cancer of the pancreas or the periampullary region (the point at which the ducts from the liver and pancreas enter the small intestine)
Pancreatic cancer is a leading cause of cancer death. Two surgical procedures can lead to a cure: the classic Whipple operation, in which part of the pancreas, the gallbladder, the duodenum, the pylorus (outlet of the stomach) and the distal (lower) part of the stomach are removed, and the so‐called pylorus‐preserving pancreaticoduodenectomy, or pylorus‐preserving Whipple operation, in which the stomach and the pylorus are not removed.
It is unclear whether the pylorus‐preserving Whipple results in a higher rate of recurrence of the tumour because it is less extensive and so may be less radical, but it is also unknown whether quality of life is decreased after removal of the lower portion of the stomach. Another uncertainty is whether the two methods are associated with different rates or types of complications.
We included in this review six randomised controlled trials with a total of 496 participants. We could identify no differences in terms of complications, long‐term survival or death due to complications after the operation, but operating time and blood loss seem to be less in the group treated with the pylorus‐preserving Whipple operation. Our conclusion is that, at present, no difference is evident between the two surgical procedures for the treatment of pancreatic or periampullary cancer.
