Abstract
Background
Pylorus-preserving pancreaticoduodenectomy (PPPD) was developed to improve postoperative gastrointestinal function while maintaining oncologic adequacy. However, conflicting evidence and concerns persist regarding increased delayed gastric emptying, warranting a national-level investigation.
Methods
This retrospective cohort study analyzed 40,063 adult pancreaticoduodenectomy procedures from the ACS NSQIP database (2014–2023). Patients were stratified into pylorus-preserving and non-pylorus-preserving groups. Multivariable regression models evaluated independent associations between pylorus-preserving status and clinical outcomes including infectious complications, blood transfusions, delayed gastric emptying, and length of stay.
Results
Of 40,063 pancreaticoduodenectomy procedures, 13,882 (34.6 %) were pylorus-preserving. PPPD was associated with lower rates of infectious complications (25.9 vs 27.5 %, P = 0.01) and blood transfusions (13.6 vs 16.4 %, P < 0.001), but higher delayed gastric emptying rates (17.1 vs 16.1 %, P = 0.02) and shorter length of stay (7 vs 8 days, P = 0.01). Readmission rates were similar (17.4 vs 17.9 %, P = 0.16). Following risk adjustment, PPPD remained associated with reduced infectious complications (AOR 0.94, 95 % CI 0.89–0.99) and blood transfusions (AOR 0.88, 95 % CI 0.82–0.95), but increased delayed gastric emptying (AOR 1.12, 95 % CI 1.04–1.21).
Conclusion
Despite declining utilization over the study period, PPPD offers significant advantages in reducing infectious complications and blood transfusion requirements while shortening operative times and hospital stay. However, the trade-off of increased delayed gastric emptying requires careful consideration in surgical decision-making. These findings support individualized approach selection based on patient complexity and surgeon expertise to optimize perioperative outcomes.
Introduction
Despite advances in its management, pancreatic cancer remains the fourth most common oncologic cause of death worldwide [1]. Pancreaticoduodenectomy (PD), commonly known as the Whipple operation, remains the standard surgical approach for resection of both malignant and benign lesions of the pancreatic head [2,3]. Following a series of technical refinements, the pylorus-preserving pancreaticoduodenectomy (PPPD) has been suggested to mitigate some of the adverse long-term events associated with the traditional PD. [4,5] Specifically, PPPD aims to reduce complications of gastric resection, such as early satiety, marginal ulceration, bile reflux gastritis and diarrhea, while maintaining oncologic adequacy for periampullary and pancreatic head lesions [[6], [7], [8]]. In recent years, surgeons have increasingly favored PPPD, with some citing reduced intraoperative blood loss and improved quality of life [9,10]. Although PPPD aims to preserve gastric function and enhance postoperative nutritional outcomes, concerns regarding increased risk of delayed gastric emptying (DGE) and potential compromise of oncological adequacy remain [11].
Interestingly, several meta-analyses and randomized controlled trials have suggested that PPPD and traditional PD yield comparable outcomes in terms of overall morbidity and long-term survival [[12], [13], [14], [15], [16]]. Furthermore, oncologic endpoints such as margin status and lymph node sampling appear to yield similar results between both techniques [16,17]. However, evidence regarding the development of DGE remains controversial with Kawai et al. demonstrating an increased incidence with PPPD [18]. Conversely, a study by Tran et al. found no significant difference in rates of DGE between PPPD and classical PD [19].
Although multiple randomized trials, meta-analyses, and large database studies have compared PPPD and classical Whipple, ongoing debate regarding DGE and other postoperative outcomes underscores the need for further analyses in diverse patient populations. In the present study, we characterized the association of pylorus preservation with short-term outcomes of PD operations in a contemporary national cohort. We hypothesized PPPD to be associated with reduced odds of most adverse clinical events, but an increased risk of DGE, shorter length of stay and lower readmission rates.
Methods
This was a retrospective cohort study of the 2014–2023 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use files. ACS NSQIP collects over 150 demographic, operative, and medical characteristics as well as 30-day postoperative outcomes from over 850 participating hospitals. Each contributing hospital conducts regular data collection and quality control audits with the help of a designated NSQIP-trained reviewer.
All elective adult (≥18 years) hospitalizations for PD were identified using previously validated Current Procedural Terminology (CPT) codes [20]. Records missing key data on age, sex, obesity, race and those discharged after November 30th of each year, were not considered (Fig. 1). The cohorts were stratified based on the operation type into Non-Pylorus Preserving and Pylorus Preserving cohorts.
Fig. 1.
Consort Diagram.
Demographic and clinical characteristics were defined using preexisting ACS NSQIP data elements and included age, female sex, body mass index (BMI), diabetes, hypertension, smoking status, chronic obstructive pulmonary disease, chronic steroid use, weight loss, preexisting bleeding disorder, functional status and American Society of Anesthesiologists (ASA) Class. Preoperative laboratory values, such as platelet count, hematocrit, white blood cell count, serum creatinine, and total bilirubin, were tabulated and treated in a continuous manner. Data from the Procedure Targeted Participant Use Files for pancreatectomy were used to stratify gland texture (soft, intermediate, hard), duct size (<3, 3–6, >6 mm) and operative approach (open and minimally invasive). Minimally invasive surgery (MIS) encompassed laparoscopic or robotic approaches while entries also containing codes for open surgery were open, open endoscopic, open laparoscopic and open laparoscopic thoracoscopic [3]. A subgroup analysis was subsequently performed among patients with cancer. In the malignancy-restricted sensitivity analysis, multivariable models additionally adjusted for T stage, perioperative chemotherapy/radiotherapy, and vascular resection to address tumor extent and treatment selection.
The primary outcomes of interest were 30-day mortality, DGE, development of pancreatic fistula, end organ damage (sepsis, septic shock, reintubation, progressive renal insufficiency and acute renal failure) and specific adverse events (cardiac, infectious and thromboembolic complications as well as reoperation and transfusion within 30 days of procedure). Infectious complications were defined using NSQIP variables and included superficial surgical site infection (SSI), deep SSI, organ/space SSI, and urinary tract infection (UTI). Secondary endpoints included operative duration, length of stay (LOS), non-home discharge and unplanned readmission within 30 days of index discharge [21].
Continuous variables are summarized as medians with interquartile range (IQR) or means with standard deviation (SD), if normally distributed. Categorical variables are reported as group proportions (%). The significance of differences was compared across groups using the Mann-Whitney U and Chi-Squared tests, respectively. Cuzick's nonparametric test was applied to determine the significance of temporal trends (nptrend) [22]. Multivariable logistic and linear regression models were developed to evaluate independent association of pylorus preservation with outcomes of interest. Model covariates were selected using elastic net regularization, which minimizes collinearity through a penalized least squares methodology [23]. Model performance was evaluated using receiver-operating characteristics and calibration plots, as appropriate. Regression outputs are reported as adjusted odds ratios (AOR) for logistic and beta coefficients (β) for linear models, both with 95 % confidence intervals (CI). α was set at 0.05 for statistical significance. All statistical analyses were performed on Stata 16.1 software (StataCorp, LLC, College Station, TX). This study was deemed exempt from full review by the Institutional Review Board at University California, Los Angeles.
Results
Patient and hospital characteristics
Of 40,063 pancreaticoduodenectomy procedures considered, 13,882 (34.6 %) comprised the Pylorus Preserving cohort. Utilization of PPPD steadily declined from 42 % in 2014 to 29 % in 2023. However, among minimally invasive cases, the proportion of PPPD increased significantly over time, suggesting a selective but growing role for PPPD in the context of MIS approaches (Fig. 2). Compared with others, PPPD patients were similar in age (50 [42–56] vs 50 [42–56] years, P = 0.13), but more commonly female (48.9 vs 45.8 %, P < 0.001). However, PPPD patients had lower rates of malignant postoperative pathological diagnosis (80.0 vs 84.5 %, P < 0.001), diabetes (25.8 vs 27.6 %; P < 0.001), congestive heart failure (0.9 vs 1.3 %; P < 0.001), and bleeding disorders (2.4 vs 3.2 %; P < 0.001), relative to others. Vascular resection (14.8 vs 19.5 %; P < 0.001) and surgical drain placement (91.7 vs 93.0 %; P < 0.001, Table 1) were less common among Pylorus Preserving. Moreover, Pylorus Preserving cases were more frequently performed via the open approach (91.4 vs 88.6 %; P < 0.001) compared to their counterparts.
Fig. 2.
Proportion of Pylorus Preserving vs Non-Pylorus Preserving Procedures Over Time.
Across the study period, the proportion of patients undergone pylorus preserving operation significantly decreased, from 42 % in 2014 to 29 % in 2023 while the proportion of non-pylorus preserving patients undergoing minimally invasive surgery increased from 9 % in 2014 to 13 % in 2023 (NPtrend<0.001). *Indicates statistical significance, P < 0.001.
Table 1.
Demographic and Clinical Characteristics, stratified by Pylorus preserving status.
Reported as percentages, unless otherwise noted. P-value ≤0.05 was considered statistically significant.
*IQR, interquartile range; SD, standard deviation; BMI, body mass index; ASA, American Society of Anesthesiologists (1, no disturbance; 2, mild disturbance; 3, severe disturbance; 4, life threatening; 5, moribund).
|
Pylorus Preserving (n = 13,882) |
Non- Pylorus Preserving (n = 26,181) |
P-value | |
|---|---|---|---|
| Age (median years [IQR]) | 50 [42–56] | 50 [42–56] | 0.13 |
| Female | 48.9 | 45.8 | <0.001 |
| Clinical Characteristics | |||
| Perioperative Biliary Stenting | 52.9 | 52.7 | 0.78 |
| Independent Functional Status | 99.3 | 99.1 | 0.04 |
| Perioperative Broad-spectrum Antibiotics | 41.1 | 39.3 | 0.01 |
| Open Operative Approach | 91.4 | 88.6 | <0.001 |
| Intra Operative Characteristics | |||
| Vascular Resection | 14.8 | 19.5 | <0.001 |
| Surgical Drain Placed | 91.7 | 93.0 | <0.001 |
| Race | 0.05 | ||
| White | 81.6 | 81.4 | |
| Black or African American | 8.3 | 8.9 | |
| Asian or Pacific Islander | 5.6 | 5.1 | |
| Other / Unknown | 4.5 | 4.6 | |
| Comorbidities | |||
| Diabetes | 25.8 | 27.6 | <0.001 |
| Hypertension | 53.2 | 54.0 | 0.11 |
| Smoker | 16.6 | 15.3 | <0.001 |
| Chronic Obstructive Pulmonary Disease | 4.0 | 3.8 | 0.27 |
| Congestive Heart Failure | 0.9 | 1.3 | <0.001 |
| Bleeding Disorder | 2.4 | 3.2 | <0.001 |
| Chronic Steroid Usage | 3.5 | 4.0 | 0.01 |
| Ascites | 0.2 | 0.3 | 0.35 |
| Obesity (BMI ≥ 30) | 26.8 | 27.6 | 0.10 |
| ASA Classification | 0.02 | ||
| 1 | 0.3 | 0.2 | |
| 2 | 20.2 | 19.7 | |
| 3 | 74.9 | 74.9 | |
| 4–5 | 4.5 | 5.1 | |
| Post Operation Pathological Diagnosis | <0.001 | ||
| Benign | 20.0 | 15.5 | |
| Malignant | 80.0 | 84.5 | |
| Gland Texture | 0.01 | ||
| Hard | 40.4 | 42.5 | |
| Intermediate | 12.0 | 12.1 | |
| Soft | 47.6 | 45.4 | |
| Duct Size | <0.001 | ||
| <3 mm | 29.7 | 31.7 | |
| 3–6 mm | 55.7 | 53.0 | |
| >6 mm | 14.6 | 15.2 |
Unadjusted outcomes
On unadjusted analysis, Pylorus Preserving patients were less likely to experience infectious complications (25.9 vs 27.5 %; P = 0.01) and blood transfusions (13.6 vs 16.4 %; P < 0.001), relative to others. However, Pylorus preserving had higher rates of DGE (17.1 vs 16.1 %; P = 0.02) compared to Non-Pylorus Preserving. Furthermore, Pylorus Preserving exhibited shorter length of stay (7 [6–11] vs 8 [6–11] days; P = 0.01) and operative time (6.0 ± 2.1 vs 6.5 ± 2.2 h; P < 0.001, Supplementary Table 1, Supplementary Fig. 1). Additionally, there was no statistically significant difference in 30-day readmission rates between Pylorus Preserving and Non-Pylorus Preserving groups (17.4 vs 17.9 %; P = 0.16, Fig. 3).
Supplementary Fig. 1.
Distribution of total length of stay by pylorus preservation status and DGE occurrence. PPPD demonstrates shorter hospital stays among DGE patients.
PPPD, pylorus preserving pancreaticoduodenectomy; DGE, delayed gastric emptying.
Fig. 3.
Cumulative risk of readmission within 30 days of discharge comparing PPPD and Non-PPPD.
CI, confidence interval; PPPD, pylorus preserving pancreaticoduodenectomy.
Risk-adjusted outcomes
Following adequate risk adjustment, the pylorus preserving technique was associated with reduced odds of infectious complications (AOR 0.95, 95 % CI 0.90–1.00), blood transfusions (AOR 0.93, 95 % CI 0.87–0.99) but increased odds of DGE (AOR 1.15, 95 % CI 1.08–1.22). Moreover, pylorus preservation was linked with a marginally shorter length of stay by 0.16 days (95 % CI -0.31-0.10) and operative times by 0.32 h (95 % CI -0.37-0.27, Supplementary Table 1, Fig. 4, Supplementary Fig. 2).
Fig. 4.
Risk-Adjusted Rates of Postoperative Complications by Pylorus Preservation.
* Indicates statistical significance, P < 0.001.
‡ End Organ Damage: Sepsis, Septic Shock, Renal Complications, Reintubation.
Supplementary Fig. 2.
Association of Pylorus preservation with outcomes of interest.
Following risk adjustment, pylorus preserving remained associated with greater odds of delayed gastric emptying and end organ damage but lower odds of blood transfusion and infectious complications.
End Organ Damage: Sepsis, Septic Shock, Renal Complications, Reintubation.
Subgroup analysis of patients with malignancy
Among patients with malignant pathology, PPPD accounted for a smaller proportion of resections relative to classic PD, consistent with the lower rate of malignant postoperative diagnosis in PPPD (80.0 % vs 84.5 %). Within the malignant subgroup, the relative utilization of PPPD was lower than in the overall cohort, reflecting selective use in less oncologically extensive cases. Among malignant, PPPD patients were similar in age (50 [43–57] vs 50 [43–57] years, P = 0.25), but more commonly female (48.0 vs 45.3 %, P < 0.001) compared to others. However, Pylorus Preserving had lower rates of perioperative chemotherapy (28.1 vs 35.6 %; P < 0.001), perioperative radiotherapy (7.5 vs 11.8 %; P < 0.001) and vascular resection (17.2 vs 21.8 %; P < 0.001) compared to their Non-Pylorus Preserving counterparts. Nonetheless, Pylorus Preserving patients demonstrated higher rates of perioperative biliary stenting (61.6 vs 59.1 %; P < 0.001). Additionally, Pylorus Preserving cases were more frequently performed via open approach (91.6 vs 89.2 %; P < 0.001, Table 2).
Table 2.
Demographic and Clinical Characteristics of Malignant, Stratified by Pylorus preserving.
Reported as percentages, unless otherwise noted. P-value ≤0.05 was considered statistically significant.
*IQR, interquartile range; BMI, body mass index; ASA, American Society of Anesthesiologists (1, no disturbance; 2, mild disturbance; 3, severe disturbance; 4, life threatening; 5, moribund).
|
Pylorus Preserving (n = 13,882) |
Non- Pylorus Preserving (n = 26,181) |
P-value | |
|---|---|---|---|
| Age (median years [IQR]) | 50 [43–57] | 50 [43–57] | 0.25 |
| Female | 48.0 | 45.3 | <0.001 |
| Clinical Characteristics | |||
| Perioperative Biliary Stenting | 61.6 | 59.1 | <0.001 |
| Independent Functional Status | 99.2 | 99.1 | 0.18 |
| Disseminated Cancer | 4.2 | 5.1 | 0.01 |
| Perioperative Broad-spectrum Antibiotics | 41.7 | 39.8 | 0.01 |
| Preoperative Chemotherapy | 28.1 | 35.6 | <0.001 |
| Preoperative Radiotherapy | 7.5 | 11.8 | <0.001 |
| Open Operative Approach | 91.6 | 89.2 | <0.001 |
| Intra Operative Characteristics | |||
| Vascular Resection | 17.2 | 21.8 | <0.001 |
| Surgical Drain Placed | 91.6 | 93.1 | <0.001 |
| Race | 0.02 | ||
| White | 81.2 | 81.5 | |
| Black or African American | 8.1 | 8.7 | |
| Asian or Pacific Islander | 5.9 | 5.1 | |
| Other / Unknown | 4.7 | 4.7 | |
| Comorbidities | |||
| Diabetes | 26.6 | 28.2 | 0.01 |
| Hypertension | 53.8 | 53.8 | 0.99 |
| Smoker | 14.9 | 14.3 | 0.19 |
| Chronic Obstructive Pulmonary Disease | 3.7 | 3.6 | 0.49 |
| Congestive Heart Failure | 0.9 | 1.3 | 0.01 |
| Bleeding Disorder | 2.6 | 3.4 | <0.001 |
| Chronic Steroid Usage | 3.4 | 4.1 | 0.01 |
| Ascites | 0.2 | 0.3 | 0.27 |
| Obesity (BMI ≥ 30) | 25.8 | 26.8 | 0.05 |
| ASA Classification | 0.16 | ||
| 1 | 0.2 | 0.1 | |
| 2 | 19.1 | 18.7 | |
| 3 | 75.8 | 75.7 | |
| 4–5 | 4.9 | 5.4 | |
| T Staging | <0.001 | ||
| T0–2 | 53.5 | 56.4 | |
| T3–4 | 46.5 | 43.6 | |
| Gland Texture | 0.01 | ||
| Hard | 43.0 | 45.3 | |
| Intermediate | 12.8 | 12.9 | |
| Soft | 44.2 | 41.8 | |
| Duct Size | 0.01 | ||
| <3 mm | 29.1 | 30.6 | |
| 3–6 mm | 56.7 | 54.4 | |
| >6 mm | 14.1 | 15.0 |
Among cancer cases, Pylorus Preserving patients were less likely to experience infectious complications (25.4 vs 26.8 %; P = 0.01) and blood transfusions (15.1 vs 17.5 %; P < 0.001). Furthermore, Pylorus Preserving exhibited shorter length of stay (7 [6–11] vs 8 [6–11] days; P < 0.001). Additionally, there was no statistically significant difference in 30-day readmission rates between Pylorus Preserving and Non-Pylorus Preserving groups (16.5 vs 16.6 %; P = 0.94). Following comprehensive risk adjustment in malignant cases, pylorus preserving was associated with reduced odds of pneumonia (AOR 0.84, 95 % CI 0.72–0.98) but notably increased odds of DGE (AOR 1.12, 95 % CI 1.04–1.21, Supplementary Table 2, Fig. 5).
Fig. 5.
Association of Pylorus preservation with outcomes of interest stratified by the presence of Malignancy.
Following risk adjustment, pylorus preserving remained associated with greater odds of delayed gastric emptying but lower odds of blood transfusions and infectious complications among malignant.
End Organ Damage: Sepsis, Septic Shock, Renal Complications, Reintubation.
Reference: Non-pylorus preserving. Error bars represent 95 % confidence intervals. * Indicates statistical significance, P < 0.001
Discussion
Given the evolving landscape of pancreatic surgery and refinement of surgical techniques, comparative evaluation of various techniques in the modern setting is warranted. In the present national study, we examined the association of pylorus preservation with clinical outcomes of pancreaticoduodenectomy and made several important observations. While the utilization of PPPD has declined significantly over the last decade, this approach remains linked with reduced risk of infectious complications and blood transfusion requirements but increased likelihood of delayed gastric emptying. Notably, PPPD was associated with shorter operative times and length of stay. Several of these findings merit further discussion.
Over the 10-year study window, the proportion of Whipple operations with pyloric preservation declined by 13 %, representing a significant shift in surgical practice patterns despite theoretical advantages. Our findings are in agreement with Calderan et.al who reported only 16.5 % of pancreatic head adenocarcinoma resections were performed as PPPD, with the majority (83.5 %) being standard PD between 2004 and 2014 [17]. These trends are corroborated by other high-volume centers, which have reported a shift away from PPPD in favor of the classic Whipple procedure, particularly with concerns about DGE and oncologic adequacy [24]. In this work, we noted PPPD patients to be less likely to have a malignant diagnosis, suggesting that surgeons may be preferentially using traditional PD for oncologic cases. Consistent with this pattern, the higher frequency of vascular resection in the classic PD cohort likely reflects greater oncologic extent (e.g., venous involvement and/or larger tumors).This trend is supported by Li et.al who demonstrated PPPD is more commonly selected for benign lesions or low-grade malignancies [25]. However, meta-analyses by Yan g et al. and Diener et al. revealed no significant differences in long-term survival, overall morbidity or mortality between PPPD and PD for periampullary and pancreatic carcinoma [12,16].
In the present analysis, PPPD was linked with significantly lower odds of infectious complications, despite being performed more frequently via an open approach. This may be attributed to shorter operative times, reduced intraoperative blood loss, and decreased need for transfusion [16,26,27]. However, we noted higher rates of DGE among PPPD patients. Importantly, the absolute effect size was small (approximately a one-percentage-point increase) and was not accompanied by longer length of stay, higher readmission, or greater non-home discharge, suggesting a clinically modest impact in most patients. This finding aligns with Jung et al., who demonstrated that higher DGE rates could be attributed to pylorus preservation, resulting in functional obstruction due to pylorospasm, denervation, or devascularization of the pyloric ring [28]. As demonstrated by Hackert et al., surgeon experience and institutional volume significantly modulate outcomes, with high-volume centers and experienced surgeons achieving lower DGE rates regardless of the surgical approach [14]. Taken together, while PPPD offers clear advantages in reducing infectious complications and transfusion requirements, the increased risk of DGE appears modest overall and likely reflects a combination of anatomic and technical factors that may be further mitigated through operative approach and surgeon expertise.
Our analysis demonstrated that PPPD was associated with significantly shorter operative time and hospital stay compared to classic PD. At first glance, this seems paradoxical given the higher rates of DGE in the PPPD cohort. However, as illustrated in Supplementary Fig. 1, although DGE was linked with longer hospitalizations compared to non-DGE patients in both groups, the overall distribution of length of stay was not substantially prolonged in PPPD. This suggests that many of the DGE episodes observed in PPPD were likely clinically mild and did not result in extended hospitalization. Because NSQIP does not capture DGE severity (A,B,C), we cannot definitively assess this, but our findings are consistent with prior reports indicating that most DGE following PPPD is of limited clinical impact [[29], [30], [31]]. Additionally, reduced intraoperative blood loss, shorter operative times, and lower rates of other major complications with PPPD compared to Non-PPPD, all contribute to earlier recovery and discharge that offset the impact of DGE on hospital stay. This finding is consistent with the work of Diener et al. and Kawai et al. who reported reduced operative time by approximately 50–70 min for PPPD compared to the classic Whipple procedure [16,18]. Furthermore, Calderon et al. and Klinkenbijl et al. also reported PPPD to be associated with shorter operative time and shorter length of stay [17,32]. The shorter operative time may reflect the avoidance of gastric resection in PPPD or alternatively expertise of the surgical team, although the latter could not be assessed. Nonetheless, the body of evidence regarding the benefits of PPPD remains mixed as summarized in Supplementary Table 3. Our work provides a contemporary and pragmatic landscape of utilization trends and outcomes of PPPD across NSQIP-participating facilities and should provide further direction.
The present study has several important limitations. Due to the retrospective nature of the analysis, we are unable to establish a causal relationship. In addition, ~20 % of records in the ACS NSQIP and our institutional registry were missing data for pancreatic duct size and gland texture which may have introduced bias. Furthermore, because the ACS NSQIP does not provide hospital or surgeon level identifiers, we could not account for surgical expertise. Finally, NSQIP lacks granular data regarding anatomic factors and intraoperative decision-making. In particular, we could not assess factors known to influence delayed gastric emptying—such as the route of reconstruction (antecolic vs retrocolic); additionally, NSQIP does not capture DGE severity. Nonetheless, we employed robust statistical methods and a large cohort to mitigate the risk of bias arising from these limitations.
In conclusion, PPPD was associated with reduced infectious complications, transfusion requirements, operative times, and length of stay, but with a modestly higher incidence of delayed gastric emptying compared to classic PD. Although use of PPPD has declined over the past decade, our findings suggest that its advantages remain relevant, particularly in settings where operative efficiency and reduced transfusion risk are priorities. Rather than discouraging PPPD, these results support a nuanced approach to procedure selection and underscore the need for prospective studies to clarify the clinical impact of DGE severity and to identify strategies for mitigating it while preserving the benefits of PPPD.
The following are the supplementary data related to this article.
Unadjusted and Adjusted Outcomes, Stratified by Pylorus Preserving.
Outcomes reported as percentages or as Adjusted Odds Ratio (AOR) with 95 % confidence intervals (95 % CI) unless otherwise noted.
Reference: Non-Pylorus Preserving
*IQR, interquartile range; * Indicates statistical significance, P-Value<0.05.
Unadjusted and Adjusted Outcomes of Malignant, Stratified by Pylorus Preserving.
Outcomes reported as percentages or as Adjusted Odds Ratio (AOR) with 95 % confidence intervals (95 % CI) unless otherwise noted.
Reference: Non-Pylorus Preserving
IQR, interquartile range; * Indicates statistical significance, P-Value<0.05.
Comparison of clinical outcomes between Pylorus Preserving and Non-Pylorus Preserving.
PPPD, Pylorus Preserving Pancreaticoduodenectomy.
CRediT authorship contribution statement
Sona Mahrokhi: Writing – review & editing, Writing – original draft, Resources, Methodology, Investigation, Formal analysis. Sara Sakowitz: Supervision, Software, Investigation, Formal analysis. Esteban Aguayo: Writing – review & editing. Melissa Justo: Writing – review & editing, Software. Robert Kropp: Software, Resources, Formal analysis. Konmal Ali: Writing – review & editing, Software, Project administration. Barzin Badiee: Methodology, Investigation, Formal analysis. Timothy R. Donahue: Writing – review & editing, Supervision. Peyman Benharash: Writing – review & editing, Writing – original draft, Supervision.
Ethics approval
This study was deemed exempt from full review by the Institutional Review Board at the University of California, Los Angeles.
Funding sources
No external funding was obtained for this study.
Declaration of competing interest
PB reports receiving proctoring fees from AtriCure, Inc. TRD reports serving as a shareholder and executive board member of Trethera Corp. This manuscript does not discuss any related products or services. All other authors declare no conflicts of interest.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Unadjusted and Adjusted Outcomes, Stratified by Pylorus Preserving.
Outcomes reported as percentages or as Adjusted Odds Ratio (AOR) with 95 % confidence intervals (95 % CI) unless otherwise noted.
Reference: Non-Pylorus Preserving
*IQR, interquartile range; * Indicates statistical significance, P-Value<0.05.
Unadjusted and Adjusted Outcomes of Malignant, Stratified by Pylorus Preserving.
Outcomes reported as percentages or as Adjusted Odds Ratio (AOR) with 95 % confidence intervals (95 % CI) unless otherwise noted.
Reference: Non-Pylorus Preserving
IQR, interquartile range; * Indicates statistical significance, P-Value<0.05.
Comparison of clinical outcomes between Pylorus Preserving and Non-Pylorus Preserving.
PPPD, Pylorus Preserving Pancreaticoduodenectomy.