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Indian Journal of Medical and Paediatric Oncology
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EDITORIAL COMMENTARY
Year : 2016  |  Volume : 37  |  Issue : 4  |  Page : 209-210  

Classical or pylorus-preserving pancreatoduodenectomy in pancreatic and periampullary cancer: “The jury is still out!”


Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta - The Medicity, Sector 38, Gurgaon, Haryana, India

Date of Web Publication14-Dec-2016

Correspondence Address:
Savio George Barreto
Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta - The Medicity, Sector 38, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-5851.195747

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How to cite this article:
Barreto SG. Classical or pylorus-preserving pancreatoduodenectomy in pancreatic and periampullary cancer: “The jury is still out!”. Indian J Med Paediatr Oncol 2016;37:209-10

How to cite this URL:
Barreto SG. Classical or pylorus-preserving pancreatoduodenectomy in pancreatic and periampullary cancer: “The jury is still out!”. Indian J Med Paediatr Oncol [serial online] 2016 [cited 2017 Jul 24];37:209-10. Available from: http://www.ijmpo.org/text.asp?2016/37/4/209/195747



Hüttner et al.[1] present an update of their previous Cochrane review [2] comparing pylorus-preserving pancreaticoduodenectomy (pylorus-preserving Whipple [PPW]) versus classical pancreaticoduodenectomy (classic Whipple [CW]) for surgical treatment of periampullary and pancreatic carcinoma. The updated review included two new trials [3],[4] published since the last version taking the tally of included trials to eight overall.[3],[4],[5],[6],[7],[8],[9],[10],[11] The present review,[1] similar to the previous one,[2] looked at the primary outcomes including pancreatic fistula, delayed gastric emptying (DGE), and biliary leak rates, secondary outcomes such as survival and postoperative mortality, and perioperative parameters such as intraoperative blood loss, red blood cell transfusion, operating time, postoperative bleeding, wound infection, pulmonary complications, necessity for re-operation, duration of hospital stay, quality of life, and status of resection margin.

[Table 1] compares the various outcomes analyzed in the two manuscripts. The findings of the updated review largely echo the previous results, namely, there exists no difference between the CW and PPW in terms of overall morbidity, mortality, and survival. However, a novel finding in the updated version is the significantly increased risk of DGE in patients undergoing a PPW. On the flipside, PPW has been consistently shown to be associated with shorter operating times, lower intraoperative blood loss, and hence, a reduced need for blood transfusion.
Table 1: Comparison of the outcomes analyzed between the two studies

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As was lucidly stated by the authors in the discussion, the analysis does reveal problems related to heterogeneity between the studies, variation in definitions used within the trials as well as the process of randomization. Even the intention-to-treat analysis was specified in only one trial.[10] Also, not considered in the analysis are the data on whether the patients received neoadjuvant or adjuvant therapy – a significant determinant or morbidity, mortality, and survival.

Despite its inherent shortcomings, this manuscript represents the most updated review published on the topic and provides a “real world” overview of the differences (or lack of them) between the procedures for the management of pancreatic and periampullary cancers considering that the authors in the Collaboration with the Cochrane system have conducted an analysis reducing the influence of bias and heterogeneity as best they could.

However, this review certainly provides sufficient justification for a large randomized controlled trial investigating CW and PPW in pancreatic and periampullary cancers to more conclusively answer this question.

 
  References Top

1.
Hüttner FJ, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Büchler MW, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2016;2:CD006053.  Back to cited text no. 1
    
2.
Diener MK, Fitzmaurice C, Schwarzer G, Seiler CM, Hüttner FJ, Antes G, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2014;11:CD006053.  Back to cited text no. 2
    
3.
Srinarmwong C, Luechakiettisak P, Prasitvilai W. Standard Whipple's operation versus pylorus preserving pancreaticoduodenectomy: A randomized controlled trial study. J Med Assoc Thai 2008;91:693-8.  Back to cited text no. 3
    
4.
Taher MA, Khan ZR, Chowdhury MM, Nur-E-Elahi M, Chowdhury AK, Faruque MS, et al. Pylorus preserving pancreaticoduodenectomy vs. standard Whipple's procedure in case of carcinoma head of the pancreas and periampullary carcinoma. Mymensingh Med J 2015;24:319-25.  Back to cited text no. 4
    
5.
Bloechle C, Broering D, Latuske C. Prospective randomized study to evaluate quality of life after partial pancreatoduodenectomy according to Whipple versus pylorus preserving pancreatoduodenectomy according to Longmire-Traverso for periampullary carcinoma. Dtsch Gesellschaft Chir 1999;Suppl 1:661-4.  Back to cited text no. 5
    
6.
Lin PW, Lin YJ. Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy. Br J Surg 1999;86:603-7.  Back to cited text no. 6
    
7.
Lin PW, Shan YS, Lin YJ, Hung CJ. Pancreaticoduodenectomy for pancreatic head cancer: PPPD versus Whipple procedure. Hepatogastroenterology 2005;52:1601-4.  Back to cited text no. 7
    
8.
Seiler CA, Wagner M, Bachmann T, Redaelli CA, Schmied B, Uhl W, et al. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results. Br J Surg 2005;92:547-56.  Back to cited text no. 8
    
9.
Paquet KJ. Comparison of Whipple's pancreaticoduodenectomy with the pylorus-preserving pancreaticoduodenectomy – A prospectively controlled, randomized long-term trial [Vergleich der partiellen Duodenopankreatektomie (Whipple-Operation) mit der pyloruserhaltenden Zephaloduodenopankreatektomie – Eine prospektive kontrollierte, randomisierte Langzeitstudie]. Chir Gastroenterol 1998;14:54-8.  Back to cited text no. 9
    
10.
Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW, et al. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: A prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 2004;240:738-45.  Back to cited text no. 10
    
11.
Wenger FA, Jacobi CA, Haubold K, Zieren HU, Müller JM. Gastrointestinal quality of life after duodenopancreatectomy in pancreatic carcinoma. Preliminary results of a prospective randomized study: Pancreatoduodenectomy or pylorus-preserving pancreatoduodenectomy. Chirurg 1999;70:1454-9.  Back to cited text no. 11
    



 
 
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