Braun Enteroenterostomy Following Pancreaticoduodenectomy

Pancreaticoduodenectomy (PD) holds high postoperative morbidity. How to resolve this issue is challenged. An additional anastomosis (Braun enteroenterostomy) following PD may decrease the postoperative morbidity, but holds conflicting results. The objective of this study is to investigate the advantages and disadvantages of Braun enteroenterostomy in PD. Clinical studies compared perioperative outcomes between the Braun group and the non-Braun group following PD before December 21, 2014 were retrieved and filtered from PubMed, EMBASE, Web of Science, the Cochrane Library, and Chinese electronic databases (VIP database, WanFang database, and CNKI database). Relevant data were extracted according to predesigned sheets. Blood loss, operating time, and postoperative mortality and morbidity were evaluated using odds ratio (OR), weighted mean difference, or standard mean difference (SMD). Ten studies concerning 1614 patients were included. No significant differences between the Braun and the non-Braun group were identified in mortality (OR: 0.65, 95% confidence interval [CI]: 0.26–1.60), intraoperative blood loss (SMD: 0.035, 95% CI: 0.253 to 0.183), postoperative pancreatic fistula (POPF) (OR: 0.67, 95% CI: 0.35–1.67), bile leakage (OR: 0.537, 95% CI: 0.287–1.004), postoperative gastrointestinal hemorrhage (OR: 1.17, 95% CI: 0.578–2.385), intraabdominal abscesses (OR: 0.793, 95% CI: 0.444–1.419), wound complications (OR: 0.806, 95% CI: 0.490–1.325), and hospital stay (SMD: 0.098, g Qian, MD, Rong D, Yong-Wei Zhang, MD rate (OR: 0.66, 95% CI: 0.49–0.91), lower clinically relevant delayed gastric emptying (Grades B and C) (OR: 0.375, 95% CI: 0.164–0.858), lower nasogastric tube reinsertion (OR: 0.436, 95% CI: 0.232–0.818), and less postoperative vomiting (OR: 0.444, 95% CI: 0.262–0.755). Braun enteroenterostomy can be safely performed during PD. It is beneficial for patients and could be recommended in PD from the current published data. PROSPERO registration number: CRD42015016198. (Medicine 94(32):e1254) Abbreviations: BEE = Braun enteroenterostomy, CR-DGE = clinically relevant delayed gastric emptying, DGE = delayed gastric emptying, ISGPS = International Study Group of Pancreatic Surgery, OR = odds ratio, PD = pancreaticoduodenectomy, POPF = postoperative pancreatic fistula, SMD = standard mean difference, WMD = weighted mean difference. INTRODUCTION P ancreaticoduodenectomy (PD) is the first choice of curative treatments for pancreatic cancer and periampullary adenocarcinoma. Since the first PD was reported in the 1930s, the operative mortality rate remained between 20% and 40% in the following 50 years. With the improvements of surgical techniques, instruments, and perioperative managements, the mortality rates of PD have dramatically reduced to <5%, while the postoperative morbidity rate remains high (30% to 50%), even up to 60%. Postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE), which always result in prolonged hospital stay and increased costs, are the 2 common postoperative complications after PD. Based on the definition of the International Study Group, the incidence of POPF is 14% to 60%, and the incidence of DGE is 38% to 57%. How to reduce the postoperative mortality and morbidity, including POPF and DGE, is ever a challenged issue. The optimal way of digestive reconstructions to minimize POPF or DGE is controversial. Braun enteroenterostomy (BEE), first reported 100 years ago, might be a useful technique to decrease the morbidity rate, especially the incidence of DGE. It is an anastomosis between the afferent and efferent limbs, which is distal to a gastroenterostomy or duodenoenterostomy. It is designed to divert pancreatic juice and bile from the afferent limb, leading to decreased reflux into the stomach. It was reported that Braun jejunojejunostomy diverted jejunal contents and prevented postoperative alkaline reflux gastritis in Billroth II gastric resection, leading decreased postgastrectomy complications and offering an alternative resolution to intractable ymptomatic dyspepsia/‘‘bile reflux.’’ , Wang et al reported an addition of Billroth II in gastric cancer surgery www.md-journal.com | 1 our meta-analysis: 6 in China, 1 in USA, 1 in Australia, 1 in German, and 1 in Japan. The sample size of BEE following PD ranged from 21 to prolonged patients’ survival. In theory, BEE following classic PD potentially stabilizes and prevents kinking at the gastroenterostomy, and delivers pancreatic and biliary juices away from the stomach, suggesting that BEE is a promising reconstruction possibly associated with lower DGE. However, conflicting results of clinical effects of BEE were reported. Zhang et al reported BEE following classic PD did not decrease DGE, while others showed BEE reduced the incidence of DGE. Therefore, the advantages and disadvantages of BEE during PD remain controversial. Till now, no well-designed large-scale randomized controlled trials have been done to investigate outcomes of BEE following PD. Only several retrospective studies describe the relationships between BEE and the postoperative complications in PD, but hold inconsistent results. Abraham et al confirmed the pooling results of high-quality nonrandomized comparative trials were similar to those of randomized controlled trials when comparing surgical outcomes using meta-analysis. The purpose of this study is to evaluate possible associations between BEE and patient-relevant outcomes from PD through systematically pooling results, and to determine clinical impacts of BEE during PD. MATERIALS AND METHODS Search Strategy PubMed, EMBASE, Web of Science, the Cochrane Library, and Chinese electronic databases (VIP database, WanFang database, and CNKI database) were systematically searched, and the final search date was December 21, 2014. The following combined terms were used: ‘‘Braun enteroenterostomy’’ or ‘‘Braun anastomosis,’’ and the language was limited to English or Chinese. The reference list was also manually checked to find pertinent articles. Inclusion Criteria All studies included in this meta-analysis must meet the following criteria: the surgical procedure was PD; the intervention group was BEE following PD; the control group was PD without BEE; and one of shortor long-term postoperative outcomes could be extracted. Excluded Criteria Studies with the following characteristics were excluded: animal researches, conference abstracts, letters, comments, editorials, expert opinions, reviews without original data, and non-English or non-Chinese language articles, duplicates and repeated series published by the same centre. Data Extraction Titles and abstracts were checked for the potentially eligible studies. Full articles were founded for the detailed evaluation. Regarding articles reported by the same institution, either the study with better quality or the more recent publication was included. All data extractions were performed separately by BX and Y-HZ. Disagreements were settled by discussion. The following data from each included study were extracted: first author, year of publication, details of where the studies were conducted, the study period, sample sizes, baseline characteristics of the studies, perioperative outcomes, hospital Xu et al stay, duration of follow-ups. Perioperative outcomes included operative time, operative blood loss, reoperation rate, morbidity, mortality, etc. 2 | www.md-journal.com Qualitative Assessment The quality assessment of included studies was evaluated using Newcastle–Ottawa quality assessment scale (website URL: http://www.ohri.ca/programs/clinical_epidemiology/ oxford.asp). A score of 0 to 9 stars was used to assess the quality of each study. Studies labeled with 6 stars or greater were considered to be high quality. Statistical Analysis Estimating the mean and variance from the median, range, and the size of a sample was performed using Hozo’s method. The point estimate of the odds ratio (OR), weighted mean difference, or standard mean difference (SMD) was considered statistically significant at P< 0.05. The I squared (I) statistic and chi-squared (x) test were used to evaluate the heterogeneity; significance was identified at I> 50% and P< 10%, respectively. The random-effect model was used if there was significant heterogeneity between the studies; otherwise, the fixed-effect model was used; 0.5 was added to each cell of the 2 2 table for studies with 0 cells to avoid problems with computation of estimates and standard errors according to Cochrane Manual for data transforming. Publication bias was assessed by the funnel plot; Egger’s test and Begg’s test were used to detect the difference. Analysis of the main results was performed using Comprehensive Meta-Analysis (Version 2.0).