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Kumar A, Panwar R, Pal S, Dash NR, Sahni P. Outcome following pylorus resecting pancreaticoduodenectomy versus classical Whipple's pancreaticoduodenectomy: a randomised controlled trial. HPB (Oxford) 2025; 27:385-392. [PMID: 39757070 DOI: 10.1016/j.hpb.2024.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 11/13/2024] [Accepted: 12/12/2024] [Indexed: 01/07/2025]
Abstract
OBJECTIVE To compare pylorus resecting pancreaticoduodenectomy (PRPD) with classical pancreaticoduodenectomy (classical PD) in terms of short term outcomes. BACKGROUND There is some evidence that Pylorus resecting PD (PRPD) is associated with lesser incidence of DGE when compared to pylorus preserving PD (PPPD). However, no study has previously compared PRPD with classical PD. METHODS Patients requiring PD were randomly assigned to either PRPD or classical PD after intraoperative assessment to rule out metastases and unresectable disease. Occurrence of DGE was the primary end point. RESULTS A total of 154 patients (103 males; Mean age:53.3 ± 12.2 years) were included in the final analysis (PRPD = 78, classical PD = 76). PRPD group had significantly shorter operation [Mean difference: 41 min (95 % CI:18-65)]. There was no significant difference in the incidence of DGE [32 (41.0 %)vs37 (48.7 %); p = 0.339] and clinically significant DGE [22 (28.2 %)vs19 (25.0 %); p = 0.789] between PRPD and classical PD. There was also no difference in the rates of clinically relevant pancreatic fistula [20 (25.6 %)vs22 (28.9 %); p = 0.780], severe morbidity [21 (26.9 %)vs19 (25.0 %); p = 0.930], operative mortality [6 (7.7 %)vs2 (2.6 %); p = 0.157] and median postoperative stay [12 (5-47) days vs 12 (6-56) days; p = 0.861]. CONCLUSION We found no significant difference in the early postoperative outcomes between PRPD and classical PD. PRPD was found to be significantly faster than the classical PD.
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Affiliation(s)
- Ameet Kumar
- Department of GI Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India; Department of GI Surgery, Command Hospital, Pune, India
| | - Rajesh Panwar
- Department of GI Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.
| | - Sujoy Pal
- Department of GI Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar R Dash
- Department of GI Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
| | - Peush Sahni
- Department of GI Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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Duan P, Sun L, Kou K, Li XR, Zhang P. Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2024; 23:449-457. [PMID: 37980179 DOI: 10.1016/j.hbpd.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 10/31/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE. DATA SOURCES Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles. RESULTS In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE. CONCLUSIONS Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.
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Affiliation(s)
- Peng Duan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Lu Sun
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Kai Kou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Xin-Rui Li
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, China
| | - Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China.
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Fu Z, Gao S, Wu X, Qin J, Dang Z, Wang H, Han J, Ren Y, Zhu L, Ye X, Shi X, Yin X, Shi M, Wang J, Liu X, Guo S, Zheng K, Jin G. Hand-sewn gastrojejunal anastomosis reduces delayed gastric emptying after pancreaticoduodenectomy: A single-center retrospective clinical study of 1,077 consecutive patients. Surgery 2024; 175:1140-1146. [PMID: 38290878 DOI: 10.1016/j.surg.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/08/2023] [Accepted: 12/01/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Hand-sewn anastomosis and stapled anastomosis are the 2 main types of gastrojejunal anastomotic methods in pancreaticoduodenectomy. There is ongoing debate regarding the most effective anastomotic method for reducing delayed gastric emptying after pancreaticoduodenectomy. This study aims to identify factors that influence delayed gastric emptying after pancreaticoduodenectomy and assess the impact of different anastomotic methods on delayed gastric emptying. METHODS The study included 1,077 patients who had undergone either hand-sewn anastomosis (n = 734) or stapled anastomosis (n = 343) during pancreaticoduodenectomy between December 2016 and November 2021 at our department. We retrospectively analyzed the clinical data, and a 1:1 propensity score matching was performed to balance confounding variables. RESULTS After propensity score matching, 320 patients were included in each group. Compared with the stapled anastomosis group, the hand-sewn anastomosis group had a significantly lower incidence of delayed gastric emptying (28 [8.8%] vs 55 [17.2%], P = .001) and upper gastrointestinal tract bleeding (6 [1.9%] vs 17 [5.3%], P = .02). Additionally, the hand-sewn anastomosis group had a significantly reduced postoperative length of stay and lower hospitalization expenses. However, the hand-sewn anastomosis group had a significantly longer operative time, which was consistent with the analysis before propensity score matching. Logistic regression analysis showed that stapled anastomosis, intra-abdominal infection, and clinically relevant postoperative pancreatic fistula were independent prognostic factors for delayed gastric emptying. CONCLUSION Hand-sewn anastomosis was associated with a lower incidence rate of clinically relevant delayed gastric emptying after pancreaticoduodenectomy. Stapled anastomosis, intra-abdominal infection, and clinically relevant postoperative pancreatic fistula could increase the incidence of postoperative clinically relevant delayed gastric emptying. Hand-sewn anastomosis should be considered by surgeons to reduce the occurrence of postoperative delayed gastric emptying and improve patient outcomes.
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Affiliation(s)
- Zhendong Fu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China; Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Suizhi Gao
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xinqian Wu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jianwei Qin
- Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Zheng Dang
- Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Huan Wang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jiawei Han
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Yiwei Ren
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Lingyu Zhu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaofei Ye
- Department of Medical Statistics, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaohan Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaoyi Yin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Meilong Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jian Wang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xinyu Liu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Shiwei Guo
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Kailian Zheng
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China.
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Christodoulidis G, Kouliou MN, Koumarelas KE, Argyriou K, Karali GA, Tepetes K. Billroth II anastomosis combined with brown anastomosis reduce reflux gastritis in gastric cancer patients. World J Methodol 2024; 14:89709. [PMID: 38577202 PMCID: PMC10989415 DOI: 10.5662/wjm.v14.i1.89709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/21/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The surgeon performing a distal gastrectomy, has an arsenal of reconstruction techniques at his disposal, Billroth II among them. Braun anastomosis performed during a Billroth II procedure has shown evidence of superiority over typical Billroth II, in terms of survival, with no impact on postoperative morbidity and mortality. AIM To compare Billroth II vs Billroth II and Braun following distal gastrectomy, regarding their postoperative course. METHODS Patients who underwent distal gastrectomy during 2002-2021, were separated into two groups, depending on the surgical technique used (Billroth II: 74 patients and Billroth II and Braun: 28 patients). The daily output of the nasogastric tube (NGT), the postoperative day that NGT was removed and the day the patient started per os feeding were recorded. Postoperative complications were at the same time noted. Data were then statistically analyzed. RESULTS There was difference in the mean NGT removal day and the mean start feeding day. Mean total postoperative NGT output was lower in Braun group (399.17 mL vs 1102.78 mL) and it was statistically significant (P < 0.0001). Mean daily postoperative NGT output was also statistically significantly lower in Braun group. According to the postoperative follow up 40 patient experienced bile reflux and alkaline gastritis from the Billroth II group, while 9 patients who underwent Billroth II and Braun anastomosis were presented with the same conditions (P < 0.05). CONCLUSION There was evidence of superiority of Billroth II and Braun vs typical Billroth II in terms of bile reflux, alkaline gastritis and NGT output.
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Affiliation(s)
| | | | | | - Konstantinos Argyriou
- Department of Gastroenterology, University Hospital of Larissa, Larissa 41334, Greece
| | | | - Konstantinos Tepetes
- Department of General Surgery, University Hospital of Larissa, Larissa 41110, Greece
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Martín S, Secanella L, Sorribas M, Peláez N, Salord S, Lopez-Urdiales R, Fabregat J, Busquets J. Study of risk factors for delayed gastric emptying after partial pancretoduodenectomy. Cir Esp 2023; 101:657-664. [PMID: 36716958 DOI: 10.1016/j.cireng.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 09/21/2022] [Accepted: 10/30/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Delayed gastric emptying is one of the most frequent complications after pancreatoduodenectomy. METHODS We performed an analysis of risk factors for delayed gastric emptying on a prospective database of 390 patients operated on between 2013 and 2021. A comparative retrospective study was carried out between patients with and without delayed gastric emptying and subsequently a study of risk factors for delayed gastric emptying using univariate and multivariate logistic regression models. RESULTS The incidence of delayed gastric emptying in the overall series was 28%. The morbidity of the group was 63%, and postoperative mortality was 3.1%. Focusing on delayed gastric emptying, the median age (73 years vs 68 years, P < 0.001) and preoperative creatinine (75 vs 65.5, P < 0.001) were higher in the group with this complication. The study of risk factors showed that age over 60 years (P = 0.002) and pancreatic fistula (P < 0.001) were risk factors for delayed gastric emptying. CONCLUSION The presence of pancreatic fistula is confirmed as a risk factor for slow gastric emptying after pancreaticoduodenectomy. In addition, age over 60 years is shown to be a risk factor for slow gastric emptying.
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Affiliation(s)
- S Martín
- General and Digestive Surgery Service, Viladecans Hospital, Viladecans, Spain
| | - Ll Secanella
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain
| | - M Sorribas
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain
| | - N Peláez
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain
| | - S Salord
- Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain; Department of Digestive Diseases Unit. Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain
| | - R Lopez-Urdiales
- Department of Endocrinology and Nutrition, Bellvitge University Hospital, Barcelona, Spain
| | - J Fabregat
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain; Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
| | - J Busquets
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain; Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain.
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Keerthi BR, Hemanth GN, Ganesh MS, Prabha A, Abhinay I. Is Roux Loop a Solution to Delayed Gastric Emptying Following Pancreaticoduodenectomy? A Single Institute Analysis. Indian J Surg Oncol 2021; 12:378-385. [PMID: 34295082 DOI: 10.1007/s13193-021-01298-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/24/2021] [Indexed: 11/30/2022] Open
Abstract
Delayed gastric emptying is one of the most common complications of pancreaticoduodenectomy (PD). It almost always results in delayed oral intake, prolonged hospital stays, and a delay in initiation of vital adjuvant treatment. A few earlier studies suggested that delayed gastric emptying (DGE) rates were better with the Roux-en Y reconstruction, but Indian literature regarding this is lacking. In our institutional study, we compared the traditional single-loop reconstruction (SL group), with the Roux loop reconstruction (RY group) following a subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). A retrospective comparative study was conducted between the conventional single loop and a Roux-en-Y method of reconstruction following a subtotal stomach preserving pancreaticoduodenectomy (SSPPD). Sixty-three consecutive Whipple's procedures were analyzed for multiple clinical parameters like removal of Ryles tube, tolerance of liquid diet and solid diet, delayed gastric emptying, duration of hospital stay and interval between surgery, and initiation of adjuvant treatment. Forty-one patients in the SL group were compared with 22 patients in the RY group. Ryles tube removal (POD 8.2 versus 2.25, p < 0.001), initiation of liquid diet (POD 8.43 versus 2.88, p < 0.001), post-operative hospital stay (13.5 days versus 9.63, p < 0.001), and interval between surgery and adjuvant treatment (37.75 days versus 28.88 days, p < 0.002) were all in favor of the RY group. The delayed gastric emptying was also found to be significantly better in the Roux-en-Y surgery group (p < 0.001). The Roux loop reconstruction following a stomach-preserving pancreaticoduodenectomy (SSPPD) is superior to single-loop reconstruction with respect to delayed gastric emptying. The lesser duration of hospital stay and early initiation of adjuvant therapy are an additional benefit of the Roux loop reconstruction.
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Affiliation(s)
- B R Keerthi
- Department of Surgical Oncology, Vydehi Cancer Center, Vydehi Institute of Medical Sciences and Research Center, 82, Vijayanagar, EPIP Zone, Whitefield, Bengaluru, Karnataka 560066 India
| | - G N Hemanth
- Department of Surgical Oncology, Vydehi Cancer Center, Vydehi Institute of Medical Sciences and Research Center, 82, Vijayanagar, EPIP Zone, Whitefield, Bengaluru, Karnataka 560066 India
| | - M S Ganesh
- Department of Surgical Oncology, Vydehi Cancer Center, Vydehi Institute of Medical Sciences and Research Center, 82, Vijayanagar, EPIP Zone, Whitefield, Bengaluru, Karnataka 560066 India
| | - Amritha Prabha
- Department of Surgical Oncology, Vydehi Cancer Center, Vydehi Institute of Medical Sciences and Research Center, 82, Vijayanagar, EPIP Zone, Whitefield, Bengaluru, Karnataka 560066 India
| | - I Abhinay
- Department of Surgical Oncology, Vydehi Cancer Center, Vydehi Institute of Medical Sciences and Research Center, 82, Vijayanagar, EPIP Zone, Whitefield, Bengaluru, Karnataka 560066 India
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Mobarak S, Tarazi M, Davé MS, Varley RJ, Stott MC, Baltatzis M, Satyadas T. Roux-en-Y versus single loop reconstruction in pancreaticoduodenectomy: A systematic review and meta-analysis. Int J Surg 2021; 88:105923. [PMID: 33774175 DOI: 10.1016/j.ijsu.2021.105923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/04/2021] [Accepted: 03/11/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications. METHODS A systematic review and meta-analysis was conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models. RESULTS Fourteen studies were identified including four randomised controlled trials (RCTs) and 10 observational studies reporting a total of 2,031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction. DISCUSSION Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomised studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.
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Affiliation(s)
- Shahd Mobarak
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK.
| | - Munir Tarazi
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Madhav Sanatkumar Davé
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Rebecca J Varley
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Martyn C Stott
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Minas Baltatzis
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Thomas Satyadas
- Department of Hepato-Pancreato-Biliary Surgery, Manchester Royal Infirmary, Manchester, UK
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Gastrostomy as a Preemptive Measure after Pancreatoduodenectomy against Delayed Gastric Emptying: A Small Case Series and a Review of the Literature. Case Rep Surg 2021; 2021:6649914. [PMID: 33680529 PMCID: PMC7925062 DOI: 10.1155/2021/6649914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/01/2021] [Accepted: 02/10/2021] [Indexed: 12/02/2022] Open
Abstract
Delayed gastric emptying (DGE) is a common (20–30%) postoperative complication following pancreatoduodenectomy (PD) (Parmar et al., 2013). Various causes and preemptive measures have been suggested to decrease the occurrence of DGE. We added a simple step in the procedure of 26 consecutive pancreatic head resections, which seems to alleviate DGE and has never been highlighted before.
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Xiao Y, Hao X, Yang Q, Li M, Wen J, Jiang C. Effect of Billroth-II versus Roux-en-Y reconstruction for gastrojejunostomy after pancreaticoduodenectomy on delayed gastric emptying: A meta-analysis of randomized controlled trials. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:397-408. [PMID: 32897643 DOI: 10.1002/jhbp.828] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/PURPOSE Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). The aim of the present meta-analysis was to evaluate the effect of Billroth-II(B-II) versus Roux-en-Y (R-Y) reconstruction for gastrojejunostomy on DGE after PD. METHODS A systematic literature search was performed using the electronic database MEDLINE (via PubMed and OVID), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) of the Cochrane Library to select pertinent randomized controlled trials (RCTs) on this topic from January 1990 to January 2020. The primary outcome was identified as postoperative DGE. Subgroup analysis was established to compare the incidence of grade B and C DGE. Software Revman 5.3 was used for the statistical analysis, summary statistics were calculated using fixed effect model or random effect model. RESULTS Five RCTs including a total of 612 patients were eligible for this meta-analysis. The incidence of grade B and C DGE was significantly lower with the B-II reconstruction than with the R-Y reconstruction (8.0% vs. 14.8%, OR = 0.49, 95% CI: 0.26-0.95, P = 0.03) and the B-II reconstruction took a shorter operation time (WMD=-7.18, 95% CI: [-13.09, -1.27], P = 0,02). No statistically significant difference was found between the two reconstruction methods in terms of the incidence of postoperative pancreatic fistula (POPF), bile leak, intra-abdominal abscess, postoperative pneumonia and the length of postoperative hospital stay. CONCLUSIONS B-II reconstruction after PD has a lower incidence of grade B and C DGE and shorter operation time compared with R-Y reconstruction.
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Affiliation(s)
- Yuqing Xiao
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Xiaofei Hao
- Department of General Medicine, Chengdu Fifth People's Hospital, Chengdu, China
| | - Qin Yang
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Ming Li
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Jun Wen
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Cuina Jiang
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
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Cakir M, Akinci M, Akturk OM. Delayed Gastric Emptying as a Complication of Whipple's Procedure: Could it be Much Less Frequent than Anticipated? Could the Definition Be Revised? A Single Center Experience. Medeni Med J 2020; 35:181-187. [PMID: 33110669 PMCID: PMC7584264 DOI: 10.5222/mmj.2020.02222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/13/2020] [Indexed: 11/05/2022] Open
Abstract
Objective Whipple's procedure for periampullary tumors has significant risks and complications. Delayed gastric emptying has the highest rate. Although the International Study Group of Pancreatic Surgery defined (ISGPS) this entity, multiple definitions still exist among authors. This study aims to revise the definition. Method Seventy-three consecutive patients were analyzed for complications, particularly delayed gastric emptying. All patients underwent a standardized surgery. Procedures used for total pancreatectomies and benign diseases were excluded. Results A total of 73 patients were included in the study. Intra-abdominal complications were observed in 15 (20.6%) patients. Grade C delayed gastric emptying was observed in only one (1.4%) patient. Grade A and B disease were observed in three (4.1%) patients. However, they responded well to conservative methods, causing no extra morbidity. Conclusion Grade A and B delayed gastric emptying can be observed after any gastrointestinal surgery. These patients respond well to simple conservative methods with nasogastric intubation. Drainage of the intra-abdominal collection resolves the emptying problem (if any). Only grade C disease without other intra-abdominal complications can be accepted as a complication of this procedure. ISGPS definition does not include the cause. Thus, the definition and grading can be revised.
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Affiliation(s)
- Mikail Cakir
- University of Health Sciences Haseki Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Muzaffer Akinci
- University of Health Sciences Haseki Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Okan Murat Akturk
- University of Health Sciences Haseki Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
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Efficacy of Low Dose Proton Pump Inhibitor-Based Therapy to Eradicate Helicobacter pylori in Patients with Subtotal Gastrectomy. J Clin Med 2019; 8:jcm8111933. [PMID: 31717622 PMCID: PMC6912799 DOI: 10.3390/jcm8111933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/01/2019] [Accepted: 11/07/2019] [Indexed: 11/25/2022] Open
Abstract
Proton pump inhibitor (PPI)-based therapy is standard to eradicate Helicobacter pylori (H. pylori). Gastric acidity is lowered after gastrectomy because of bile reflux and impaired mechanism of acid secretion. Therefore, low-dose PPI may be effective for H. pylori eradication in the remnant stomach after gastrectomy. In this study, we compared the efficacy of low-dose PPI with standard double-dose PPI to eradicate H. pylori in patients who underwent subtotal gastrectomy. A total of 145 patients who were treated for eradication after gastrectomy was analyzed. They were treated with PPI-based triple regimen (PPI, clarithromycin and amoxicillin) for 14 days. We compared the eradication rate in the low-dose PPI group (lansoprazole 15 mg once daily) with that in the standard double-dose PPI group (lansoprazole 30 mg twice daily). The H. pylori eradication rate was 79.1% in the low-dose PPI group and 85.3% in the standard double-dose group; the difference was not significant statistically (p = 0.357). In the multivariate analysis, low-dose PPI (odds ratio (OR) = 1.79, 95% confidence interval (CI), 0.68–4.69) was not associated with eradication failure, while Billroth II anastomosis (OR = 4.45, 85% CI, 1.23–16.2) was significantly associated with eradication failure. Low-dose PPI-based triple regimen was as effective as standard double-dose PPI-based regimen for H. pylori eradication in patients with subtotal gastrectomy. Further study is needed to confirm the effect of low-dose PPI on H. pylori eradication in patients with gastrectomy.
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Wang THH, Angeli TR, Beban G, Du P, Bianco F, Gibbons SJ, Windsor JA, Cheng LK, O’Grady G. Slow-wave coupling across a gastroduodenal anastomosis as a mechanism for postsurgical gastric dysfunction: evidence for a "gastrointestinal aberrant pathway". Am J Physiol Gastrointest Liver Physiol 2019; 317:G141-G146. [PMID: 31169993 PMCID: PMC6734376 DOI: 10.1152/ajpgi.00002.2019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Postsurgical gastric dysfunction is common, but the mechanisms are varied and poorly understood. The pylorus normally acts as an electrical barrier isolating gastric and intestinal slow waves. In this report, we present an aberrant electrical conduction pathway arising between the stomach and small intestine, following pyloric excision and surgical anastomosis, as a novel disease mechanism. A patient was referred with postsurgical gastroparesis following antrectomy, gastroduodenostomy, and vagotomy for peptic ulceration. Scintigraphy confirmed markedly abnormal 4-h gastric retention. Symptoms included nausea, vomiting, postprandial distress, and reflux. Intraoperative, high-resolution electrical mapping was performed across the anastomosis immediately before revision gastrectomy, and the resected anastomosis underwent immunohistochemistry for interstitial cells of Cajal. Mapping revealed continuous, stable abnormal retrograde slow-wave propagation through the anastomosis, with slow conduction occurring at the scar (4.0 ± 0.1 cycles/min; 2.5 ± 0.6 mm/s; 0.26 ± 0.15 mV). Stable abnormal retrograde propagation continued into the gastric corpus with tachygastria (3.9 ± 0.2 cycles/min; 1.6 ± 0.5 mm/s; 0.19 ± 0.12 mV). Histology confirmed ingrowth of atypical ICC through the scar, defining an aberrant pathway enabling transanastomotic electrical conduction. In conclusion, a "gastrointestinal aberrant pathway" is presented as a novel proposed cause of postsurgical gastric dysfunction. The importance of aberrant anastomotic conduction in acute and long-term surgical recovery warrants further investigation.NEW & NOTEWORTHY High-resolution gastric electrical mapping was performed during revisional surgery in a patient with severe gastric dysfunction following antrectomy and gastroduodenostomy. The results revealed continuous propagation of slow waves from the duodenum to the stomach, through the old anastomotic scar, and resulting in retrograde-propagating tachygastria. Histology showed atypical interstitial cells of Cajal growth through the anastomotic scar. Based on these results, we propose a "gastrointestinal aberrant pathway" as a mechanism for postsurgical gastric dysfunction.
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Affiliation(s)
- Tim H.-H. Wang
- 1Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Timothy R. Angeli
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Grant Beban
- 3Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Peng Du
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Francesca Bianco
- 4Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota,5Departments of Medical and Surgical Sciences (DIMEC) and Veterinary Medical Sciences, University of Bologna, Bologna, Italy
| | - Simon J. Gibbons
- 4Enteric Neuroscience Program, Mayo Clinic, Rochester, Minnesota
| | - John A. Windsor
- 1Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Leo K. Cheng
- 2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand,6Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Gregory O’Grady
- 1Department of Surgery, University of Auckland, Auckland, New Zealand,2Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Busquets J, Martín S, Fabregat J, Secanella L, Pelaez N, Ramos E. Randomized trial of two types of gastrojejunostomy after pancreatoduodenectomy and risk of delayed gastric emptying (PAUDA trial). Br J Surg 2018; 106:46-54. [PMID: 30507039 DOI: 10.1002/bjs.11023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 05/14/2018] [Accepted: 09/25/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is the most important cause of an extended hospital stay after pancreatoduodenectomy. Reports suggest that a Roux-en-Y gastroenteric anastomosis may have lower incidence of DGE than a Billroth II reconstruction. The primary aim of this RCT was to compare Billroth II (single loop) and Roux-en-Y (double loop) after pancreatoduodenectomy to determine whether Roux-en-Y reconstruction is associated with a lower incidence of DGE. Secondary endpoints were postoperative complications. METHODS This was a randomized unblinded single-centre trial without masked evaluation of the main outcome. Patients undergoing pancreatoduodenectomy between 2013 and 2015 were randomized to undergo one of two types of gastroenteric anastomosis for reconstruction. RESULTS A total of 80 patients were randomized, 40 in each group. The incidence of DGE was the same in patients undergoing Billroth II or Roux-en-Y gastroenteric anastomosis (both 18 of 40 patients; P = 1·000). The grade of DGE was also similar in the Billroth II and Roux-en-Y groups (grade A, both 10 of 40; grade B, 5 of 40 versus 6 of 40; grade C, 3 of 40 versus 2 of 40; P = 0·962). The mortality rate was 3 per cent, with no significant difference between the two groups. There were no differences in the overall rate of postoperative morbidity, relaparotomy rate or duration of hospital stay. CONCLUSION The incidence and severity of DGE does not differ between single- or double-loop gastroenteric anastomosis performed after pancreatoduodenectomy. Registration number: NCT00915863 (http://www.clinicaltrials.gov).
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Affiliation(s)
- J Busquets
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - S Martín
- Cirurgia General i Digestiva, Hospital Viladecans, Barcelona, Spain
| | - J Fabregat
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - L Secanella
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - N Pelaez
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - E Ramos
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
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Panwar R, Pal S. The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int 2017; 16:353-363. [PMID: 28823364 DOI: 10.1016/s1499-3872(17)60037-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 02/03/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence. DATA SOURCE We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles. RESULTS Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0-100%; median: 18.7%) and 14.3% (range: 1.8%-58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Braun's entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies. CONCLUSIONS ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.
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Affiliation(s)
- Rajesh Panwar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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Murata Y, Tanemura A, Kato H, Kuriyama N, Azumi Y, Kishiwada M, Mizuno S, Usui M, Sakurai H, Isaji S. Superiority of stapled side-to-side gastrojejunostomy over conventional hand-sewn end-to-side gastrojejunostomy for reducing the risk of primary delayed gastric emptying after subtotal stomach-preserving pancreaticoduodenectomy. Surg Today 2017; 47:1007-1017. [PMID: 28337543 PMCID: PMC5493708 DOI: 10.1007/s00595-017-1504-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/25/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND PURPOSE Delayed gastric emptying (DGE) is the most common complication following pancreaticoduodenectomy (PD). The clinical efficacy of stapled side-to-side anastomosis using a laparoscopic stapling device during alimentary reconstruction in PD is not well understood and its superiority over conventional hand-sewn end-to-side anastomosis remains controversial. The objective of this study was to evaluate the effectiveness of the stapled side-to-side anastomosis in preventing the development of DGE after PD. METHODS The subjects of this retrospective study were 137 patients who underwent pancreaticoduodenectomy, as subtotal stomach-preserving pancreaticoduodenectomy (SSPPD; n = 130), or conventional whipple procedure (n = 7) with Child reconstruction, between January 2010 and May 2014. The patients were divided into two groups according to whether they had had a stapled side-to-side anastomosis (SA group; n = 57) or a conventional hand-sewn end-to-side anastomosis (HA group; n = 80). RESULTS SA reduced the operative time (SA vs. HA: 508 vs. 557 min, p = 0.028) and the incidence of delayed gastric emptying (SA vs. HA: 21.1 vs. 46.3%, p = 0.003) and was associated with shorter hospitalization (SA vs. HA: 33 vs. 39.5 days, p = 0.007). In this cohort, SA was the only significant factor contributing to a reduction in the incidence of DGE (p = 0.002). CONCLUSIONS Stapled side-to-side gastrojejunostomy reduced the operative time and the incidence of DGE following PD with Child reconstruction, thereby also reducing the length of hospitalization.
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Affiliation(s)
- Yasuhiro Murata
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Akihiro Tanemura
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Kato
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naohisa Kuriyama
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yoshinori Azumi
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masanobu Usui
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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16
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Peparini N, Benedetti F. Pylorus-Resecting Pancreaticoduodenectomy with Proximal Roux-en-Y Gastrojejunal Anastomosis: Is This the Winning Combination for Prevention of Delayed Gastric Emptying After Pancreaticoduodenectomy? J Gastrointest Surg 2017; 21:420-421. [PMID: 27730402 DOI: 10.1007/s11605-016-3291-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 09/27/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Nadia Peparini
- Azienda Sanitaria Locale Roma H, Distretto 3, Via Mario Calò, 5, 00043, Ciampino, Rome, Italy.
| | - Fabio Benedetti
- Department of Surgical Sciences, Sapienza University of Rome, viale Regina Elena 324, 00161, Rome, Italy
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17
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Barreto SG, Windsor JA. Does the Ileal Brake Contribute to Delayed Gastric Emptying After Pancreatoduodenectomy? Dig Dis Sci 2017; 62:319-335. [PMID: 27995402 DOI: 10.1007/s10620-016-4402-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/29/2016] [Indexed: 12/18/2022]
Abstract
Delayed gastric emptying (DGE) represents a significant cause for morbidity following pancreatoduodenectomy (PD). At a time when no specific and universally effective therapy exists to treat these patients, elucidating other potential (preventable or treatable) mechanisms for DGE is important. The aim of the manuscript was to test the hypothesis that ileal brake contributes to DGE in PD patients receiving jejunal tube feeding by systematically reviewing experimental and clinical literature. A series of clinically relevant questions were framed related to the potential role of the ileal brake in development of DGE post-PD and formed the basis of targeted literature searches. A comprehensive search of major reference databases from January 1980 to June 2015 was carried out which included human and animal studies. The ileal brake is a feedback loop neurally mediated by the vagus and sympatho-adrenergic pathways and hormonally by gut peptides including glucagon-like peptide-1, peptide YY (PYY), and neurotensin. The most potent stimulus for this inhibitory reflex is intra-ileal fat. There is evidence to indicate the role of an inhibitory reflex (on gastric emptying) mediated by PYY and CCK which, in turn, are stimulated by nutrient delivery into the distal small intestine providing indirect support to the role of ileal brake in post-PD DGE. The ileal brake is a likely factor contributing to DGE post-PD. While there has been no study to directly test this hypothesis, there is compelling indirect evidence to support it. Designing a trial that would answer such a question appears to be the most appropriate way forward.
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Affiliation(s)
- Savio G Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, SA, Australia
| | - John A Windsor
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand.
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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19
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20
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Noorani A, Rangelova E, Del Chiaro M, Lundell LR, Ansorge C. Delayed Gastric Emptying after Pancreatic Surgery: Analysis of Factors Determinant for the Short-term Outcome. Front Surg 2016; 3:25. [PMID: 27200357 PMCID: PMC4843166 DOI: 10.3389/fsurg.2016.00025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/11/2016] [Indexed: 01/04/2023] Open
Abstract
Background Delayed gastric emptying (DGE) frequently complicates pancreatoduodenectomy (PD). Mainly DGE develops as consequence of postoperative intra-abdominal complications (secondary), while the incidence of primary DGE (i.e., not related to surgical complications) has rarely been studied. Moreover, the pathogenesis of DGE is complex and needs to be further elucidated. The present study aimed at highlighting potential mechanisms behind primary and above all secondary DGE by studying a variety of different pancreatic surgical procedures. Patients and methods During the time period 2008–2011, 327 patients underwent pancreatic resective procedures at Karolinska University Hospital. Of these, 242 were PD and 56 tail resections, 17 had a duodenal preserving pancreatectomy for chronic pancreatitis, and 15 patients with familial duodenal polyposis had a pancreas preserving duodenectomy. All postoperative courses were assessed and scored according to Clavien–Dindo. The presence of DGE was evaluated and recorded according to the definition launched by the International Study Group for Pancreatic Surgery (ISGPS). Crude associations were studied in a univariate model, followed by a multivariate analysis of the respective factors. The associations were presented as odds ratios (ORs) with 95% confidence intervals (CIs). Results In total DGE emerged during the postoperative course in about 40% of the PD cases. About half of those (n = 47) were scored as being primary. The majority of the primary DGEs were classified as A (n = 26) and only four as grade C, whereas among the secondary cases significantly more patients were scored as grade C (p < 0.01). In those submitted to a pancreatic body and tail resection 25% reported DGE. The distribution of the different grades of DGE in patients with a tail resection followed the same pattern with a predominance of Grade A cases with an equal distribution between those being scored as primary and secondary. Duodenal preservation, as well as keeping the pancreas intact following duodenectomy, was not followed by primary DGE. Multivariate risk factor analyses for the development of primary GE revealed no specific risk profile except for high age. Conclusion DGE is frequently seen after different surgical procedures directed toward the pancreatic gland. DGE is most commonly seen after PD, and half of these cases are scored as primary DGE. Primary and secondary DGE are seen in one-quarter of the cases even after pancreatic tail resection emphasizing the complex nature of the pathogenesis. Resection of the duodenum as an important mechanism behind DGE is not supported by the present results.
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Affiliation(s)
- A Noorani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Center for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Elena Rangelova
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Center for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - M Del Chiaro
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Center for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Lars Ragnar Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Center for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Christoph Ansorge
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Center for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
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21
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Imamura M, Kimura Y, Ito T, Kyuno T, Nobuoka T, Mizuguchi T, Hirata K. Effects of antecolic versus retrocolic reconstruction for gastro/duodenojejunostomy on delayed gastric emptying after pancreatoduodenectomy: a systematic review and meta-analysis. J Surg Res 2016; 200:147-157. [PMID: 26344400 DOI: 10.1016/j.jss.2015.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/17/2015] [Accepted: 08/06/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a relatively common complication after pancreatoduodenectomy (PD). The aim of this study was to determine whether DGE is affected by antecolic or retrocolic reconstruction for gastro/duodenojejunostomy after PD. METHODS A literature search was performed of the MEDLINE (PubMed), Ovid SP, ISI Web of Knowledge, EMBASE, and Cochrane databases to identify randomized controlled trials (RCTs) and clinical observational studies related to this topic from January 1995 to November 2014. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for categorical outcomes, and mean differences (MD) using fixed-effect and random-effects models were calculated for the meta-analysis. RESULTS Fourteen studies including 1969 patients met the inclusion criteria. Six studies were RCTs, and eight studies were clinical observational studies. DGE was less common in the antecolic reconstruction group than in the retrocolic reconstruction group (OR = 0.24 [0.12-0.48], P < 0.0001). Postoperative days to start solid foods (MD = -3.67 d [-5.10 to -2.33], P < 0.00001) and length of hospital stay (MD = -2.90 d [-5.36 to -2.33], P < 0.00001) were also significantly in favor of the antecolic reconstruction group. There was no difference in the incidence of pancreatic fistula, intra-abdominal fluid collection or abscess, biliary fistula, or mortality. However, in the subgroup analyses, using the data of six RCTs or seven studies according to the International Study Group of Pancreatic Surgery definition, there was no significant difference in the incidence of DGE. CONCLUSIONS Antecolic reconstruction for gastro/duodenojejunostomy does not seem to offer an advantage over retrocolic reconstruction with respect to DGE after PD.
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Affiliation(s)
- Masafumi Imamura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan.
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Tatsuya Ito
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Takuro Kyuno
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Takayuki Nobuoka
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Toru Mizuguchi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Koichi Hirata
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
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Barakat O, Cagigas MN, Bozorgui S, Ozaki CF, Wood RP. Proximal Roux-en-y Gastrojejunal Anastomosis with Pyloric Ring Resection Improves Gastric Emptying After Pancreaticoduodenectomy. J Gastrointest Surg 2016; 20:914-23. [PMID: 26850262 PMCID: PMC4850182 DOI: 10.1007/s11605-016-3091-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/21/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication of pancreaticoduodenectomy. We determined the efficiency of a new reconstruction technique, designed to preserve motilin-secreting cells and maximize the utility of their receptors, in reducing the incidence of DGE after pancreaticoduodenectomy. METHODS From April 2005 to September 2014, 217 consecutive patients underwent pancreaticoduodenectomy at our institution. Nine patients who underwent total pancreatectomy were excluded. We compared outcomes between patients who underwent pancreaticoduodenectomy with resection of the pyloric ring followed by proximal Roux-en-y gastrojejunal anastomosis (group I, n = 90) and patients who underwent standard pancreaticoduodenectomy with the orthotopic reconstruction technique (group II, n = 118). RESULTS Overall and clinically relevant rates of DGE were significantly lower in group I than in group II (10 and 2.2 % vs. 57 and 24 %, respectively; p < 0.05). Length of hospital stay as a result of DGE was shorter in group I than in group II. In univariate analysis, older age, comorbidities, ASA grade 4, operative time, preoperative diabetes, standard reconstruction technique, and postoperative complications were significant risk factors for DGE. In multivariate analysis, older age, standard technique, and postoperative complications were independent risk factors for DGE. CONCLUSION Our new reconstruction technique reduces the occurrence of DGE after pancreaticoduodenectomy.
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Affiliation(s)
- Omar Barakat
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
| | - Martha N. Cagigas
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
| | - Shima Bozorgui
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
| | - Claire F. Ozaki
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
| | - R. Patrick Wood
- Department of Hepatobiliary and Pancreatic Surgery, CHI St. Luke’s Health–Baylor St. Luke’s Medical Center, 6624 Fannin, Suite 2180, Houston, TX 77030 USA
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23
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Skipenko OG, Bedzhanjan K, Shatverjan D, Bagmet K, Chardarov K. [Prevention of gastrostasis after pancreaticoduodenal resection: new technique of gastroenterostomy]. Khirurgiia (Mosk) 2015:17-30. [PMID: 26081183 DOI: 10.17116/hirurgia2015417-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It was performed a retrospective comparative analysis of treatment results of 113 patients with pancreatic head and periampular cancer. The main group consisted of 58 patients in whom pancreaticoduodenal resection was performed according to an original technique of Russian Scientific Center of Surgery. Control group included 55 patients who underwent end-to-side gastrojejunostomy reconstruction. We have analyzed immediate postoperative complications in 2 groups without taking into consideration nosological forms of the disease. Pancreaticojejunostomy failure was diagnosed postoperatively in 5 (8.6%) patients in main group and in 10 (18.2%) patients in control group. There was no hepaticoentero- and gastroenterostomy failure in patients who underwent new technique of gastrojejunostomy while these events were observed in 8 (14.5%) and 3 (5.5%) patients respectively in control group. Mortality was 1.7% (n=1) in main group and 5.5% (n=3) in control group (p=0.29). Mild degree of gastrostasis (A class) was observed in 54 (93.7%) patients of main group and in 34 (61.8%) patients of control group (p=0.0004). There was B class of gastrostasis in 4 (6.9%) patients of main group. Severe gastrostasis (C class) was not revealed in any observation. In control group B class of gastrostasis was diagnosed in 14 (25.5%) patients, severe degree - in 7 (12.7%) patients. Univariant analysis showed hemotransfusion (p=0.037), pancreatic fistula (p=0.001), enteric fistula (p=0.005) and reconstruction technique (p=0.00004) as predictors of gastrostasis. Multivariant analysis defined pancreatic fistula (p=0.01), enteric fistula (p=0.04) and reconstruction technique (p=0.001) as significant predictors of gastrostasis. Thus, our study revealed significant decreasing gastrostasis incidence in case of original technique in comparison with conventional anastomosis, as well as demonstrated effect of anastomoses failure on augmentation of gastrostasis frequency after pancreaticoduodenal resection. Further randomized investigations are necessary to confirm our results.
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Affiliation(s)
- O G Skipenko
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Bedzhanjan
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - D Shatverjan
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Bagmet
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Chardarov
- acad. B.V. Petrovskiy Russian Research Surgery Center
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Zhou Y, Lin J, Wu L, Li B, Li H. Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a meta-analysis. BMC Gastroenterol 2015; 15:68. [PMID: 26076690 PMCID: PMC4467059 DOI: 10.1186/s12876-015-0300-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 06/05/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most frequent complications after pancreaticoduodenectomy (PD). This meta-analysis aimed to evaluate the effect of antecolic versus retrocolic reconstruction of gastro/duodenojejunostomy on DGE after PD. METHODS Randomized controlled trials (RCTs) comparing antecolic versus retrocolic reconstruction of gastro/duodenojejunostomy on DGE after PD were eligible for inclusion. Pooled estimates of treatment effect were calculated using either the fixed effects model or random effects model. RESULTS Five RCTs involving 534 randomized patients were eligible. The comparison of DGE showed no significant difference (odds ratio, 0.66; 95% confidence interval, 0.32 to 1.33; P = 0.24). The antecolic and retrocolic groups also had comparable outcomes for clinical parameters related to DGE, other complications, hospital mortality, and length of hospital stay. CONCLUSIONS The route of gastro/duodenojejunostomy reconstruction has no impact on DGE after PD. Therefore, the choice of reconstruction route should be selected according to the surgeon's preference.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University; Oncologic Center of Xiamen, Xiamen, China.
| | - Jincan Lin
- Department of Digestive Diseases, First Xiamen Hospital, Fujian Medical University, Xiamen, China.
| | - Lupeng Wu
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University; Oncologic Center of Xiamen, Xiamen, China.
| | - Bin Li
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University; Oncologic Center of Xiamen, Xiamen, China.
| | - Hua Li
- Department of Digestive Diseases, First Xiamen Hospital, Fujian Medical University, Xiamen, China.
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Proposal and Critical Appraisal of Exclusion Criteria to the International Study Group for Pancreatic Surgery Definition of Delayed Gastric Emptying. J Am Coll Surg 2015; 220:1036-1043.e1. [DOI: 10.1016/j.jamcollsurg.2014.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/01/2014] [Accepted: 12/01/2014] [Indexed: 01/04/2023]
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Enteral nutrition in pancreaticoduodenectomy: a literature review. Nutrients 2015; 7:3154-65. [PMID: 25942488 PMCID: PMC4446744 DOI: 10.3390/nu7053154] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 04/03/2015] [Accepted: 04/15/2015] [Indexed: 12/19/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is considered the gold standard treatment for periampullory carcinomas. This procedure presents 30%–40% of morbidity. Patients who have undergone pancreaticoduodenectomy often present perioperative malnutrition that is worse in the early postoperative days, affects the process of healing, the intestinal barrier function and the number of postoperative complications. Few studies focus on the relation between enteral nutrition (EN) and postoperative complications. Our aim was to perform a review, including only randomized controlled trial meta-analyses or well-designed studies, of evidence regarding the correlation between EN and main complications and outcomes after pancreaticoduodenectomy, as delayed gastric emptying (DGE), postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), length of stay and infectious complications. Several studies, especially randomized controlled trial have shown that EN does not increase the rate of DGE. EN appeared safe and tolerated for patients after PD, even if it did not reveal any advantages in terms of POPF, PPH, length of stay and infectious complications.
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Braun enteroenterostomy reduces delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: a retrospective review. Am J Surg 2015; 209:369-77. [DOI: 10.1016/j.amjsurg.2014.05.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 04/30/2014] [Accepted: 05/15/2014] [Indexed: 02/06/2023]
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Cordesmeyer S, Lodde S, Zeden K, Kabar I, Hoffmann MW. Prevention of delayed gastric emptying after pylorus-preserving pancreatoduodenectomy with antecolic reconstruction, a long jejunal loop, and a jejuno-jejunostomy. J Gastrointest Surg 2014; 18:662-73. [PMID: 24553874 DOI: 10.1007/s11605-013-2446-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 12/18/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the major complications following pylorus-preserving pancreatoduodenectomy (PPPD). It leads to significant patient distress and prolonged hospitalization and therefore increased treatment costs. DGE etiology remains unclear but seems to be multifactorial. In order to decrease DGE rates, reconstruction methods have been modified. The presented retrospective study was to evaluate outcomes of different surgical techniques at our institution with special emphasis on retrocolic and antecolic reconstruction types. MATERIAL AND METHODS One hundred thirteen consecutive patients underwent PPPD between September 2004 and December 2011 for periampullary and bile duct lesions of the pancreatic head and the papilla of Vater. These patients were reviewed for DGE occurrence and other factors. Four different types of reconstruction were applied: the classic retrocolic reconstruction using a short jejunal loop (short loop, n = 40) and three types of reconstructions using a long loop: one with a long loop and retrocolic duodenojejunostomy (n = 22), another with a long loop and an additional latero-lateral enterostomy (Braun's anastomosis, n = 23), and finally, an antecolic group with Braun's anastomosis (n = 28). Patients were reviewed for DGE incidence and severity following the International Study Group of Pancreatic Surgery definition of DGE. RESULTS The highest DGE occurrence was noted in the retrocolic group using a short jejunal loop (15 of 32 patients, 46.9%), whereas the reconstruction types using long loops showed a notable decrease: DGE occurred in 4 of 16 patients (25%) in the retrocolic group, in 6 of 21 patients (28.6%) in the retrocolic group with an additional latero-lateral enterostomy (Braun's anastomosis), and finally, only 1 of 22 patients (4.5%, p = 0.009) in the antecolic group with Braun's anastomosis presenting with DGE, grade A. However, neither hospitalization time nor days in the intensive care unit were significantly different. There was no difference in DGE rates between the retrocolic long-loop groups with and without Braun's anastomosis. CONCLUSION The results of this retrospective study suggest that the antecolic route with a long jejunal loop and Braun's anastomosis minimizes DGE rates.
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Affiliation(s)
- S Cordesmeyer
- Department of General and Visceral Surgery, Raphaelsklinik, Loerstraße 23, 48143, Münster, Germany,
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Ramia JM, de la Plaza R, Quiñones JE, Veguillas P, Adel F, García-Parreño J. [Gastroenteric reconstruction route after pancreaticoduodenectomy: antecolic versus retrocolic]. Cir Esp 2013; 91:211-216. [PMID: 23452819 DOI: 10.1016/j.ciresp.2013.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 12/20/2012] [Accepted: 01/11/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) is a relatively common complication after cephalic pancreaticoduodenectomy (CPD). Its origin is not very clear, and it is believed that its appearance is due to multiple factors (hormones, appearance of other complications, particularly pancreatic fistulas, and the surgical technique). Among the technical aspects associated with DGE, it has been proposed that the route of gastroenteric reconstruction (antecolic or retrocolic) could have an effect on its incidence. MATERIAL AND METHODS A systemic review was made of the literature, searching for articles that compared both reconstruction routes after CPD, finding only 11 articles: 4 randomised clinical trials, one prospective study, and 6 retrospective studies. A meta-analysis could not be performed on them, due to the large methodological differences between them. RESULTS In the 4 randomised studies, 2 were in favour of the antecolic route, and 2 did not observe any differences between either of them. The antecolic route obtained a much lower DGE rate than the retrocolic one in the only prospective study. In 4 of the retrospective studies the antecolic route obtained a very low rate. The results of both routes were similar in another 2 retrospective studies, with the retrocolic route slightly better in one of them. CONCLUSIONS Using the published literature, the gastric reconstruction route associated with less DGE after CPD cannot currently be determined.
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Affiliation(s)
- José M Ramia
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Spain.
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Peparini N, Chirletti P. Does antecolic reconstruction decrease delayed gastric emptying after pancreatoduodenectomy? World J Gastroenterol 2012; 18:6527-6531. [PMID: 23236224 PMCID: PMC3516209 DOI: 10.3748/wjg.v18.i45.6527] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 10/26/2012] [Accepted: 11/13/2012] [Indexed: 02/06/2023] Open
Abstract
Delayed gastric emptying (DGE) is a frequent complication after pylorus-preserving pancreatoduodenectomy (PpPD). Kawai and colleagues proposed pylorus-resecting pancreatoduodenectomy (PrPD) with antecolic gastrojejunal anastomosis to obviate DGE occurring after PpPD. Here we debate the reported differences in the prevalence of DGE in antecolic and retrocolic gastro/duodeno-jejunostomies after PrPD and PpPD, respectively. We concluded that the route of the gastro/duodeno-jejunal anastomosis with respect to the transverse colon; i.e., antecolic route or retrocolic route, is not responsible for the differences in prevalence of DGE after pancreatoduodenectomy (PD) and that the impact of the reconstructive method on DGE is related mostly to the angulation or torsion of the gastro/duodeno-jejunostomy. We report a prevalence of 8.9% grade A DGE and 1.1% grade C DGE in a series of 89 subtotal stomach-preserving PDs with Roux-en Y retrocolic reconstruction with anastomosis of the isolated Roux limb to the stomach and single Roux limb to both the pancreatic stump and hepatic duct. Retrocolic anastomosis of the isolated first jejunal loop to the gastric remnant allows outflow of the gastric contents by gravity through a “straight route”.
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Enteral nutrition reduces delayed gastric emptying after standard pancreaticoduodenectomy with child reconstruction. J Gastrointest Surg 2012; 16:1004-11. [PMID: 22258876 DOI: 10.1007/s11605-012-1821-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/04/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication following pancreaticoduodenectomy (PD). Our retrospective study aimed to evaluate the influence of enteral nutrition (EN) on DGE incidence after standard PD with antrectomy and Child reconstruction. METHODS We retrospectively analyzed 275 consecutive patients who underwent standard PD between January 2000 and September 2009. Patients operated on after January 2005 received EN (EN group, n = 152) until total oral alimentation. Patients operated on prior to 2005 did not receive EN (control group, n = 123) and were orally fed after removing the nasogastric tube. Primary endpoint was the incidence of DGE according to the International Study Group of Pancreatic Surgery criteria. Secondary endpoints were the incidence of any other complications. RESULTS The incidence of DGE was 26% vs. 38% (p = 0.04) in the EN and control groups, respectively, with 17% vs. 19% for grade B DGE (NS) and 9% vs. 19% for grade C DGE (p = 0.02). The differences in DGE did not significantly decrease the duration of stay (18 ± 11 vs. 19 ± 13 days; NS). Postpancreatectomy hemorrhage was significantly reduced in the EN group (8% vs. 20%, p = 0.008), with the incidence of postoperative pancreatic fistula being similar in both groups (15% vs. 12%; NS). Using multivariate analysis, EN (p = 0.047, OR = 0.559 [0.315; 0.994]), operative time (p < 0.001, OR = 1.007 [1.003; 1.010]), and patient age (p = 0.014, OR = 1.031 [1.006; 1.057]) were independent factors affecting the incidence of DGE. CONCLUSIONS EN reduces DGE and postpancreatectomy hemorrhage after PD.
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Kurahara H, Shinchi H, Maemura K, Mataki Y, Iino S, Sakoda M, Ueno S, Takao S, Natsugoe S. Delayed gastric emptying after pancreatoduodenectomy. J Surg Res 2011; 171:e187-92. [PMID: 22001182 DOI: 10.1016/j.jss.2011.08.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 07/27/2011] [Accepted: 08/01/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antecolic reconstruction after pylorus-preserving pancreatoduodenectomy (PPPD) has been reported to decrease the incidence of delayed gastric emptying (DGE), which is one of the main postoperative complications. Subtotal stomach-preserving PD (SSPPD), in which duodenum and pylorus ring were removed, was introduced for the purpose of decreasing the incidence of DGE. This prospective randomized control study was performed to assess whether antecolic reconstruction decreases the incidence of DGE compared with retrocolic reconstruction after SSPPD. MATERIALS AND METHODS Forty-six patients were enrolled in this trial between May 2007 and June 2010. Twenty-two and 24 patients were randomized for the retrocolic and antecolic groups, respectively. The primary endpoint was DGE incidence. RESULTS The overall incidence of DGE in the retrocolic group was significantly higher than that in the antecolic group (50% versus 20.8%, P=0.0364). In particular, this difference was most striking in the incidence of DGE grade B/C (27.3% versus 4.2%, P=0.0234). Furthermore, patients in the retrocolic group required significantly longer time to full resumption of diet compared with the antecolic group. No significant difference was observed in other postoperative complications between the two groups. CONCLUSION Antecolic reconstruction, and not retrocolic reconstruction, decreases DGE incidence after SSPPD.
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Affiliation(s)
- Hiroshi Kurahara
- Department of Surgical Oncology and Digestive Surgery, Graduate School of Medical Sciences, Kagoshima University, Kagoshima, Japan.
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Using the greater omental flap to cover the cut surface of the liver for prevention of delayed gastric emptying after left-sided hepatobiliary resection: a prospective randomized controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:176-83. [PMID: 20835732 DOI: 10.1007/s00534-010-0323-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this randomized controlled trial is to evaluate the effect on delayed gastric emptying (DGE) of using the greater omental flap to cover the cut surface of the liver after left-sided hepatobiliary resection. METHODS From June 2007 to December 2008, all eligible patients were randomly assigned to either the greater omental flap group (OF group) or the control group (non-OF group). RESULTS A total of 40 patients remained for final analysis. The incidence of DGE after left-sided hepatobiliary resection was 25%. The incidence of DGE showed no statistically significant differences between the OF group (10%) and the non-OF group (40%) (p = 0.065). The assessment of DGE using radiopaque rings revealed that changes over time in the gastric emptying ratio (GER, percentage of rings excreted from stomach) did not differ in a significant manner between the two groups. There were significant differences in changes over time in GER (p = 0.044) between the patients with and without DGE. The patients with DGE also showed higher GER at 5 h (p = 0.042) and at 6 h (p = 0.034) than those without DGE. CONCLUSIONS Using the greater omental flap to cover the cut surface of the liver may reduce the incidence of DGE after left-sided hepatobiliary resection. Assessment using radiopaque markers may be useful to evaluate DGE.
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Delayed gastric emptying after pancreaticoduodenectomy: influence of the orthotopic technique of reconstruction and intestinal motilin receptor expression. J Gastrointest Surg 2011; 15:1158-67. [PMID: 21547592 DOI: 10.1007/s11605-011-1554-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 04/21/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is still a common postoperative complication after pancreaticoduodenectomy (PD). Because different reconstruction techniques after PD and the influence of motilin receptor expression are controversially discussed, the present study analyzed the influence of a total orthotopic reconstruction technique on DGE after PD. METHODS Data from patients undergoing PD and reconstruction using a total orthotopic technique were reviewed, and correlations between DGE and clinico-pathological variables were analyzed. Motilin receptor expression was measured within the duodenum, jejunum, and terminal ileum. RESULTS Three hundred seven patients received orthotopic reconstruction using a single jejunal loop. DGE grade B or C could be observed in 16.6% of the patients. DGE was significantly associated with the severity of a postoperative pancreatic fistula, the need for a reoperation, wound infections, and vascular complications. Furthermore, these parameters correlated significantly with the grade of DGE. The density of motilin receptor expression decreased significantly behind the duodenum in aboral direction. CONCLUSIONS The orthotopic reconstruction after PD is the shortest distance without resection of a jejunal segment, preserves the greatest length of jejunum and thus the highest density of motilin receptors, and should therefore be recommended to reduce the incidence of DGE after PD.
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Malleo G, Crippa S, Butturini G, Salvia R, Partelli S, Rossini R, Bacchion M, Pederzoli P, Bassi C. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB (Oxford) 2010; 12:610-8. [PMID: 20961369 PMCID: PMC2999788 DOI: 10.1111/j.1477-2574.2010.00203.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study evaluates the incidence and clinical features and associated risk factors of delayed gastric emptying (DGE) after pancreaticoduodenectomy, employing the International Study Group of Pancreatic Surgery (ISGPS) consensus definition. METHODS Demographic, pathological and surgical details for 260 consecutive patients who underwent pylorus-preserving pancreaticoduodenectomy at a single institution were analysed using univariate and multivariate models. RESULTS Postoperative complications occurred in 108 (41.5%) and DGE was diagnosed in 36 (13.8%) of 260 patients. Among the 36 DGE patients, 16 had grade A, 18 grade B and two grade C DGE. Resumption of a solid diet (P < 0.001), time to passage of stool (P= 0.002) and hospital discharge (P < 0.001) occurred later in DGE patients. The need for total parenteral nutrition was significantly higher in DGE grade B/C patients (P < 0.001). In the univariate analysis, abdominal collections (P≤ 0.001), pancreatic fistula (PF) grades B and C (P < 0.001), biliary fistula (P= 0.002), pulmonary complications (P < 0.001) and sepsis (P= 0.002) were associated with DGE. Only abdominal collections (P= 0.009), PF grade B/C (P < 0.001) and sepsis (P= 0.024) were associated with clinically relevant DGE. In the multivariate analysis, PF grade B/C (P= 0.004) and biliary fistula (P= 0.039) were independent risk factors for DGE. CONCLUSIONS The ISGPS classification and grading systems correlate well with the clinical course of DGE and are feasible for patient management. The principal risk factors for DGE seem to be pancreatic and biliary fistulas.
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Affiliation(s)
- Giuseppe Malleo
- Department of Surgery, General Surgery B Unit, G. B. Rossi Hospital, University of Verona, Verona, Italy
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Comparison of different pancreatic anastomosis techniques using the definitions of the International Study Group of Pancreatic Surgery: a single surgeon's experience. Pancreas 2009; 38:896-902. [PMID: 19672206 DOI: 10.1097/mpa.0b013e3181b365f7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We aimed to compare different techniques using the definitions of the International Study Group of Pancreatic Surgery for postoperative complications after pancreaticoduodenectomy. METHODS The perioperative data of 119 patients that underwent pancreaticoduodenectomy by a single surgeon were retrospectively analyzed. Pancreaticojejunal anastomosis was performed using the dunking method (n = 39), the duct-to-mucosa anastomosis method (n = 40), and the duct-to-mucosa adaptation (n = 40). RESULTS The most frequent complication was postoperative pancreatic fistula (POPF; grades A, 21%; B, 8%; and C, 3%), postpancreatectomy hemorrhage (PPH; grades B, 7% and C, 1%), and delayed gastric emptying (DGE; grades A, 1% and B, 6%). No significant differences in POPF were found between patients who underwent different types of pancreatic anastomoses. Only pancreatic ductal adenocarcinoma (P = 0.001) and pancreatic texture (P = 0.012) were potentially related to POPF. Patients with or without POPF grade A had shorter postoperative stays than patients with grade B or C POPF (P < 0.001), and similar findings were obtained for DGE and PPH. CONCLUSIONS The successful management of pancreatic anastomoses depends more on a meticulous surgical technique and appropriate experience rather than on the type of technique. Furthermore, the International Study Group of Pancreatic Surgery definitions of POPF, DGE, and PPH seem objective and universally acceptable.
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Tien YW, Yang CY, Wu YM, Hu RH, Lee PH. Enteral nutrition and biliopancreatic diversion effectively minimize impacts of gastroparesis after pancreaticoduodenectomy. J Gastrointest Surg 2009; 13:929-37. [PMID: 19224292 DOI: 10.1007/s11605-009-0831-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Accepted: 01/28/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Since gastroparesis is unavoidable in a certain proportion of patients after pancreaticoduodenectomy, measures to avoid its occurrence or at least minimize its impact are needed. A prospective randomized trial was performed to test the effectiveness of biliopancreatic diversion with modified Roux-en-Y gastrojejunostomy reconstruction and of enteral feeding to minimize impacts of gastroparesis after pancreaticoduodenectomy. METHODS In total, 247 patients with periampullary tumors were randomized at the time of pancreaticoduodenectomy to have either (1) modified Roux-en-Y gastrojejunostomy reconstruction (by creating a side-to-side jejunojejunostomy between afferent and efferent loop and closing the afferent loop with a TA-30-3.5 stapler) and insertion of a jejunostomy feeding tube (modified group) or (2) conventional gastric bypass (control group). Outcomes including complications, duration of nasogastric tube placement, and length of hospital stay were followed prospectively. RESULTS Gastroparesis occurred in 20 patients (16.3%) in the modified group and 27 patients in the control group (21.7%, P = 0.27). However, the International Study Group of Pancreatic Surgery grades of gastroparesis were significantly lower in the modified group (10A, 5B, 5C) than in the control group (4A, 5B, 18C, P = 0.01). CONCLUSIONS Modified procedure does not reduce the risk of gastroparesis but appears to reduce the severity when it occurs.
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Affiliation(s)
- Yu-Wen Tien
- Department of Surgery, College of Medicine, National Taiwan University Hospital and National Taiwan University, Taipei, Taiwan, Republic of China.
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Ueno T, Takashima M, Iida M, Yoshida S, Suzuki N, Oka M. Improvement of early delayed gastric emptying in patients with Billroth I type of reconstruction after pylorus preserving pancreatoduodenectomy. ACTA ACUST UNITED AC 2009; 16:300-4. [PMID: 19283336 DOI: 10.1007/s00534-009-0054-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2008] [Accepted: 10/01/2008] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early delayed gastric emptying (DGE) is the most common complication after pylorus-preserving pancreatoduodenectomy (PpPD). Recently, a vertical antecolic reconstruction for duodenojejunostomy was recommended to decrease the incidence of early DGE in patients with Billroth II-type reconstruction after PpPD. However, Billroth I-type reconstruction (B-I) after PpPD is still favored in Japan. METHODS Twelve consecutive patients with B-I were prospectively enrolled. Our technique includes an end-to-side duodenojejunostomy and alignment of the stomach contours with fixation of the greater omentum to the abdominal wall in order to promote passage from the stomach through the jejunal loop. DGE was evaluated according to the consensus definition of the International Study Group of Pancreatic Surgery (ISGPS). RESULTS DGE was absent, with the nasogastric tube removed within 3 days in all patients. Mean duration of nasogastric tube placement was 1.5 +/- 0.4 days. Mean maximum suction volume was 85 +/- 32 ml/day. CONCLUSION Preliminary results were encouraging simply with relief of the outflow disturbance around the duodenojejunostomy in patients with B-I after PpPD. These findings warrant further prospective randomized trials at either multiple or high-volume centers.
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Affiliation(s)
- Tomio Ueno
- Department of Digestive Surgery and Surgical Oncology (Department of Surgery II), Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-kogushi, Ube, Yamaguchi, 755-8505, Japan.
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Reply to Comments on “An Antecolic Roux-en-Y Reconstruction Decreased Delayed Gastric Emptying After Pylorus-Preserving Pancreatoduodenectomy”. J Gastrointest Surg 2008. [DOI: 10.1007/s11605-008-0626-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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An antecolic Roux-en Y type reconstruction decreased delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. J Gastrointest Surg 2008; 12:1081-6. [PMID: 18256885 DOI: 10.1007/s11605-008-0483-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 01/16/2008] [Indexed: 01/31/2023]
Abstract
The aim of this study was to identify a preferable procedure reducing the incidence of delayed gastric emptying (DGE) after pylorus-preserving pancreatoduodenectomy (PPPD). Data on 132 consecutive patients with pancreatobiliary disease, who underwent PPPD, were collected retrospectively. A retrocolic Billroth I type reconstruction (B-I group) and an antecolic Roux-en Y type reconstruction (R-Y group) were performed for 54 and 78 patients after PPPD, respectively. Clinical measures of DGE were compared between the two groups. The incidence of DGE was 81% in B-I group and 10% in R-Y group (P < 0.001). The type of reconstruction (P < 0.001), operative time (P = 0.016), and postoperative complications (P = 0.001) were significantly associated with DGE by univariate analysis. Only the type of reconstruction (P < 0.001) was identified as an independent factor, which was associated with DGE by multivariate analysis. An antecolic Roux-en Y type duodenojejunostomy could be a useful reconstruction method after PPPD to prevent the occurrence of DGE.
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Prophylactic octreotide and delayed gastric emptying after pancreaticoduodenectomy: results of a prospective randomized double-blinded placebo-controlled trial. Eur J Surg Oncol 2008; 34:868-875. [PMID: 18299182 DOI: 10.1016/j.ejso.2008.01.014] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 01/15/2008] [Indexed: 01/21/2023] Open
Abstract
AIMS To evaluate the impact of prophylactic octreotide on gastric emptying in patients undergoing pancreaticoduodenectomy. Postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE) are common complications after pancreaticoduodenectomy. Whereas several prospective randomized trials propose the prophylactic use of octreotide to prevent pancreatic fistula formation, somatostatin has, however, been associated with delayed gastric emptying after partial duodenopancreatectomy. METHODS In this prospective, randomized, double-blinded, placebo-controlled trial we analyzed the influence of prophylactic octreotide on delayed gastric empting after pancreaticoduodenectomy. Patients were randomized to the placebo group (n=32) and the octreotide group (n=35). Primary endpoint was the incidence of delayed gastric emptying, secondary endpoints included perioperative morbidity other than DGE. DGE was measured by clinical signs, gastric scintigraphy and the hydrogen breath test. Risk factors for DGE other than octreotide were analyzed by univariate and multivariate analyses. RESULTS DGE measured by clinical signs was similar between both groups studied ( approximately 20% of the patients). Gastric scintigraphy (T(1/2)) was 76.3+/-15.2 min in the octreotide group and 86.7+/-18.0 min in controls at day 7, respectively. The H(2) breath test was 65.0+/-6.5 min in octreotide treatment group and 67.0+/-5.7 min in controls at day 8. POPF grade C occurred in approximately 3% of the patients, although prophylactic treatment of octreotide did not reduce the incidence of POPF. Multivariate analysis showed that postoperative intraabdominal bleeding and infection were independent risk factors for DGE. Furthermore preoperative biliary stenting reduced postoperative DGE after partial duodenopancreatectomy. CONCLUSION Prophylactic octreotide has no influence on gastric emptying and does not decrease the incidence of postoperative pancreatic fistula after pancreaticoduodenectomy.
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Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142:761-8. [PMID: 17981197 DOI: 10.1016/j.surg.2007.05.005] [Citation(s) in RCA: 2262] [Impact Index Per Article: 125.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2006] [Revised: 03/14/2007] [Accepted: 05/11/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after pancreatic resection. In the literature, the reported incidence of DGE after pancreatic surgery varies considerably between different surgical centers, primarily because an internationally accepted consensus definition of DGE is not available. Several surgical centers use a different definition of DGE. Hence, a valid comparison of different study reports and operative techniques is not possible. METHODS After a literature review on DGE after pancreatic resection, the International Study Group of Pancreatic Surgery (ISGPS) developed an objective and generally applicable definition with grades of DGE based primarily on severity and clinical impact. RESULTS DGE represents the inability to return to a standard diet by the end of the first postoperative week and includes prolonged nasogastric intubation of the patient. Three different grades (A, B, and C) were defined based on the impact on the clinical course and on postoperative management. CONCLUSION The proposed definition, which includes a clinical grading of DGE, should allow objective and accurate comparison of the results of future clinical trials and will facilitate the objective evaluation of novel interventions and surgical modalities in the field of pancreatic surgery.
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Affiliation(s)
- Moritz N Wente
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, Germany
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Paraskevas KI, Avgerinos C, Manes C, Lytras D, Dervenis C. Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: A review of the literature and critical reappraisal of the implicated pathomechanism. World J Gastroenterol 2006; 12:5951-8. [PMID: 17009392 PMCID: PMC4124401 DOI: 10.3748/wjg.v12.i37.5951] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pylorus-preserving pancreaticoduodenectomy (PPPD) is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying (DGE) comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/Medline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy (PD) vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported (but not yet tested in large-scale studies) modification, that is, PPPD with antecolic duodenojejunostomy.
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Lytras D, Paraskevas KI, Avgerinos C, Manes C, Touloumis Z, Paraskeva KD, Dervenis C. Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection. Langenbecks Arch Surg 2006; 392:1-12. [PMID: 17021788 DOI: 10.1007/s00423-006-0096-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Accepted: 08/11/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality. METHODS We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were "delayed gastric emptying," "pancreaticoduodenectomy," "Whipple procedure," "pylorus-preserving pancreaticoduodenectomy," and "complications following pancreatic resection" in various combinations. RESULTS A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported. CONCLUSIONS The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as "centralizing" pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.
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Affiliation(s)
- Dimitrios Lytras
- 1st Department of Surgery, Agia Olga Hospital, 3-5 Agias Olgas Street, 14233 Nea Ionia, Greece
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Abstract
PURPOSE OF REVIEW To examine the available documentation addressing the introduction of early food after major upper gastrointestinal surgery. RECENT FINDINGS No high-quality trials, recent or old, have addressed this topic. A few attempts have been identified. Information is extracted from papers discussing other topics of postoperative care in this field. Generally, nasogastric tubes and nil-by-mouth prevail in the early postoperative period. SUMMARY The reluctance to allow early food at will is not evidence based, but neither is the safety of an alternative regimen. Early food at will should probably be allowed after hepatic resections, gastric resections, and total gastrectomies and maybe also after pancreaticoduodenectomies. Resections of the esophagus remain the most challenging issue. The need is urgent for high-powered and high-quality randomized controlled clinical trials.
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Affiliation(s)
- Kristoffer Lassen
- Department of Digestive Surgery, University Hospital Northern Norway, Tromsø, Norway.
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Tani M, Terasawa H, Kawai M, Ina S, Hirono S, Uchiyama K, Yamaue H. Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy: results of a prospective, randomized, controlled trial. Ann Surg 2006; 243:316-20. [PMID: 16495694 PMCID: PMC1448934 DOI: 10.1097/01.sla.0000201479.84934.ca] [Citation(s) in RCA: 237] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine if an antecolic or a retrocolic duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy (PpPD) was associated with the least incidence of delayed gastric emptying (DGE), in a prospective, randomized, controlled trial. SUMMARY BACKGROUND DATA The pathogenesis of DGE after PpPD has been speculated to be related to factors such as inflammation, ischemia, gastric atony, motilin levels, and type of surgical procedure. Previous retrospective studies have shown a lower incidence of DGE after antecolic duodenojejunostomy. A prospective trial is needed. METHODS Forty patients were enrolled in this trial between May 2002 and April 2004. Just before duodenojejunostomy during PpPD, the patients were randomly assigned to undergo either an antecolic or a retrocolic duodenojejunostomy. RESULTS DGE occurred in 5% of patients with the antecolic route for duodenojejunostomy versus 50% with the retrocolic route (P = 0.0014). Those with the antecolic route had a significantly shorter duration of postoperative nasogastric tube drainage than did those with the retrocolic route (4.2 days versus 18.9 days, respectively, P = 0.047). By postoperative day 14, all patients with the antecolic route could take solid foods, while only 55% (11 of 20) of the patients with the retrocolic route could take solid foods (P = 0.0007). The length of stay in the hospital was 28 days for the antecolic group versus 48 days for the retrocolic group (P = 0.018). CONCLUSIONS Antecolic reconstruction for duodenojejunostomy during PpPD decreases postoperative morbidity and length of hospital stay by decreasing DGE. Our data suggest that PpPD with antecolic duodenojejunostomy is a safer operation.
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Affiliation(s)
- Masaji Tani
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
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Doi R, Fujimoto K, Kobayashi H, Imamura M. Impact of reconstruction methods on outcome of pancreatoduodenectomy in pancreatic cancer patients. World J Surg 2005; 29:500-4. [PMID: 15770374 DOI: 10.1007/s00268-004-7723-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Local recurrence is one of the most frequent forms of pancreatic cancer recurrence, although local recurrence is rare for other periampullary cancers. Because the type of recurrence and outcome differ depending on the type of cancer, these factors should be considered when the type of reconstruction is chosen. Fifty-four pancreatoduodenectomies were performed in patients with ductal adenocarcinoma of the pancreas from 1994 to 2001. Billroth I reconstruction was performed in 27 consecutive patients before 1999, and thereafter Billroth II reconstruction was performed in another consecutive 27 patients. Postoperative nasogastric intubation and the duration before oral ingestion were longer for Billroth I patients than Billroth II patients. Seven complications occurred in Billroth I patients, whereas there were two complications in Billroth II patients. Disease-free survival and overall survival were not different between the two groups; however, bypass operations were required in nine patients of the Billroth I group and in one patient of the Billroth II group. Percutaneous transhepatic cholangio-drainage (PTCD) procedures were required in six patients of the Billroth I goup and in two patients of the Billroth II group. The Billroth II reconstruction may have some advantages over the Billroth I reconstruction in terms of postoperative oral ingestion and avoiding bypass surgery and PTCD at the time of recurrence.
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Affiliation(s)
- Ryuichiro Doi
- Department of Surgery and Surgical Basic Science, Kyoto University, 54 Shogoinkawaracho, Sakyo, Kyoto 606-8507, Japan.
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Kurosaki I, Hatakeyama K. Preservation of the left gastric vein in delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy. J Gastrointest Surg 2005; 9:846-52. [PMID: 15985243 DOI: 10.1016/j.gassur.2005.02.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2005] [Accepted: 02/15/2005] [Indexed: 01/31/2023]
Abstract
The definition of delayed gastric emptying (DGE) after pyloric-preserving pancreaticoduodenectomy (PPPD) varies among surgeons. We compared and evaluated three different definitions reported elsewhere. In addition, we investigated the correlation between multiple surgical factors and recovery of gastric motility. First, 55 consecutive patients were reviewed to assess the three different definitions. Second, surgical factors affecting gastric motility were investigated in 46 patients showing no major complications. All 55 patients underwent PPPD, which was reconstructed with antecolic duodenojejunostomy, with aggressive lymph node dissection and with no mortality. The duration of nasogastric intubation was 2 days, and a solid diet started on the 12th postoperative day (median). Re-nasogastric intubation or emesis was observed in 12.7% of patients. Overall, DGE occurrence rate was 5.5%-29.1%, with striking differences depending on the type of definition. Technically, division of the left gastric vein was accompanied with significantly delayed removal of the nasogastric tube (3 versus 2 days, P = 0.0002) and delayed start on a solid diet (14 versus 9 days, P < 0.0001) compared with its preservation. Antecolic duodenojejunostomy after PPPD improved DGE occurrence despite aggressive surgery, and preservation of LGV accelerated restoration of gastric motility in our experiments. However, an understanding of a common definition of DGE is needed when discussing the outcome of the various interventions.
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Affiliation(s)
- Isao Kurosaki
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.
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Tani M, Kawai M, Terasawa H, Ueno M, Hama T, Hirono S, Ina S, Uchiyama K, Yamaue H. Complications with Reconstruction Procedures in Pylorus-preserving Pancreaticoduodenectomy. World J Surg 2005; 29:881-4. [PMID: 15951940 DOI: 10.1007/s00268-005-7697-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This study was conducted retrospectively to examine the efficacy of Traverso reconstruction compared with Billroth I reconstruction after pylorus-preserving pancreaticoduodenectomy, in the prevention of several complications. Pylorus-preserving pancreaticoduodenectomy is an aggressive surgery, and insufficiency of the pancreaticoenterostomy plays an important role in the postoperative progression. However, reports examining the correlation between pancreatic fistula and the type of reconstruction after pylorus-preserving pancreaticoduodenectomy have been limited. Sixty-four patients who underwent pylorus-preserving pancreaticoduodenectomy (33 reconstructed by the Traverso technique and 31 reconstructed by the Billroth I technique) were entered into this study to investigate whether the complications were related to the type of reconstruction procedure employed. Insufficiency of the pancreaticojejunostomy, including major leakage and pancreatic fistula, occurred in 18.2% of the reconstructions by Billroth I and 0% of the reconstructions by Traverso (p < 0.05). In addition, jejunal obstruction by recurrent tumor in the remnant pancreas was observed in 3 patients reconstructed by Billroth I, and required palliative bypass surgery. Reconstruction by the Traverso procedure after pylorus-preserving pancreaticoduodenectomy is a safe surgical method and has an advantage for advanced pancreatic cancer, which has high risk of jejunal obstruction by recurrent tumor in the remnant pancreas.
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Affiliation(s)
- Masaji Tani
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
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de Bree E, Melissas J, Schoretsanitis G, Sanidas E, Tsiftsis DD. Pylorus-preserving pancreaticoduodenectomy with external pancreatic remnant drainage. Acta Chir Belg 2004; 104:668-672. [PMID: 15663272 DOI: 10.1080/00015458.2004.11679640] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy is the mainstay of surgical treatment for various benign and malignant diseases of the head of the pancreas and the periampullar region. The incidence of postoperative morbidity remains significantly high. Various modifications have been advocated for the restoration of the digestive continuity and drainage of bile and pancreatic ducts in order to diminish this high morbidity rate. METHODS A new modification with the combination of an end-to-end duodenojejunal anastomosis and creation of an external pancreatic fistula following pylorus-preserving pancreaticoduodenectomy is described. Our initial experience with this modification in seven patients is reported and its advantages are discussed. RESULTS There was no mortality, while morbidity was 29%, including postoperative pneumonia and psychosis in one patient, and intra-abdominal abscess in another patient. No significantly delayed gastric emptying was observed and no patient developed diabetes, anastomotic ulcer or reflux cholangitis postoperatively. CONCLUSIONS The reported technique seems to be a safe modification of restoration after pancreaticoduodenectomy, with maintenance of anatomical gastrointestinal continuity, avoidance of complications from anastomosis with the pancreatic remnant, as well as maintenance of endocrine pancreatic function. However, long-term follow-up and larger comparative studies are needed to evaluate the impact of this modification on morbidity and mortality, including long-term nutritional complications.
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Affiliation(s)
- E de Bree
- Department of Surgical Oncology, University Hospital, Medical School of Crete, Herakleion, Greece.
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