Table 1.

Effects of surgical interventions on POPF following pancreatectomy

Author	Type of study	No. of patients	Type of intervention	Results
Ke et al. (2013) [13]	Prospective randomized trial	216 • 107 • 109	Roux-en-Y reconstruction with isolated pancreatic drainage vs. conventional loop reconstruction	• Similar incidence of POPF (15.7 vs. 17.6 % in the Roux-en-Y group vs. conventional group) • Conventional group had higher incidence of grade B fistula, longer hospital stay, and higher hospital costs
Antila et al. (2014) [7]	Prospective randomized trial	16 • 8 • 8	Finnish binding pancreaticojejunal anastomosis vs. hand-sewn closure of pancreatic remnant in patients undergoing left pancreatectomy	• Higher incidence of POPF (60 %) in FBPJ group vs. hand-sewn group (13 %, p < 0.05) • FPBJ technically feasible in only 28 % of patients undergoing LP
Nakeeb et al. (2014) [16]	Prospective randomized study	90 • 45 • 45	Isolated Roux loop pancreaticojejunostomy vs. pancreaticogastrostomy after PD	• No significant difference in rate of POPF between the two groups • Incidence of steatorrhea was lower in IRPJ group along with early oral feeding and maintenance of oral feeding in cases even where POPF developed
Lillemoe et al. (2004) [50]	Prospective randomized trial	125 • 59 • 66	Application of fibrin glue sealant at the pancreatic anastomosis vs. no application	• No significant difference in the incidence of DGE in the fibrin application group and the no fibrin application group (26 vs. 30 %, p = Not significant)
Winter et al. (2006) [34]	Prospective randomized trial	234 • 115 • 119	Placement of stent	• No significant difference in the incidence of POPF in patients who underwent stent placement and those who did not both in the soft/normal texture (21.1 vs. 10.7 %; p = 0.1) and the hard texture (1.7 vs. 4.8 %; p = 0.4) groups
Poon et al. (2007) [41]	Prospective randomized trial	120 • 60 • 60	External drainage of pancreatic duct with a stent after PD	• Stented group had significantly lower rates of POPF (6.7 vs. 20 %, p = 0.32)
Motoi et al. (2012)	Randomized clinical trial	93 • 47 • 46	External pancreatic duct stent placement in patients undergoing PD	• Rate of clinically significant POPF were significantly lower in patient who had stent placed (3 (6 %) vs. 10 (22 %), p = 0.04)
Pessaux et al. (2011)	Prospective randomized trial	158 • 81 • 77	External pancreatic duct stent placement in patients undergoing PD	• Reduction in the overall POPF rates in patient who received stent placement (20 (26 %) vs. 34 (42 %), p = 0.03).
Diener et al. (2011) [44]	Randomized controlled multicenter trial	450 • 221 • 229 352 analyzed • 177 • 175	Closure of pancreatic remnant by a stapler vs. hand-sewn technique	• No significant difference between stapler device closure and hand-sewn closure in the development of POPF and death (32 vs. 28 %, p = 0.56).
Bassi et al. (2003) [19]	Prospective randomized trial	144 • 72 • 72	Duct to mucosa vs. end to side pancreaticojejunostomy reconstruction after PD	• No difference in incidence of POPF between the two groups (13 % in duct to mucosa PJ vs. 15 % in end to side PJ, p = not significant)
Nakeeb et al. (2015) [20]	Prospective randomized study	107 • 53 • 54	Duct to mucosa vs. invagination pancreaticojejunostomy after PD	• No significant difference between the two techniques in incidence (p = 0.46) or severity (p = 0.4) of POPF.
Que et al. (2015) [33]	Meta-analysis of 8 randomized controlled trials	1211 • 607 • 604	Pancreaticogastrostomy vs. pancreaticojejunostomy after PD	• Significantly lower risk of POPF in PG group as compared to PJ group (RR 0.6853, p = 0.0024) • Reduced severity of POPF after pancreaticogastrostomy • No difference in the incidence of DGE between the two techniques
Klaiber et al. (2015) [18]	Meta-analysis of 3 randomized controlled trials and 4 controlled clinical trials	802	Conventional single-loop vs. dual loop (Roux-en-Y) with isolated pancreaticojejunostomy reconstruction after PD	• No significant difference in POPF rates between the two groups (RR = 0.91, p = 0.54)
Yeo et al. (1995)	Prospective randomized trial	145 • 73 • 72	Pancreaticogastrostomy vs. Pancreaticojejunostomy after PD	• No significant difference in POPF rates between the two groups (12.3 % PG vs. 11.1 % PJ, p > 0.05)
Duffas et al. (2005) [31]	Controlled randomized multicenter trial	149 • 81 • 68	Pancreaticogastrostomy vs. pancreaticojejunostomy after PD	• No significant difference in POPF rates (16 % PG vs. 20 % PJ, p ≥ 0.05) and severity between the two groups
Bassi et al. (2005) [28]	Prospective randomized study	151 • 82 • 69	Pancreaticojejunostomy vs. pancreaticogastrostomy after PD	• No significant difference in the incidence of POPF between PG (13 %) and PJ (16 %, p > 0.05) • Significantly lower rate of multiple surgical complications (p = 0.002), biliary fistula (p = 0.01), DGE (p = 0.03), and postoperative collections (p = 0.01) in patients who received PG
Wellner et al. (2012) [27]	Randomized controlled trial	116 • 59 • 57	Pancreaticogastrostomy vs. pancreaticojejunostomy after partial PD	• No significant difference in the incidence of POPF between PG and PJ (10 vs. 12 %, p = 0.775)
Topal et al. (2013) [26]	Multicenter randomized trial	329 • 167 • 162	Pancreaticogastrostomy vs. pancreaticojejunostomy after PD	• Significantly higher incidence of POPF in the PJ group (19.8 % in PJ vs. 9.0 % in PG, p = 0.002) • Lower incidence of DGE in the PJ group (8 % in PJ vs. 15 % in PG, p = 0.04)
Figueras et al. (2013) [32]	Randomized clinical trial	123 • 58 • 65	Pancreaticogastrostomy vs. pancreaticojejunostomy after PD	• Significantly higher incidence (20 of 58 in PJ vs. 10 of 65 in PG, p = 0.014) and severity (p = 0.006) of POPF in the PJ group as compared to PG
Olah et al. (2009) [43]	Randomized clinical trial	70 • 35 • 35	Closure of pancreatic remnant by stapler alone vs. stapler closure and covering with a seromuscular patch of jejunum following distal PD	• Higher overall pancreas-related complications in the stapling alone group (p = 0.041) • No significant difference between the two techniques in the development of clinically relevant (grade B or C) POPF and fluid collection (p = 0.0428)
Berger et al. (2009) [21]	Randomized prospective trial	197 • 97 • 100	Duct to mucosa pancreaticojejunostomy vs. invagination pancreaticojejunostomy after PD	• Significantly lower incidence of POPF in invagination PJ as compared to duct to mucosa PJ (12 vs. 24 %, p < 0.05)
Buren II et al. (2014) [42]	Randomized prospective multicenter trial	137 • 68 • 69	PD with and without intraperitoneal drainage	• PD without drain placement associated with increased number of complications per patient (p = 0.029), increase in number of patients with at least 1 grade 2 or more severe complication (p = 0.0047), increased average complication severity (0.027), higher incidence of DGE (p = 0.021), intra-abdominal fluid collection (p = 0.033), and abscess (0.033), severe diarrhea (p = 0.005), need for postoperative percutaneous drain placement, and increased duration of hospital stay • No significant difference in POPF rates between the two groups (p = 0.155) • Study stopped early due to increase in mortality from 3 to 12 % in patients without drain placement
Carter et al. (2013) [46]	Randomized controlled trial	109 • 55 • 54	Stapled or sutured closure of pancreatic remnant after PD vs. stapled or sutured closured and addition of a falciform patch and fibrin glue	• No significant difference in POPF rates between the two groups (20 % in the SS group vs. 19 % in the FF group, p = 1.000)
Peng et al. (2007) [22]	Prospective randomized trial	217 • 111 • 106	Binding Pancreaticojejunostomy vs. invagination pancreaticojejunostomy after PD	• Significantly lower POPF in binding PJ group (0 % in binding PJ vs. 7.2 % in invagination PJ, p = 0.014)
Fernandez-Cruz et al. (2008) [25]	Prospective randomized study	108 • 53 • 55	Pancreaticogastrostomy with gastric partition after PPPD vs. conventional pancreaticojejunostomy	• Lower postoperative complications (23 % in PPPD-GP group and 44 % after PPPD-PJ, p < 0.01) • Lower incidence of POPF in the PPPD-GP group as compared to PPPD- PJ (4 vs. 18 %, p < 0.01)
Frozanpur et al. (2012) [36]	Prospective controlled clinical trial	58 • 29 • 29	Prophylactic transpapillary pancreatic stent following distal pancreatectomy vs. no stent after DP	• No significant difference in POPF rates between the two groups (p = 0.122)
Montorsi et al. (2012) [51]	Multicenter randomized controlled trial	275 • 145 • 130	Standard surgical suturing or stapling with or without TachoSil (absorbable fibrin sealant patch) after distal pancreatectomy	• No significant difference between the two groups in POPF rates (62 % TachoSil vs. 68 % standard, p = 0.267)
Tani et al. (2014) [17]	Randomized clinical trial	151 • 75 • 76	Isolated Roux-en-Y vs. conventional reconstruction after PD	• No significant difference in POPF rates (33 vs. 34 %, p = 0.909) and number of patients with clinically relevant POPF (10 vs. 11, p = 0.789) between the two groups
Suc et al. (2003) [52]	Prospective randomized trial	182 • 102 • 80	Temporary fibrin glue occlusion of the main pancreatic duct	• Duct occlusion did not significantly decrease the rate of POPF. (duct occlusion vs. control: 17 (17 %) vs. 12 (15 %), p > 0.05)