Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial

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To the Editor:
We read with great interest the article by Keck et al,1 tilted “Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial,” which was recently published in Annals of Surgery.
In this study, the authors conducted the largest multicenter randomized clinical trial to compare pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) after pancreatoduodenectomy (PD) in terms of postoperative pancreatic fistula (POPF) and perioperative complications and long-term outcomes. Results demonstrated that there was no significant difference in the incidence of POPF between the patients who underwent PG and PJ after PD according to the ISGPS definitions. Moreover, PG was associated with an increased rate of hemorrhages, perioperative stroke, and improved quality of life. However, we feel that there were still several aspects that required further clarifications.
One concern regarding this study is the very heterogeneous patient group in terms of the surgical indications (cystic neoplasm, neuroendocrine tumor, and so on) and suture methods (interrupted mattress, pursestring, and pursestring + interrupted), although the distributions between the two surgical groups were approximately equal. However, there may be specific clinicopathologic effects among these cases. It will be profound to describe separately according to different surgical indications and suture methods.
The second concern is the overall quality of life, the author revealed that the physical functioning scale scores measured by EORTC QLQ-C30 and PAN26 were significantly higher in the PG group that that in the PJ group, however, they did not make a comparison to the preoperative scores between the treatment groups. We want to know whether the authors are trying to describe that “quality of life can be improved by surgical management with PG after PD as the preferred option.” The study would be more valuable if the preoperative and postoperative scores were compared.
The third concern is the management and outcomes of postpancreatectomy hemorrhage (PPH). PPH is a major cause of morbidity and mortality after PD.2,3 The author revealed that there was a significantly more PPH event in the PG group. However, we want to know whether the treatment of such PPH patients is conservative, intervention, or reoperation? If patients received intervention procedure, whether patients underwent PG have better endoscopic accessibility than patients underwent PJ?
In summary, in view of these above limitations, results of the study should be interpreted with caution. Future studies are clearly needed before any final conclusion can be drawn especially in terms of symptomatic pancreatic fistula and other morbidities.
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