Postoperative weight gain after standard Whipple's procedure versus pylorus-preserving pancreatoduodenectomy: The influence of tumour status

Department of Surgery, Academic Medical Centre, University of Amsterdam, The Netherlands.
British Journal of Surgery (Impact Factor: 5.21). 08/1998; 85(7):922-6. DOI: 10.1046/j.1365-2168.1998.00745.x
Source: PubMed

ABSTRACT Recent reports suggest a better postoperative weight gain after pylorus-preserving pancreatoduodenectomy (PPPD) compared with standard pancreatoduodenectomy (PD). Factors that could also influence postoperative weight gain, such as tumour-positive resection margins and tumour recurrence, have not been taken into account in these studies. The aim of this prospective study was to evaluate weight gain in the first 15 months after PD or PPPD and to investigate the influence of other tumour-related factors.
From 1991 to 1995, 140 patients underwent subtotal pancreatoduodenectomy; 125 patients underwent resection for malignant disease of the pancreatic head region (56 had PD and 69 PPPD). Patients' weights were evaluated in the pre-illness phase, before operation and during four postoperative phases (at 3, 7, 11 and 15 months). Weight was calculated as a percentage of the pre-illness weight. Patients were subdivided according to tumour status: PD with positive and PD with negative tumour status; PPPD with positive and PPPD with negative tumour status. Tumour-positive status was defined as either microscopically tumour-positive resection margins or radiologically or cytologically proven tumour recurrence within 2 years of surgery.
Five patients died during the hospital stay (PD, four; PPPD, one) (overall mortality rate 4 per cent). There was no difference in overall weight gain between patients having PD and PPPD. There was, however, a difference in patients with positive and negative tumour status for PD (P = 0.0003) and PPPD (P< 0.0001).
There is only a minimal difference in postoperative weight gain between patients having PD and PPPD. Differences in postoperative weight gain are related more to positive resection margins and tumour recurrence than to the type of resection.

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    ABSTRACT: HintergrundZur chirurgischen Therapie des Pankreaskopfkarzinoms und des periampullären Karzinoms stehen die pyloruserhaltende und die klassische Operation nach Whipple („pylorus-preserving Whipple“ und „classical Whipple“) zur Verfügung. MethodenDie vorliegende Arbeit stellt eine Erweiterung einer in Annals of Surgery publizierten systematischen Übersichtsarbeit mit Metaanalyse dar. Mithilfe einer systematischen Suchstrategie wurde in den Datenbanken MEDLINE, EMBASE und THE Cochrane Library (CENTRAL) nach kontrollierten und randomisierten kontrollierten Studien (RCT) zum Vergleich der klassischen Whipple-Operation und der pyloruserhaltende Pankreatikoduodenektomie gesucht. Eine auf dem Random-effects-Modell basierende Metaanalyse wurde für die Endpunkte Überleben (Hazard Ratios, HR) und postoperative Mortalität (Odds Ratio, OR) durchgeführt. Die postoperative Lebensqualität konnte nicht quantitativ im Sinne einer Metaanalyse analysiert werden und wurde daher qualitativ zusammengefasst. Subgruppen- und Sensitivitätsanalysen wurden nach Studientyp (RCTs, prospektive Studien, PS, retrospektive Studien, RS), Studienqualität und Tumorlokalisation durchgeführt. ErgebnisseDie systematische Literatursuche ergab 4503 Suchresultate, von denen 4460 nicht den Einschlusskriterien entsprachen. 23Studien mit insgesamt 3893 Patienten wurden eingeschlossen (6RCTs, 12PS und 25RS). Für Patienten mit Pankreaskopfkarzinom (RCTs: HR 0,80; 95%-KI 0,53–1,22; p=0,16; PS: HR 0,84; 95%-KI 0,7–1,0; p=0,95; RS: HR 0,84; 95%-KI 0,7–1,01; p=0,21) und periampullären Karzinom (RCTs: HR 1,02; 95%-KI 0,49–2,13; p=0,3; PS: HR 1,26; 95%-KI 0,46–3,42; p=0,65; RS: HR 0,86; 95%-KI 0,6–1,24; p=0,33) zeigte sich in den einzelnen Studientypen kein Unterschied im Überleben. Im Vergleich der beiden Operationsmethoden unterschied sich die postoperative Mortalität nicht signifikant (RCTs: OR 0,49; 95%-KI 0,17–1,4; p=0,18; PS: OR 0,63; 95%-KI 0,34–1,18; p=0,15; RS: OR 0,7; 95%-KI 0,37–1,31; p=0,27). Die postoperative Lebensqualität wurde in den einzelnen Studien entweder als nicht unterschiedlich oder als besser nach pyloruserhaltender Operation beschrieben. SchlussfolgerungDiese systematische Übersichtsarbeit zeigt bei insgesamt eingeschränkter Qualität der eingeschlossenen Studien keine Unterschiede für Überleben, Mortalität und Lebensqualität im Vergleich der pyloruserhaltenden und der klassischen Whipple-Operation. Die Bestätigung dieser Ergebnisse durch eine große, pragmatische randomisiert kontrollierte Studie erscheint sinnvoll. BackgroundTwo surgical procedures are mainly performed for the treatment of pancreatic head cancer and periampullary carcinoma: the classical Whipple operation and the pylorus-preserving Whipple operation. 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The remaining 43 studies (6 RCTs, 12 PSs and 25 RSs) representing 3,893 patients were finally included in the review. There was neither a significant survival difference for patients with pancreatic head cancer in the pooled estimate of the RCTs (HR 0.80; 95% CI 0.53–1.22; p=0.16) nor in the pooled estimate of the PSs (HR 0.84; 95% CI 0.7–1.0; p=0.95) or the RSs (HR 0.84; 95% CI 0.7–1.01; p=0.21). Survival of patients with periampullary carcinoma was not significantly different in the RCTs (HR 1.02; 95% CI 0.49–2.13; p=0.3), the PSs (HR 1.26; 95% CI 0.46–3.42; p=0.65) or the RSs (HR 0.86; 95% CI 0.6–1.24; p=0.33). Postoperative mortality was not significantly different after both types of operations (RCTs: HR 0.49; 95% CI 0.17–1.4; p=0.18; PSs: HR 0.63; 95% CI 0.34–1.18; p=0.15; RSs: HR 0.7; 95% CI 0.37–1.31; p=0.27). QoL was reported as either the same in both groups or in favor of the pylorus-preserving Whipple operation. 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