All 7 studies compared the 2 anastomotic techniques with regard to the POPF rate (RR, 0.61; 95% CI, 0.34-1.09; P=0.09) (Fig. 3). The rate of POPF in the 3 multicenter studies was lower in the PG group (RR, 0.45; 95% CI, 0.21-0.98; P=0.04) (Fig. 4A), but no significant difference was found in single-center studies (RR, 0.87; 95% CI, 0.35-2.17; P=0.76) (Fig. 4B). The incidence of POPF after 2-layer PG was not significantly different from that of PJ (RR, 0.8; 95% CI, 0.22-3.18; P=0.80) (Fig. 4C). No statistically significant differences were observed in the incidence rates of POPF in 4 of 7 RCTs, and the incidence after single-layer PG was not significantly different from that of PJ (RR, 0.53; 95% CI, 0.27-1.02; P=0.06) (Fig. 4D). The meta-analysis of 7 studies also showed no significant difference in the rate of POPF in the PG group versus the duct-to-mucosa or telescope PJ group (RR, 0.63; 95% CI, 0.33-2.18; P=0.15 vs. RR, 0.74; 95% CI, 0.15-3.79; P=0.72) (Figs. 5E, F).
Six RCTs reported the overall PPH incidence (81/555 vs. 48/523) in the PG and PJ groups, respectively. A meta-analysis of the 6 studies, using a fixed-effect model, demonstrated that PJ was significantly superior to PG (RR, 1.65; 95% CI, 1.13-2.42, P=0.01) (Fig. 5A). Three RCTs that reported the overall PPH incidence were multicenter trials. A meta-analysis of these 3 studies demonstrated that PJ was significantly superior to PG (RR, 1.80; 95% CI, 1.19-2.72; P=0.005) (Fig. 5B). Four RCTs reported the overall PPH incidence in single centers. A meta-analysis of these 4 studies showed that PJ was not significantly superior to PG (RR, 1.09; 95% CI, 0.44-2.67; P=0.85) (Fig. 5C). Two RCTs reported the overall PPH incidence after 2-layer PG. A meta-analysis of these 2 studies demonstrated that PJ was not significantly superior to PG (RR, 1.89; 95% CI, 0.79-4.48; P=0.15) (Fig. 5D). Four RCTs reported the overall PPH incidence after single-layer PG. A meta-analysis of these 4 studies demonstrated that PJ was significantly superior to PG (RR, 1.69; 95% CI, 1.10-2.59; P=0.02) (Fig. 5D).
Six RCTs reported the overall DGE incidence (13/555 vs. 116/531) in the PG and PJ groups. A meta-analysis of these 6 studies demonstrated that PG was not significantly superior to PJ (RR, 1.10; 95% CI, 0.82-1.48; P=0.50) (Fig. 6A).
Three RCTs reported the bile fistula incidence (9/269 vs. 10/249) in the PG and PJ groups. A meta-analysis of 6 studies demonstrated that PG was not significantly superior to PJ (RR, 0.85; 95% CI, 0.34-2.11; P=0.73) (Fig. 6B).
Seven RCTs reported mortality rates (24/603 vs. 24/581) in the PG and PJ groups. A meta-analysis of these 7 studies demonstrated that PG was not significantly superior to PJ (RR, 0.84; 95% CI, 0.53-1.68; P=0.84) (Fig. 6C).
Four RCTs reported morbidity rates (158/308 vs. 161/317) in the PG and PJ groups. A meta-analysis of 4 studies demonstrated that PG was not significantly superior to PJ (RR, 1.00, 95% CI, 0.57-1.72, P=1.00) (Fig. 6D).
Five RCTs reported reoperation rates (46/490 vs. 52/473) in the PG and PJ groups. A meta-analysis of 5 studies demonstrated that PG was not significantly superior to PJ (RR, 0.81; 95% CI, 0.53-1.24, P=0.34) (Fig. 6E).
The surgical reconstruction techniques of PG include single-layer or double-layer PG with or without anterior gastrotomy. Few studies have examined the effect of different PG reconstruction techniques on POPF occurrence. This study demonstrated no difference in the incidence of POPF between 2-layer and single-layer techniques. Similar results were obtained in another study.16 Two predominant methods of PJ reconstruction exist: duct-to-mucosa anastomosis and invagination of the pancreatic remnant. No conclusive evidence to favor 1 method over the other exists. The subgroup analysis of the duct-to-mucosa and telescope techniques showed no difference between PG and PJ. These studies may indicate that specific surgical approaches in PG and PJ have little impact on POPF occurrence. The choice is determined by surgeon preference and the familiarity with different surgical approaches. However, it remains debatable which is the better reconstruction method after PD. However, the details of specific surgical methods were varied in these studies, and this conclusion remains to be further studied.
Another complication after PD is PPH. In the previous RCTs, the incidence of PPH was significantly higher in the PG group than in the PJ group.1,28,29 One potential reason is the abundant blood supply. A similar conclusion is also shown in the present study.35 The different PG anastomotic techniques include the single-layer or double-layer technique. For this reason, we have provided a subgroup analysis. In the 2-layer subgroup, the incidence of PPH in the PG group was similar to that of the PJ group. However, the rate of PPH was higher in the single-layer PG subgroup. A possible explanation is that double-layer anastomosis reduces the incidence of gastrointestinal tract bleeding after PG. PPH includes gastrointestinal bleeding and intraperitoneal hemorrhage. Among the 7 included RCTs, some studies did not distinguish between gastrointestinal bleeding and intraperitoneal hemorrhage. Further study on bleeding due to different causes is needed.
No differences were observed in DGE after PD between the 2 anastomosis groups. High heterogeneity was found between studies because of the lack of a standard definition of DGE among the studies. As previously described, some factors such as old age, early enteral nutrition and resection techniques, including PD and pylorus preserving pancreatoduodenectomy (PPPD), are the major risk factors of DGE after PD. Therefore, more RCTs on this subject are needed. No differences were observed between groups in the incidence of other site-related complications such as enteric or biliary fistula, mortality, morbidity, and reoperation, although these factors were only reported in a few studies.
Some limitations should be considered with regard to this review. First, the details of the surgical technique, such as the use of pancreatic stents and different types of sutures, are highly heterogeneous. In addition, because it was not possible to perform subgroup analyses according to pancreatic duct size, pancreatic texture or pancreatic pathology, it is unclear whether the potential advantages of PG are applicable to all subgroups of patients. Third, the use of prophylactic somatostatin or somatostatin analogs may also contribute to reducing the risk of POPF.
We would like to acknowledge and thank the native English-speaking biologists who provided medical writing services on behalf of American Journal Experts.
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