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

Background Pancreatic cancer is the fourth leading cause of cancer death for men and the fifth for women. The standard treatment for resectable tumours is either a classic Whipple (CW) operation or a pylorus-preserving pancreaticoduodenectomy (PPW). It is unclear which of the 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 each operation. Search strategy We conducted searches on 28 March 2006 and 11 January 2011 to identify all randomised controlled trials (RCTs), applying no language restrictions. We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), CDSR and DARE from The Cochrane Library (2010, Issue 4), MEDLINE (1966 to January 2011), and EMBASE (1980 to January 2011). Abstracts from Digestive Disease Week and United European Gastroenterology Week (1995 to 2010). No additional studies were indentified upon updating the systematic review in 2011. Selection criteria We considered RCTs comparing the CW with PPW to be eligible if they included patients with periampullary or pancreatic carcinoma. Data collection and analysis Two authors independently extracted data from the included studies. We used a random-effects model for pooling data. We compared binary outcomes using odds ratios (OR), pooled continuous outcomes using mean differences (MD) and used hazard ratios (HR) for meta-analysis of survival. Two authors independently evaluated the methodological quality and risk of bias of the included studies according to Cochrane standards. Main results We included six randomised controlled trials with a total of 465 patients. 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 = 0.18), overall survival (HR 0.84; 95% CI 0.61 to 1.16; P = 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 = 0.0004) and intra-operative blood loss (MD -0.76 millilitres; 95% CI -0.96 to -0.56; P < 0.00001) were significantly reduced in the PPW group. All significant results have low quality of evidence based on GRADE criteria. Authors' conclusions There is no evidence of 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. 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 exist for a cure: the classic Whipple operation, where 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, where the stomach and the pylorus are not removed. It is unclear if 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 decreases after removal of the lower portion of the stomach. Another uncertainty is whether the two methods have different rates or types of complications. We included seven randomised controlled trials using a total of 496 patients in this review. We could identify no differences for complications, long-term survival or death due to complications after the operation, but operating time and blood loss seem to be lower in the pylorus-preserving Whipple operation. Our conclusion is that, at present, no difference is evident between the two operation methods for the surgical treatment of pancreatic or periampullary cancer.