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A comparison of pancreaticoduodenectomy with extended pancreaticoduodenectomy: A meta-analysis of 1909 patients

      Abstract

      Aim

      To compare outcomes between pancreaticoduodenectomy (PD) and extended pancreaticoduodenectomy (EPD) from all published comparative studies in the literature.

      Methods

      Using meta-analytical techniques the present study compared operative details, post-operative adverse events and survival following PD and EPD. Comparative studies published between 1988 and 2005 of PD versus EPD were included. End points were classified into peri-operative details, post-operative complications including 30 day mortality, and survival as measured during follow up. A random effect model was employed.

      Results

      Sixteen comparative studies comprising 1909 patients (865 PD and 1044 EPD), including 3 randomized controlled trials with 454 patients (226 PD and 228 EPD) were identified. Tumour size was comparable between the groups (weighted mean difference (WMD) −0.16 cm, p = 0.76). Significantly more lymph nodes were harvested from those patients undergoing EPD (WMD p = 14 nodes, p ≤ 0.001). Operative time was longer in EPD (WMD −48.9 min, p < 0.001) and there was a trend towards fewer positive resection margins (odds ratio (OR) 1.78, p = 0.080). Peri-operative adverse events were similar between the groups with only delayed gastric emptying (OR 0.59, p = 0.030) occurring less frequently in the PD group. Peri-operative mortality (OR 1.48, p = 0.180) and long-term survival (hazard ratio 0.77, p = 0.100) showed a non-significant trend favouring EPD.

      Conclusions

      EPD is associated with a greater nodal harvest and fewer positive resection margins than PD. However, the risk of delayed gastric emptying is increased and no significant survival benefit has been shown. Better designed, adequately powered studies are required to settle this question.

      Keywords

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      References

        • O'Sullivan A.
        • Kocher H.M.
        Pancreatic cancer.
        BMJ Clin Evid. 2007; 11 (http://clinicalevidence.bmj.com/ceweb/conditions/dsd/0409/0409_contribdetails.jsp): 409-436
        • Neoptolemos J.P.
        • Stocken D.D.
        • Friess H.
        • et al.
        A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer.
        N Engl J Med. 2004; 350: 1200-1210
        • Fortner J.G.
        Regional resection of cancer of the pancreas: a new surgical approach.
        Surgery. 1973; 73: 307-320
        • Ishikawa O.
        • Ohhigashi H.
        • Sasaki Y.
        • et al.
        Practical usefulness of lymphatic and connective tissue clearance for the carcinoma of the pancreas head.
        Ann Surg. 1988; 208: 215-220
        • Manabe T.
        • Ohshio G.
        • Baba N.
        • et al.
        Radical pancreatectomy for ductal cell carcinoma of the head of the pancreas.
        Cancer. 1989; 64: 1132-1137
        • Satake K.
        • Nishiwaki H.
        • Yokomatsu H.
        • et al.
        Surgical curability and prognosis for standard versus extended resection for T1 carcinoma of the pancreas.
        Surg Gynecol Obstet. 1992; 175: 259-265
        • Naganuma T.
        • Isaji S.
        • Kawarada Y.
        Staging and extended resection for pancreatic cancer.
        Pancreas. 1998; 16: 355-362
        • Nakao A.
        • Harada A.
        • Nonami T.
        • Kaneko T.
        • Inoue S.
        • Takagi H.
        Clinical significance of portal invasion by pancreatic head carcinoma.
        Surgery. 1995; 117: 50-55
        • Mukaiya M.
        • Hirata K.
        • Satoh T.
        • et al.
        Lack of survival benefit of extended lymph node dissection for ductal adenocarcinoma of the head of the pancreas: retrospective multi-institutional analysis in Japan.
        World J Surg. 1998; 22: 248-252
        • Miyzaki I.
        • Nagakawa T.
        Extended lymphadenectomy in pancreatic resection for cancer.
        Williams & Wilkins, Baltimore1998
        • Yeo C.J.
        • Cameron J.L.
        • Lillemoe K.D.
        • et al.
        Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality.
        Ann Surg. 2002; 236: 355-366
        • Farnell M.B.
        • Pearson R.K.
        • Sarr M.G.
        • et al.
        A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma.
        Surgery. 2005; 138: 618-628
        • Pedrazzoli S.
        • DiCarlo V.
        • Dionigi R.
        • et al.
        Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group.
        Ann Surg. 1998; 228: 508-517
        • Henne-Bruns D.
        • Vogel I.
        • Luttges J.
        • Kloppel G.
        • Kremer B.
        Ductal adenocarcinoma of the pancreas head: survival after regional versus extended lymphadenectomy.
        Hepatogastroenterology. 1998; 45: 855-866
        • Michalski C.W.
        • Kleeff J.
        • Wente M.N.
        • Diener M.K.
        • Buchler M.W.
        • Friess H.
        Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer.
        Br J Surg. 2007; 94: 265-273
        • Clarke M.
        • Horton R.
        Bringing it all together: Lancet–Cochrane collaborate on systematic reviews.
        Lancet. 2001; 357: 1728
        • Stroup D.F.
        • Berlin J.A.
        • Morton S.C.
        • et al.
        Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group.
        JAMA. 2000; 283: 2008-2012
        • Egger M.
        • Davey Smith G.
        • Schneider M.
        • Minder C.
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Haldane J.B.
        The estimation and significance of the logarithm of a ratio of frequencies.
        Ann Hum Genet. 1956; 20: 309-311
        • Mantel N.
        • Haenszel W.
        Statistical aspects of the analysis of data from retrospective studies of disease.
        J Natl Cancer Inst. 1959; 22: 719-748
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • Sterne J.A.
        • Davey Smith G.
        Sifting the evidence-what's wrong with significance tests?.
        BMJ. 2001; 322: 226-231
        • Parmar M.K.
        • Torri V.
        • Stewart L.
        Extracting summary statistics to perform meta-analyses of the published literature for survival endpoints.
        Stat Med. 1998; 17: 2815-2834
        • Athanasiou T.
        • Al-Ruzzeh S.
        • Kumar P.
        • et al.
        Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients.
        Ann Thorac Surg. 2004; 77: 745-753
        • Capussotti L.
        • Massucco P.
        • Ribero D.
        • Vigano L.
        • Muratore A.
        • Calgaro M.
        Extended lymphadenectomy and vein resection for pancreatic head cancer: outcomes and implications for therapy.
        Arch Surg. 2003; 138: 1316-1322
        • Gazzaniga G.M.
        • Cappato S.
        • Papadia F.
        • Mori L.
        • Filauro M.
        D1 versus D2 pancreatoduodenectomy in surgical therapy of pancreatic head cancer.
        Hepatogastroenterology. 2001; 48: 1471-1478
        • Henne-Bruns D.
        • Kremer B.
        • Meyer-Pannwitt U.
        • Vogel I.
        • Schroder S.
        Partial duodenopancreatectomy with radical lymphadenectomy in patients with pancreatic and periampullary carcinomas: initial results.
        Hepatogastroenterology. 1993; 40: 145-149
        • Henne-Bruns D.
        • Vogel I.
        • Luttges J.
        • Kloppel G.
        • Kremer B.
        Surgery for ductal adenocarcinoma of the pancreatic head: staging, complications, and survival after regional versus extended lymphadenectomy.
        World J Surg. 2000; 24: 595-601
        • Iacono C.
        • Accordini S.
        • Bortolasi L.
        • et al.
        Results of pancreaticoduodenectomy for pancreatic cancer: extended versus standard procedure.
        World J Surg. 2002; 26: 1309-1314
        • Iacono C.
        • Bortolasi L.
        • Facci E.
        • et al.
        Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy?.
        J Gastrointest Surg. 1997; 1: 446-453
        • Kremer B.
        • Vogel I.
        • Luttges J.
        • Kloppel G.
        • Henne-Bruns D.
        Surgical possibilities for pancreatic cancer: extended resection.
        Ann Oncol. 1999; 10: S252-S256
        • Nguyen T.C.
        • Sohn T.A.
        • Cameron J.L.
        • et al.
        Standard vs. radical pancreaticoduodenectomy for periampullary adenocarcinoma: a prospective, randomized trial evaluating quality of life in pancreaticoduodenectomy survivors.
        J Gastrointest Surg. 2003; 7: 1-9
        • Popiela T.
        • Kedra B.
        • Sierzega M.
        Does extended lymphadenectomy improve survival of pancreatic cancer patients?.
        Acta Chir Belg. 2002; 102: 78-82
        • Riall T.S.
        • Cameron J.L.
        • Lillemoe K.D.
        • et al.
        Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma – part 3: update on 5-year survival.
        J Gastrointest Surg. 2005; 9: 1191-1206
        • Yang Y.-m.
        • Wan Y.-l.
        • Tian X.-d.
        • Zhuang Y.
        • Huang Y.-t.
        Outcome of pancreaticoduodenectomy with extended retroperitoneal lymphadenectomy for adenocarcinoma of the head of the pancreas.
        Chin Med J. 2005; 118: 1863-1869
        • Yeo C.J.
        • Cameron J.L.
        • Sohn T.A.
        • et al.
        Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome.
        Ann Surg. 1999; 229: 613-622
        • McCulloch P.
        • Nita M.E.
        • Kazi H.
        • Gama-Rodrigues J.
        Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach.
        Cochrane Database Syst Rev. 2004; (CD001964)
        • Singh Ranger G.
        • Mokbel K.
        The evolving role of sentinel lymph node biopsy for breast cancer.
        Eur J Surg Oncol. 2003; 29: 423-425
        • Crowe P.
        • Temple W.
        Management of the axilla in early breast cancer: is it time to change tack?.
        Aust N Z J Surg. 2000; 70: 288-296
        • Cserni G.
        • Gregori D.
        • Merletti F.
        • et al.
        Meta-analysis of non-sentinel node metastases associated with micrometastatic sentinel nodes in breast cancer.
        Br J Surg. 2004; 91: 1245-1252
        • Kim T.
        • Giuliano A.E.
        • Lyman G.H.
        Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis.
        Cancer. 2006; 106: 4-16
        • Kocher H.M.
        • Sohail M.
        • Benjamin I.S.
        • Patel A.G.
        Technical limitations of lymph node mapping in pancreatic cancer.
        Eur J Surg Oncol. 2007; 33: 887-891
      1. Iqbal N, Lovegrove RE, Tilney HS, et al. A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: a meta-analysis of 2822 patients. Eur J Surg Oncol 2008, in this issue.

        • van Berge Henegouwen M.I.
        • van Gulik T.M.
        • DeWit L.T.
        • et al.
        Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients.
        J Am Coll Surg. 1997; 185: 373-379
        • Schniewind B.
        • Bestmann B.
        • Henne-Bruns D.
        • Faendrich F.
        • Kremer B.
        • Kuechler T.
        Quality of life after pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head.
        Br J Surg. 2006; 93: 1099-1107
        • Stocken D.D.
        • Buchler M.W.
        • Dervenis C.
        • et al.
        Meta-analysis of randomised adjuvant therapy trials for pancreatic cancer.
        Br J Cancer. 2005; 92: 1372-1381
        • Knaebel H.P.
        • Marten A.
        • Schmidt J.
        • et al.
        Phase III trial of postoperative cisplatin, interferon alpha-2b, and 5-FU combined with external radiation treatment versus 5-FU alone for patients with resected pancreatic adenocarcinoma – CapRI: study protocol (ISRCTN62866759).
        BMC Cancer. 2005; 5: 37
        • Garcea G.
        • Dennison A.R.
        • Ong S.L.
        • et al.
        Tumour characteristics predictive of survival following resection for ductal adenocarcinoma of the head of pancreas.
        Eur J Surg Oncol. 2007; 33: 892-897
        • Kleeff J.
        • Michalski C.W.
        • Friess H.
        • Buchler M.W.
        Surgical treatment of pancreatic cancer: the role of adjuvant and multimodal therapies.
        Eur J Surg Oncol. 2007; 33: 817-823
        • Pedrazzoli S.
        • Beger H.G.
        • Obertop H.
        • et al.
        A surgical and pathological based classification of resective treatment of pancreatic cancer. Summary of an international workshop on surgical procedures in pancreatic cancer.
        Dig Surg. 1999; 16: 337-345