Key messages
- We do not know whether duct-to-mucosa pancreaticojejunostomy (attachment of the excretory duct of the pancreas to the second part of the small intestine) reduces postoperative pancreatic fistula (leakage of juice from the pancreas to the abdominal tissues) compared to invagination pancreaticojejunostomy (insertion of the pancreas within the second part of the small intestine).
- We do not know whether modified duct-to-mucosa pancreaticojejunostomy is superior, equivalent or inferior to traditional duct-to-mucosa pancreaticojejunostomy.
- Future studies should use adequate methods to improve our confidence in the evidence.
What is a postoperative pancreatic fistula?
The pancreas is a digestive gland located at the back of the upper abdomen; it is also vital to the normal control of blood sugar. The standard surgical treatment for cancer or inflammation of the pancreas is partial removal of the head of the pancreas, together with the nearby gut, through a procedure known as pancreaticoduodenectomy. Pancreaticoduodenectomy involves reconnecting the pancreas and the second part of the small intestine (a procedure known as pancreaticojejunostomy) to allow pancreatic juice containing digestive enzymes to enter the digestive system. A postoperative pancreatic fistula occurs when the reconnection does not heal properly, creating a leakage of pancreatic juice from the pancreas to the abdominal tissues. Postoperative pancreatic fistula is a complication that delays recovery from surgery and often requires further treatment to ensure complete healing.
What can we do to reduce postoperative pancreatic fistula?
Methods of reconnecting the pancreas and the second part of the small intestine for people undergoing pancreaticoduodenectomy include:
-duct-to-mucosa pancreaticojejunostomy;
-invagination pancreaticojejunostomy;
-binding pancreaticojejunostomy (binding the pancreas and the second part of the small intestine).
Duct-to-mucosa pancreaticojejunostomy is a method that is commonly used worldwide to reduce postoperative pancreatic fistula after pancreaticoduodenectomy. However, the safety and effectiveness of duct-to-mucosa pancreaticojejunostomy is still uncertain.
What did we want to find out?
We wanted to find out whether duct-to-mucosa pancreaticojejunostomy is better than any other type of pancreaticojejunostomy to improve:
- rate of postoperative pancreatic fistula (proportion of participants with postoperative pancreatic fistula);
- death rate.
We also wanted to find out if duct-to-mucosa pancreaticojejunostomy is associated with any unwanted effects.
What did we do?
We searched for studies that compared:
- duct-to-mucosa pancreaticojejunostomy against any other type of pancreaticojejunostomy; or
- different types of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy.
We compared and summarized the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 10 studies involving 1472 people in which duct-to-mucosa pancreaticojejunostomy was compared with invagination pancreaticojejunostomy in people undergoing pancreaticoduodenectomy. The largest study included 308 people, and the smallest study included 64 people. The studies were conducted in countries around the world; most were done in China (4). Most studies lasted for approximately 2 years; only three studies lasted for 4 years or more. Non-commercial grants funded four of the studies. We cannot tell from the results of these studies whether duct-to-mucosa pancreaticojejunostomy reduces:
- rate of postoperative pancreatic fistula; or
- death rate.
The studies did not report any unwanted effects.
We found only one single-center study involving 224 people in which modified duct-to-mucosa pancreaticojejunostomy was compared with traditional duct-to-mucosa pancreaticojejunostomy in people undergoing pancreaticoduodenectomy. The study was conducted in Japan and lasted for approximately 4 years. The study did not report its funding sources. We cannot tell from the results of this study whether modified duct-to-mucosa pancreaticojejunostomy reduces:
- rate of postoperative pancreatic fistula; or
- death rate.
The study did not report any unwanted effects.
What are the limitations of the evidence?
We have very little confidence in the evidence because most of the studies included had some limitations in terms of how they were conducted or reported.
How up to date is this evidence?
The evidence is up to date to January 2021.
The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.
Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain.
To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques.
We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021).
We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy.
Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes.
We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias.
Duct-to-mucosa versus any other type of pancreaticojejunostomy
We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes.
One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy
We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes.