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Cochrane Database of Systematic Reviews

Pylorus‐preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma

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Information

DOI:
https://doi.org/10.1002/14651858.CD006053.pub5Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 11 November 2014see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Gut Group

Copyright:
  1. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Markus K Diener

    Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany

  • Christina Fitzmaurice

    Hematology‐Oncology, University of Washington/Fred Hutchinson Cancer Research Center, Seattle, USA

  • Guido Schwarzer

    Center for Medical Biometry and Medical Informatics, Medical Center ‐ University of Freiburg, Freiburg, Germany

  • Christoph M Seiler

    Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany

  • Felix J Hüttner

    Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany

  • Gerd Antes

    German Cochrane Centre, University Medical Center Freiburg, Freiburg, Germany

  • Hanns‐Peter Knaebel

    Clinical Science, Business Development, Biosurgicals, AESCULAP AG, Tuttlingen, Germany

  • Markus W Büchler

    Correspondence to: Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany

    [email protected]

Contributions of authors

Markus Diener and Christina Fitzmaurice contributed equally to this work.

MKD
Designing the review.
Collecting data for the review.
Undertaking searches.
Screening search results.
Organising retrieval of papers.
Screening retrieved papers against inclusion criteria.
Appraising quality of papers.
Extracting data from papers.
Writing to authors of papers to ask for additional information.
Providing additional data about papers.
Obtaining and screening data on unpublished studies.
Managing data for the review.
Entering data into RevMan.
Analysing data.
Interpreting data.
Providing a methodological perspective.
Providing a clinical perspective.
Providing a consumer perspective.
Writing the review.
Performing previous work that served as the foundation of the current study.

CF
Collecting data for the review.
Designing search strategies.
Undertaking searches.
Screening search results.
Organising retrieval of papers.
Screening retrieved papers against inclusion criteria.
Appraising quality of papers.
Extracting data from papers.
Writing to authors of papers to ask for additional information.
Providing additional data about papers.
Obtaining and screening data on unpublished studies.
Managing data for the review.
Entering data into RevMan.
Analysing data.
Interpreting data.
Writing the review.
Revising the review after peer review.

GS
Extracting data from papers.
Analysing data.
Interpreting data.

CMS
Providing a methodological perspective.
Providing general advice on the review.
Interpreting the data.
Providing a clinical perspective.
Providing a policy perspective.

FH
Screening search results.
Organising retrieval of papers.
Screening retrieved papers against inclusion criteria.
Providing a clinical perspective.
Updating the review.

GA
Providing a methodological perspective.
Providing general advice on the review.

MWB
Providing a clinical perspective.
Providing a policy perspective.
Providing general advice on the review.

HPK
Conceiving of the review.
Co‐ordinating the review.
Interpreting the data.
Providing general advice on the review.
Providing a clinical perspective.
Providing a policy perspective.

Declarations of interest

MKD: none known.

CF: holds a T32 NIH training grant (United States of America).

GS: none known.

CS: none known.

FH: none known.

GA: none known.

HPK: After the publication of the first version of this review, Hanns‐Peter Knaebel became the Chief Executive Officer of Aesculap AG (a medical device company which produces surgical instruments) and as such is now in breach of Cochrane's commercial sponsorship policy. As the conclusions of the review have not changed since it was first conducted, the review has not been withdrawn. Hanns‐Peter Knaebel will not be an author of future versions of this review while he is employed by Aesculap AG.

MB: none known.

Acknowledgements

This review was carried out on the basis of a systematic review and meta‐analysis published elsewhere (Diener 2007).

Christina Fitzmaurice holds a T32 NIH training grant (United States of America).

Version history

Published

Title

Stage

Authors

Version

2016 Feb 16

Pylorus‐preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma

Review

Felix J Hüttner, Christina Fitzmaurice, Guido Schwarzer, Christoph M Seiler, Gerd Antes, Markus W Büchler, Markus K Diener

https://doi.org/10.1002/14651858.CD006053.pub6

2014 Nov 11

Pylorus‐preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma

Review

Markus K Diener, Christina Fitzmaurice, Guido Schwarzer, Christoph M Seiler, Felix J Hüttner, Gerd Antes, Hanns‐Peter Knaebel, Markus W Büchler

https://doi.org/10.1002/14651858.CD006053.pub5

2011 May 11

Pylorus‐preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma

Review

Markus K Diener, Christina Fitzmaurice, Guido Schwarzer, Christoph M Seiler, Gerd Antes, Hanns‐Peter Knaebel, Markus W Büchler

https://doi.org/10.1002/14651858.CD006053.pub4

2011 Feb 16

Pancreaticoduodenectomy (classic Whipple) versus pylorus‐preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma

Review

Markus K Diener, Christina Heukaeufer, Guido Schwarzer, Christoph M Seiler, Gerd Antes, Hanns‐Peter Knaebel, Markus W Büchler

https://doi.org/10.1002/14651858.CD006053.pub3

2008 Apr 23

Pancreaticoduodenectomy (classic Whipple) versus pylorus‐preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma

Review

Markus K Diener, Christina Heukaeufer, Guido Schwarzer, Christoph M Seiler, Gerd Antes, Hanns‐Peter Knaebel, Markus W Büchler

https://doi.org/10.1002/14651858.CD006053.pub2

2006 Apr 19

Pancreaticoduodenectomy (classical Whipple) versus pylorus‐preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma

Protocol

Markus Diener, C Heukaufer, Christoph M Seiler, Gerd Antes, Markus W Büchler, Hanns‐Peter Knaebel, C Heukaeufer

https://doi.org/10.1002/14651858.CD006053

Differences between protocol and review

The review differs in five points from the previously published protocol.

  • We summarised the outcomes of postoperative bleeding and postoperative gastrointestinal bleeding into a single outcome.

  • We discarded the outcomes of intra‐abdominal fluid collection/abscess, duration of intensive care unit stay, early and late dumping, postoperative reflux, number and status of removed lymph nodes, shock, sepsis, renal failure, weight loss and endocrine and exocrine insufficiency because no usable data were available.

  • We performed an additional quality assessment on the basis of a checklist developed by Downs et al (Downs 1998).

  • We performed a subgroup analysis for pancreatic head cancer and periampullary cancer for survival.

  • We performed a sensitivity analysis for DGE by using different definitions.

Notes

Christina Fitzmaurice and Markus Diener are joint first review authors and have contributed equally to this work.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 1

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Study flow diagram.
Figures and Tables -
Figure 3

Study flow diagram.

Funnel plot of comparison: 1 Survival, outcome: 1.1 Overall.
Figures and Tables -
Figure 4

Funnel plot of comparison: 1 Survival, outcome: 1.1 Overall.

Funnel plot of comparison: 2 Mortality, outcome: 2.1 Postoperative mortality.
Figures and Tables -
Figure 5

Funnel plot of comparison: 2 Mortality, outcome: 2.1 Postoperative mortality.

Funnel plot of comparison: 3 Pancreatic fistula, outcome: 3.1 Pancreatic fistula.
Figures and Tables -
Figure 6

Funnel plot of comparison: 3 Pancreatic fistula, outcome: 3.1 Pancreatic fistula.

Comparison 1 Survival, Outcome 1 Overall.
Figures and Tables -
Analysis 1.1

Comparison 1 Survival, Outcome 1 Overall.

Comparison 1 Survival, Outcome 2 Pancreatic head carcinoma.
Figures and Tables -
Analysis 1.2

Comparison 1 Survival, Outcome 2 Pancreatic head carcinoma.

Comparison 1 Survival, Outcome 3 Periampullary cancer.
Figures and Tables -
Analysis 1.3

Comparison 1 Survival, Outcome 3 Periampullary cancer.

Comparison 2 Mortality, Outcome 1 Postoperative mortality.
Figures and Tables -
Analysis 2.1

Comparison 2 Mortality, Outcome 1 Postoperative mortality.

Comparison 3 Pancreatic fistula, Outcome 1 Pancreatic fistula.
Figures and Tables -
Analysis 3.1

Comparison 3 Pancreatic fistula, Outcome 1 Pancreatic fistula.

Comparison 4 Delayed gastric emptying (with sensitivity analysis), Outcome 1 All studies.
Figures and Tables -
Analysis 4.1

Comparison 4 Delayed gastric emptying (with sensitivity analysis), Outcome 1 All studies.

Comparison 4 Delayed gastric emptying (with sensitivity analysis), Outcome 2 Studies in which DGE was defined (includes different definitions).
Figures and Tables -
Analysis 4.2

Comparison 4 Delayed gastric emptying (with sensitivity analysis), Outcome 2 Studies in which DGE was defined (includes different definitions).

Comparison 4 Delayed gastric emptying (with sensitivity analysis), Outcome 3 Studies with the same definitions of DGE.
Figures and Tables -
Analysis 4.3

Comparison 4 Delayed gastric emptying (with sensitivity analysis), Outcome 3 Studies with the same definitions of DGE.

Comparison 5 Biliary leakage, Outcome 1 Biliary leakage.
Figures and Tables -
Analysis 5.1

Comparison 5 Biliary leakage, Outcome 1 Biliary leakage.

Comparison 6 Intraoperative blood loss, Outcome 1 Intraoperative blood loss (litres).
Figures and Tables -
Analysis 6.1

Comparison 6 Intraoperative blood loss, Outcome 1 Intraoperative blood loss (litres).

Comparison 7 Red blood cell transfusion, Outcome 1 Red blood cell transfusion.
Figures and Tables -
Analysis 7.1

Comparison 7 Red blood cell transfusion, Outcome 1 Red blood cell transfusion.

Comparison 8 Operating time, Outcome 1 Operating time (minutes).
Figures and Tables -
Analysis 8.1

Comparison 8 Operating time, Outcome 1 Operating time (minutes).

Comparison 9 Postoperative bleeding, Outcome 1 Postoperative bleeding.
Figures and Tables -
Analysis 9.1

Comparison 9 Postoperative bleeding, Outcome 1 Postoperative bleeding.

Comparison 10 Wound infection, Outcome 1 Wound infection.
Figures and Tables -
Analysis 10.1

Comparison 10 Wound infection, Outcome 1 Wound infection.

Comparison 11 Pulmonary complications, Outcome 1 Pulmonary complications.
Figures and Tables -
Analysis 11.1

Comparison 11 Pulmonary complications, Outcome 1 Pulmonary complications.

Comparison 12 Necessity for reoperation, Outcome 1 Necessity for reoperation.
Figures and Tables -
Analysis 12.1

Comparison 12 Necessity for reoperation, Outcome 1 Necessity for reoperation.

Comparison 13 Hospital stay, Outcome 1 Hospital stay (days).
Figures and Tables -
Analysis 13.1

Comparison 13 Hospital stay, Outcome 1 Hospital stay (days).

Summary of findings for the main comparison. Survival after surgical treatment for periampullary or pancreatic carcinoma

Survival after surgical treatment for periampullary or pancreatic carcinoma

Patient or population: patients with surgical treatment of periampullary or pancreatic carcinoma
Settings:
Intervention: survival

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Survival

Overall survival
Follow‐up: 18 to 144 months

Medium‐risk population

HR 0.84
(0.61 to 1.16)

0
(3 studies)

⊕⊕⊝⊝
lowa,b

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; HR: Hazard ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aInadequate information about sequence generation and allocation concealment. No intention‐to‐treat analysis.
bVery wide confidence intervals, unknown number of losses to follow‐up, low total number of events, no sample size calculations reported.

Figures and Tables -
Summary of findings for the main comparison. Survival after surgical treatment for periampullary or pancreatic carcinoma
Summary of findings 2. Mortality after surgical treatment for periampullary or pancreatic carcinoma

Mortality after surgical treatment for periampullary or pancreatic carcinoma

Patient or population: patients with surgical treatment for periampullary and pancreatic carcinoma
Settings:
Intervention: mortality

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Mortality

Postoperative mortality

Study population

OR 0.49
(0.17 to 1.4)

417
(5 studies)

⊕⊕⊝⊝
lowa,b

52 per 1000

26 per 1000
(9 to 71)

Medium‐risk population

44 per 1000

22 per 1000
(8 to 61)

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aConfidence intervals are wide because of small number of events. No sample size calculation was reported for trials except for Seiler and Tran.
bPublication bias is unlikely but cannot be excluded. Funnel plotting did not reveal vast asymmetry. However, publication bias cannot be quantified because of the small number of available trials.

Figures and Tables -
Summary of findings 2. Mortality after surgical treatment for periampullary or pancreatic carcinoma
Summary of findings 3. Intraoperative blood loss in surgical treatment of patients with periampullary or pancreatic carcinoma

Intraoperative blood loss in surgical treatment of patients with periampullary or pancreatic carcinoma

Patient or population: patients with surgical treatment for periampullary or pancreatic carcinoma
Settings:
Intervention: intraoperative blood loss

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Intraoperative blood loss

Intraoperative blood loss (litres)

Mean intraoperative blood loss (litres) in the intervention groups was
0.76 lower
(0.96 to 0.56 lower)

33
(1 study)

⊕⊕⊝⊝
lowa,b

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aSmall number of participants.
bPublication bias is unlikely but cannot be excluded. Funnel plotting did not reveal vast asymmetry. However, publication bias cannot be quantified because of the small number of available trials.

Figures and Tables -
Summary of findings 3. Intraoperative blood loss in surgical treatment of patients with periampullary or pancreatic carcinoma
Summary of findings 4. Operating time in surgical treatment for periampullary or pancreatic carcinoma

Operating time in surgical treatment for periampullary or pancreatic carcinoma

Patient or population: patients with surgical treatment for periampullary and pancreatic carcinoma
Settings:
Intervention: operating time

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Operating time

Operating time (minutes)

Mean operating time (minutes) in the intervention groups was
68.26 lower
(105.7 to 30.83 lower)

125
(3 studies)

⊕⊕⊝⊝
lowa,b,c

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aSerious limitations in the study design in the trials of Bloechle, Lin and Wenger are a potential source of bias. All are characterised by small sample sizes, lack of blinding and incomplete outcome reporting.
bWide confidence intervals indicate significant imprecision of this pooled outcome variable, which causes potential bias. This imbalance in operating time across included trials might be caused by the overall small sample sizes or by unstandardised assessment.
cPublication bias is unlikely but cannot be excluded. Funnel plotting did not reveal vast asymmetry. However, publication bias cannot be quantified because of the small number of available trials.

Figures and Tables -
Summary of findings 4. Operating time in surgical treatment for periampullary or pancreatic carcinoma
Comparison 1. Survival

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Overall Show forest plot

3

Hazard ratio (Random, 95% CI)

0.84 [0.61, 1.16]

2 Pancreatic head carcinoma Show forest plot

3

Hazard ratio (Random, 95% CI)

0.73 [0.43, 1.22]

3 Periampullary cancer Show forest plot

2

Hazard ratio (Random, 95% CI)

0.83 [0.39, 1.76]

Figures and Tables -
Comparison 1. Survival
Comparison 2. Mortality

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Postoperative mortality Show forest plot

5

417

Odds Ratio (M‐H, Random, 95% CI)

0.49 [0.17, 1.40]

Figures and Tables -
Comparison 2. Mortality
Comparison 3. Pancreatic fistula

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pancreatic fistula Show forest plot

5

421

Odds Ratio (M‐H, Random, 95% CI)

0.86 [0.41, 1.81]

Figures and Tables -
Comparison 3. Pancreatic fistula
Comparison 4. Delayed gastric emptying (with sensitivity analysis)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 All studies Show forest plot

5

412

Odds Ratio (M‐H, Random, 95% CI)

2.35 [0.72, 7.61]

2 Studies in which DGE was defined (includes different definitions) Show forest plot

3

328

Odds Ratio (M‐H, Random, 95% CI)

1.14 [0.35, 3.68]

3 Studies with the same definitions of DGE Show forest plot

2

198

Odds Ratio (M‐H, Random, 95% CI)

4.02 [0.14, 119.16]

Figures and Tables -
Comparison 4. Delayed gastric emptying (with sensitivity analysis)
Comparison 5. Biliary leakage

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Biliary leakage Show forest plot

3

333

Odds Ratio (M‐H, Random, 95% CI)

1.35 [0.10, 18.55]

Figures and Tables -
Comparison 5. Biliary leakage
Comparison 6. Intraoperative blood loss

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Intraoperative blood loss (litres) Show forest plot

1

33

Mean Difference (IV, Random, 95% CI)

‐0.76 [‐0.96, ‐0.56]

Figures and Tables -
Comparison 6. Intraoperative blood loss
Comparison 7. Red blood cell transfusion

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Red blood cell transfusion Show forest plot

2

79

Mean Difference (IV, Random, 95% CI)

‐0.65 [‐1.92, 0.61]

Figures and Tables -
Comparison 7. Red blood cell transfusion
Comparison 8. Operating time

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Operating time (minutes) Show forest plot

3

125

Mean Difference (IV, Random, 95% CI)

‐68.26 [‐105.70, ‐30.83]

Figures and Tables -
Comparison 8. Operating time
Comparison 9. Postoperative bleeding

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Postoperative bleeding Show forest plot

3

333

Odds Ratio (M‐H, Random, 95% CI)

0.74 [0.29, 1.88]

Figures and Tables -
Comparison 9. Postoperative bleeding
Comparison 10. Wound infection

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Wound infection Show forest plot

4

251

Odds Ratio (M‐H, Random, 95% CI)

0.85 [0.35, 2.05]

Figures and Tables -
Comparison 10. Wound infection
Comparison 11. Pulmonary complications

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pulmonary complications Show forest plot

3

218

Odds Ratio (M‐H, Random, 95% CI)

0.67 [0.29, 1.58]

Figures and Tables -
Comparison 11. Pulmonary complications
Comparison 12. Necessity for reoperation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Necessity for reoperation Show forest plot

2

300

Odds Ratio (M‐H, Random, 95% CI)

0.82 [0.38, 1.75]

Figures and Tables -
Comparison 12. Necessity for reoperation
Comparison 13. Hospital stay

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Hospital stay (days) Show forest plot

1

48

Mean Difference (IV, Random, 95% CI)

‐1.80 [‐8.94, 5.34]

Figures and Tables -
Comparison 13. Hospital stay