A Network Meta-Analysis Comparing Gastric Resection Approaches and Enteric Anastomotic Configurations on Delayed Gastric Emptying Following Pancreaticoduodenectomy

Abstract

Introduction: Delayed gastric emptying (DGE) is frequent following pancreaticoduodenectomy (PD). Several randomized controlled trials (RCTs) have explored operative strategies to minimize DGE, however, the optimal combination of gastric resection approach, anastomotic route, configuration and the use of enteroenterostomy remains unclear. Method: MEDLINE, Embase, and CENTRAL databases were systematically searched for RCTs comparing gastric resection (classic Whipple, pylorus-resecting, pylorus-preserving), anastomotic route (antecolic, retrocolic), configuration (loop gastroenterostomy/Billroth II, Roux-en-Y), and use of Braun enteroenterostomy. A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimizing DGE. Results: A total of 24 RCTs, including 2526 patients and 14 approaches to PD were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6%. Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy (Figure 1) was associated with the lowest rates of DGE, and ranked the best in 35% of comparisons. Classic Whipple, retrocolic, Billroth II with Braun enteroenterostomy ranked the worst for DGE, in 32% of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (OR 2.10, 95% CrI: 0.92-4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when a Braun enteroenterostomy was used (OR 1.90, 95% CrI: 0.92-3.90). Conclusions: Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE.