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Wu XD, Yan HJ, Xu YM, Zhao SY, Zhang XD, Lv L, Zhu KL. Effect and mechanism of needleless transcutaneous neuromodulation on gastrointestinal function after pancreaticoduodenectomy. Scand J Gastroenterol 2024; 59:133-141. [PMID: 37752679 DOI: 10.1080/00365521.2023.2261060] [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: 06/30/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Gastrointestinal motility disorders tend to develop after pancreaticoduodenectomy (PD). The objectives of this study were: (1) to investigate the impact of needleless transcutaneous neuromodulation (TN) on the postoperative recuperation following pancreaticoduodenectomy (PD), and (2) to explore the underlying mechanisms by which TN facilitates the recovery of gastrointestinal function after PD. METHODS A total of 41 patients scheduled for PD were randomized into two groups: the TN group (n = 21) and the Sham-TN group (n = 20). TN was performed at acupoints ST-36 and PC-6 twice daily for 1 h from the postoperative day 1 (POD1) to day 7. Sham-TN was performed at non-acupoints. Subsequent assessments incorporated both heart rate variation and dynamic electrogastrography to quantify alterations in vagal activity (HF) and gastric pacing activity. RESULTS 1)TN significantly decreased the duration of the first passage of flatus (p < 0.001) and defecation (p < 0.01) as well as the time required to resume diet (p < 0.001) when compared to sham-TN;2)Compared with sham-TN, TN increased the proportion of regular gastric pacing activity (p < 0.01);3) From POD1 to POD7, there was a discernible augmentation in HF induced by TN stimulation(p < 0.01);4) TN significantly decreased serum IL-6 levels from POD1 to POD7 (p < 0.001);5) TN was an independent predictor of shortened hospital stay(β = - 0.349, p = 0.035). CONCLUSION Needleless TN accelerates the recovery of gastrointestinal function and reduces the risk of delayed gastric emptying in patients after PD by enhancing vagal activity and controlling the inflammatory response.
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Affiliation(s)
- Xu-Dong Wu
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Huan-Jun Yan
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Yue-Mei Xu
- Gastroenterology, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Shuang-Ying Zhao
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Xiao-Dong Zhang
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Li- Lv
- Department of Infectious Diseases, Zhejiang University School of Medicine, Hangzhou, China
| | - Ke-Lei Zhu
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
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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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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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Ellis RJ, Gupta AR, Hewitt DB, Merkow RP, Cohen ME, Ko CY, Bilimoria KY, Bentrem DJ, Yang AD. Risk factors for post-pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra-abdominal infection. J Surg Oncol 2019; 119:925-931. [PMID: 30737792 PMCID: PMC7747058 DOI: 10.1002/jso.25398] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/08/2019] [Accepted: 01/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), but the rate of DGE in the absence of other intra-abdominal complications is poorly understood. The objectives of this study were to define the incidence of DGE and identify risk factors for DGE in patients without pancreatic fistula or other intra-abdominal infections. METHODS Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy variables to identify patients with DGE following PD without evidence of fistula or intra-abdominal infection. Multivariable models were developed to assess preoperative, intraoperative, and technical factors associated with DGE. RESULTS The rate of DGE was 11.7% in 10502 cases without pancreatic fistula or intra-abdominal infection. Patients were more likely to develop DGE if age ≥75 (odds ratio [OR], 1.22; P = 0.003), male (OR, 1.29; P < 0.001), underwent pylorus-sparing PD (OR, 1.27; P = 0.004), or had a prolonged operative time (OR, 1.38 if greater than seven vs less than 5 hours; P = 0.005). Factors not associated with DGE included BMI, pathologic indication, and surgical approach. CONCLUSION The incidence of DGE after PD is notable even in patients without other abdominal complications. Identification of patients at increased risk for DGE may aid patient counseling as well as decisions regarding surgical technique, enteral feeding access, and enhanced-recovery pathways.
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Affiliation(s)
- Ryan J. Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Aakash R. Gupta
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - D. Brock Hewitt
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan P. Merkow
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Mark E. Cohen
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Clifford Y. Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Karl Y. Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - David J. Bentrem
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Anthony D. Yang
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
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5
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Ben-Ishay O, Zhaya RA, Kluger Y. Dual loop (Roux en Y) reconstruction with isolated gastric limb reduces delayed gastric emptying after pancreatico-duodenectomy. World J Gastrointest Surg 2019; 11:93-100. [PMID: 30842815 PMCID: PMC6397796 DOI: 10.4240/wjgs.v11.i2.93] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 02/23/2019] [Accepted: 02/25/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Single loop reconstruction (SLR) was routine in our institution for patients undergoing pancreatico-duodenectomy (PD). Roux-en Y reconstruction with an isolated gastric limb (RIGL) recently became the reconstruction of choice.
AIM To evaluate the impact of RIGL on incidence and severity of delayed gastric emptying (DGE).
METHODS This is a single institution, retrospective analysis of patients undergoing PD. All patients undergoing PD from July 2010 through December 2016 were included in the study. Outcome of RIGL were compared to SLR. Primary measure of outcome included incidence and severity of DGE. Secondary measures of outcome were overall complications and postoperative mortality.
RESULTS One hundred and seventy-nine patients were included in the study. Fifty-two had RIGL, 127 had SLR. Overall complication rate was 40.2%, patients in the RIGL group experienced lower rates of DGE (15.4% vs 59.1%, P = 0.001). Other patient related outcomes were also significantly reduced: day of nasogastric tube removal (3 vs 5, P < 0.001), regain of normal diet (8 vs 9, P < 0.001). On multivariate analysis RIGL was associated independently with reduced rates of DGE (P < 0.001, OR 0.14)
CONCLUSION The current study shows that RIGL reduces the rate of DGE after PD. Further prospective randomized controlled trials are required to affirm the current data.
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Affiliation(s)
- Offir Ben-Ishay
- Surgical Oncology Unit, Division of General Surgery, Rambam Health Care Campus, Haifa 35254, Israel
| | - Reem Abu Zhaya
- Surgical Oncology Unit, Division of General Surgery, Rambam Health Care Campus, Haifa 35254, Israel
| | - Yoram Kluger
- Surgical Oncology Unit, Division of General Surgery, Rambam Health Care Campus, Haifa 35254, Israel
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Romański KW. Importance of the enteric nervous system in the control of the migrating motility complex. Physiol Int 2017; 104:97-129. [PMID: 28665193 DOI: 10.1556/2060.104.2017.2.4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The migrating motility complex (MMC), a cyclical phenomenon, represents rudimentary motility pattern in the gastrointestinal tract. The MMC is observed mostly in the stomach and gut of man and numerous animal species. It contains three or four phases, while its phase III is the most characteristic. The mechanisms controlling the pattern are unclear in part, although the neural control of the MMC seems crucial. The main goal of this article was to discuss the importance of intrinsic innervation of the gastrointestinal tract in MMC initiation, migration, and cessation to emphasize that various MMC-controlling mechanisms act through the enteric nervous system. Two main neural regions, central and peripheral, are able to initiate the MMC. However, central regulation of the MMC may require cooperation with the enteric nervous system. When central mechanisms are not active, the MMC can be initiated peripherally in any region of the small bowel. The enteric nervous system affects the MMC in response to the luminal stimuli which can contribute to the initiation and cessation of the cycle, and it may evoke irregular phasic contractions within the pattern. The hormonal regulators released from the endocrine cells may exert a modulatory effect upon the MMC mostly through the enteric nervous system. Their central action could also be considered. It can be concluded that the enteric nervous system is involved in the great majority of the MMC-controlling mechanisms.
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Affiliation(s)
- K W Romański
- 1 Department of Animal Physiology, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences , Wrocław, Poland
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7
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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] [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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Shahbazov R, Yoshimatsu G, Haque WZ, Khan OS, Saracino G, Lawrence MC, Kim PT, Onaca N, Naziruddin B, Levy MF. Clinical effectiveness of a pylorus-preserving procedure on total pancreatectomy with islet autotransplantation. Am J Surg 2016; 213:1065-1071. [PMID: 27760705 DOI: 10.1016/j.amjsurg.2016.09.051] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The impact of pylorus preserving procedures (PP) on total pancreatectomy with islet autotransplantation (TPIAT) has not been examined. This study aimed to investigate the clinical impact of the PP on TPIAT. METHODS The Baylor Simmons Transplant Institute database was queried to identify seventy-three patients who underwent TPIAT from 2006 to 2014. All patients were investigated in postoperative complications, long-term nutritional status, and graft function. RESULTS Patients with PP did not face worse outcomes in terms of delayed gastric emptying and length of hospital stay. Also, nutritional status and metabolic outcome, such as body weight, serum albumin level, serum vitamin level, HbA1c level, graft survival rate and insulin independent rate, were similar between both groups. CONCLUSIONS Clinical results including the graft function indicated that patients undergoing TPIAT with PP did not amplify surgical complications such as delayed gastric emptying and showed no significant advantage of nutrition and metabolic outcome.
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Affiliation(s)
- Rauf Shahbazov
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Waqas Z Haque
- Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - Omar S Khan
- Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - Giovanna Saracino
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | - Peter T Kim
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Nicholas Onaca
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Bashoo Naziruddin
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
| | - Marlon F Levy
- Transplant Division, Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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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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10
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Limongelli P, D'Alessandro A, Parisi S, Pirozzi R, Bondanese M, Colella C, Docimo G, Del Genio G, Del Genio A, Docimo L. Double loop reconstruction following pancreaticoduodenectomy for malignant tumor: Short-term outcome. Int J Surg Case Rep 2016; 20S:16-20. [PMID: 26872635 DOI: 10.1016/j.ijscr.2016.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To evaluate the use of a double loop reconstruction following pylorus preserving proximal pancreaticoduodenectomy (PPPPD). METHODS Morbidity and mortality were evaluated in 55 patients undergoing PPPPD for malignant tumors, followed by a double loop reconstruction. RESULTS The mean intra-operative blood loss was 908mL±531. In-hospital mortality was 5.4% (3/55 pts). The mean length of hospital stay was 17±5 days (range 12-45 days). Postoperative complications occurred in 25 patients (46.2%). Five patients developed an anastomotic leak, one biliary and four pancreatic (4/55; 7%). Delayed gastric emptying occurred in 8 patients (14.5%). Reoperation was required in two patients for hemorrhage. CONCLUSIONS A double loop alimentary reconstruction following PPPPD led to a low incidence of DGE and pancreatic fistula. Although mortality rate was higher than that reported by referral centres, this technique has been performed in a not specialized unit attaining acceptable results.
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Affiliation(s)
- Paolo Limongelli
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy.
| | - A D'Alessandro
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - S Parisi
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - R Pirozzi
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - M Bondanese
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - C Colella
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - Giovanni Docimo
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - Gianmattia Del Genio
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - Alberto Del Genio
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
| | - Ludovico Docimo
- XI Division of General and Obesity Surgery, Second University of Naples, Naples, Italy
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11
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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: 10] [Impact Index Per Article: 1.1] [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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A Long Gastrojejunostomy Is Associated With Decreased Incidence and Severity of Delayed Gastric Emptying After Pancreaticoduodenectomy. Pancreas 2015; 44:1273-9. [PMID: 26390414 DOI: 10.1097/mpa.0000000000000415] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) is associated with increased hospital length of stay (LOS) and health care costs. We hypothesized that a long gastrojejunostomy for PD (LGPD) is associated with decreased incidence of DGE. METHODS Data were reviewed from patients who underwent standard PD (SPD), pylorus-preserving PD (PPPD), or LGPD with a 9-cm-long anastomosis between August 2000 and July 2010. Primary outcomes included presence and grade of DGE and LOS. The International Study Group of Pancreatic Surgery definition was used to define DGE. RESULTS A total of 194 PDs (28 SPDs, 82 PPPDs, and 84 LGPDs) were performed. The rates of DGE were 46.4%, 37.8%, and 16.7%, respectively (P = 0.001). The LGPD was associated with fewer grades B/C DGE (2.4%) compared to SPD (10.7%) and PPPD (17.5%). Rates of postoperative abdominal fluid collection and abscess were similar among the groups. Patients with DGE had significantly longer LOS (14.0 vs 7.0 days, P < 0.001). CONCLUSIONS This is the first study evaluating the effect of a long gastrojejunostomy on the incidence of DGE after PD. The LGPD is associated with significantly decreased DGE compared to SPD and PPPD and warrants further exploration as a means to improve outcome for patients who undergo PD.
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13
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Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand? Indian J Surg 2015; 77:409-25. [PMID: 26722205 DOI: 10.1007/s12262-015-1366-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic resection has become a feasible treatment of pancreatic neoplasms, and with improvements in surgical techniques and perioperative management, mortality associated with pancreatic surgery has decreased considerably. Despite this improvement, a high rate of complications is still associated with these procedures. Among these complications, delayed gastric emptying (DGE) and postoperative pancreatic fistula (POPF) have a substantial impact on patient outcomes and burden our healthcare system. Technical modifications and postoperative approaches have been proposed to reduce rates of both POPF and DGE in patients undergoing pancreatectomy; however, to date, their rates have remained unchanged. In the present study, we summarize the findings of the most significant studies that have investigated these complications. In particular, several studies focused on technical modifications including extent of dissection, stent placement, nature of anastomosis, type of reconstruction, and application of biological or non-biological agents to site of anastomosis. Moreover, postoperatively, drain placement, duration of drain usage, postoperative feeding, and use of pharmacological agents were studied to reduce rates of POPF and DGE. In this review, we summarize the most relevant literature on this fundamental aspect of pancreatic surgery. Despite studies identifying the potential benefit of technical modifications and postoperative approaches, these findings remain controversial and suggest need for further extensive investigation. Most importantly, we recommend that all surgeons performing these procedures base their practice on the most updated and highest available level of evidence.
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Sato G, Ishizaki Y, Yoshimoto J, Sugo H, Imamura H, Kawasaki S. Factors influencing clinically significant delayed gastric emptying after subtotal stomach-preserving pancreatoduodenectomy. World J Surg 2014; 38:968-75. [PMID: 24136719 DOI: 10.1007/s00268-013-2288-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pylorus ring is resected and most of the stomach is preserved, has been performed recently in Japan. This study was undertaken to clarify the incidence of delayed gastric emptying (DGE) after SSPPD at a high-volume hospital and to determine the independent factors that influence the development of DGE after SSPPD. METHODS Between 2002 and 2011, 201 consecutive patients underwent standardized SSPPD. After SSPPD, DGE (defined according to the International Study Group of Pancreatic Surgery) was analyzed, and associated variables were assessed by univariate and multivariate analyses, retrospectively. RESULTS Clinically significant DGE (grades B and C) occurred in 35 (17 %) of the 201 patients; 26 patients had other accompanying abdominal complications (secondary DGE), and pancreatic leakage was the sole risk factor for DGE (odds ratio 6.63, 95 % CI 2.86-15.74; p < 0.001). Only nine (4 % of all patients) of the 35 patients with clinically significant DGE were classified as having DGE that had arisen without any obvious etiology (primary DGE). CONCLUSIONS DGE after SSPPD is strongly linked to the occurrence of other postoperative intra-abdominal complications such as pancreatic fistula. The incidence rate of primary DGE after SSPPD was 4 %. Although the ISGPS classification of DGE is clearly applicable, the grades do not explain why DGE occurs. Primary and secondary DGE should therefore be defined separately.
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Affiliation(s)
- Go Sato
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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15
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Zhang XF, Yin GZ, Liu QG, Liu XM, Wang B, Yu L, Liu SN, Cui HY, Lv Y. Does Braun enteroenterostomy reduce delayed gastric emptying after pancreaticoduodenectomy? Medicine (Baltimore) 2014; 93:e48. [PMID: 25101987 PMCID: PMC4602449 DOI: 10.1097/md.0000000000000048] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Whether an additional Braun enteroenterostomy is necessary in reducing delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) has not yet been well investigated. Herein, in this retrospective study, 395 consecutive cases of patients undergoing classic PD from 2009 to 2013 were reviewed. Patients with and without Braun enteroenterostomy were compared in preoperative baseline characteristics, surgical procedure, postoperative diagnosis, and morbidity including DGE. The DGE was defined and classified by the International Study Group of Pancreatic Surgery recommendation. The incidence of DGE was similar in patients with or without Braun enteroenterostomy following PD (37/347, 10.7% vs 8/48, 16.7%, P = 0.220). The patients in the 2 groups were not different in patient characteristics, lesions, surgical procedure, or postoperative complications, although patients without Braun enteroenterostomy more frequently presented postoperative vomiting than those with Braun enteroenterostomy (33.3% vs 15.3%, P = 0.002). Bile leakage, pancreatic fistula, and intraperitoneal abscess were risk factors for postoperative DGE (all P < 0.05). Prokinetic agents and acupuncture were effective in symptom relief of DGE in 24 out of 45 patients and 12 out of 14 patients, respectively.The additional Braun enteroenterostomy following classic PD was not associated with a decreased rate of DGE. Postoperative abdominal complications were strongly correlated with the onset of DGE. Prokinetic agents and acupuncture could be utilized in some patients with DGE.
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Affiliation(s)
- Xu-Feng Zhang
- Department of Hepatobiliary Surgery (X-FZ, G-ZY, Q-GL, X-ML, BW, LY, S-NL, YL); Institute of Advanced Surgical Technology and Engineering (X-FZ, X-ML, YL); Department of Chinese Acupuncture and Moxibustion, First Affiliated Hospital of Medical College, Xi'an Jiaotong University (H-YC), Xi'an, China
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Krishna A, Bansal VK, Kumar S, Sridhar P, Kapoor S, Misra MC, Garg P. Preventing Delayed Gastric Emptying After Whipple's Procedure-Isolated Roux Loop Reconstruction With Pancreaticogastrostomy. Indian J Surg 2013; 77:703-7. [PMID: 26730093 DOI: 10.1007/s12262-013-0992-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 10/07/2013] [Indexed: 11/25/2022] Open
Abstract
Although delayed gastric emptying (DGE) after Whipple's pancreaticoduodenectomy is not life-threatening and can be treated conservatively, it results in discomfort and significant prolongation of the hospital stay and adds on to the hospital costs. To overcome this problem, we started using the isolated loop technique of reconstruction along with pancreaticogastrostomy and we present our series using this technique. All consecutive patients undergoing Whipple's pancreaticoduodenectomy in a single surgical unit from January 2009 until December 2012 were included. In the absence of hepatic and peritoneal metastasis, resection (Whipple's procedure) with curative intent was done using isolated loop technique with pancreaticogastrostomy. Delayed gastric emptying was assessed clinically and on oral gastrograffin study. Bile reflux was also assessed on clinical parameters and evidence of beefy friable gastric mucosa on upper GI endoscopy and presence of reflux on hepatobiliary scintigraphy. A total of 52 patients were operated using this technique from January 2009 to October 2012. The mean operative time was 260.8 ± 50.3, and the mean operative blood loss was 1,068.0 ± 606.1 ml. Mean gastric emptying time 106.0 ± 6.1 min (89-258 min). Three out of the 52(5.7 %) patients had persistent vomiting in the post-operative period requiring reinsertion of NG tube. A HIDA scan done on POD7 for all patients did not show any evidence of bile reflux in any of the patients. Pancreatogastrostomy with isolated loop in pancreaticoduodenal resection markedly reduces the post-operative incidence of alkaline reflux gastritis and DGE.
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Affiliation(s)
- Asuri Krishna
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Subodh Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - P Sridhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Sameer Kapoor
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Mahesh C Misra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Pramod Garg
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
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Clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a systematic review and meta-analysis. Eur J Surg Oncol 2013; 39:213-23. [PMID: 23294533 DOI: 10.1016/j.ejso.2012.12.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Revised: 11/29/2012] [Accepted: 12/07/2012] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The clinical risk factors of delayed gastric emptying (DGE) in patients after pancreaticoduodenectomy (PD) remains controversial. Herein, we conducted a systematic review to quantify the associations between clinical risk factors and DGE in patients after conventional PD or pylorus preserving pancreaticoduodenectomy (PPPD). METHODS A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1970 to 2012 was performed. Cohort, case-control studies, and randomized controlled trials that examined clinical risk factors of DGE were included. RESULTS Eighteen studies met final inclusion criteria (total n = 3579). From the pooled analyses, preoperative diabetes (OR 1.49, 95% CI, 1.03-2.17), pancreatic fistulas (OR 2.66, 95% CI, 1.65-4.28), and postoperative complications (OR 4.71, 95% CI, 2.61-8.50) were significantly associated with increased risk of DGE; while patients with preoperative biliary drainage (OR 0.68, 95% CI, 0.48-0.97) and antecolic reconstruction (OR 0.17, 95% CI, 0.07-0.41) had decreased risk of DGE development. Gender, malignant pathology, preoperative jaundice, intra-operative transfusion, PD vs. PPPD and early enteral feeding were not significantly associated with DGE development (all P > 0.05). CONCLUSIONS Our findings demonstrate that preoperative diabetes, pancreatic fistulas, and postoperative complications were clinical risk factors predictive for DGE. Antecolic reconstruction and preoperative biliary drainage result in a reduction in DGE. Knowledge of these risk factors may assist in identification and appropriate referral of patients at risk of DGE.
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18
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Kim YH. Management and prevention of delayed gastric emptying after pancreaticoduodenectomy. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2012; 16:1-6. [PMID: 26388898 PMCID: PMC4575017 DOI: 10.14701/kjhbps.2012.16.1.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 02/05/2012] [Accepted: 02/11/2012] [Indexed: 12/17/2022]
Abstract
Although technical advances have been made in pancreaticoduodenectomy, the incidence of delayed gastric emptying (DGE) is reported as being high. Postoperative DGE is not fatal, but often results in prolonging the length of patients' stay in hospital, increasing their medical expenses, and further lowering their quality of life. DGE is a complex process caused by disorder and incoordination of various factors in charge of gastric mobility, such as smooth muscle cells (myogenic), enteric neuron (hormonal), and autonomic nervous system (neural). DGE often occurs after operative maneuvers that cause the loss of organs responsible for gastric motility and emptying or kinetic muscular or neuromuscular ischemia. To prevent DGE, it is most important to develop and universalize a standardized surgical technique in a way to reduce factors that are considered to cause DGE after pancreaticoduodenectomy. Moreover, if it is suspected that DGE occurred after pancreaticoduodenectomy, a differential diagnosis from diseases with similar symptoms via an accurate diagnostic approach should be implemented.
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Affiliation(s)
- Yong Hoon Kim
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Keimyung University School of Medicine, Daegu, Korea
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19
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Kim MK, Park JM, Choi YS, Chi KC. Smaller-diameter circular stapler has an advantage in Billroth I stapled anastomosis after laparoscopy-assisted distal gastrectomy. J Laparoendosc Adv Surg Tech A 2011; 22:236-41. [PMID: 22166246 DOI: 10.1089/lap.2011.0330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION Billroth I gastroduodenostomy using a circular stapler is the most preferred reconstruction method after laparoscopy-assisted distal gastrectomy (LADG). The optimal stapler size for this procedure has not yet been proposed. METHODS Sixty-five patients who underwent LADG and stapled anastomosis with a 25-mm stapler (25-mm group) and a 29-mm stapler (29-mm group) were enrolled in this study. Clinical data and gastroscopic findings at 6 and 12 months after surgery were retrospectively reviewed. RESULTS Postoperative complications and postprandial symptoms were similar in both groups. Gastroscopically, food materials remained more frequently in the remnant stomach in the 25-mm group than in the 29-mm group at 6 months after surgery (P=.041). Gastritis and bile reflux were observed more frequently in the 29-mm group than in the 25-mm group (P=.012 and P=.015, respectively). All these differences in the gastroscopic findings between the two groups decreased at 12 months after surgery except for reflux esophagitis, which was observed more frequently in the 29-mm group (P=.002). The length of the incision was smaller in the 25-mm group than in the 29-mm group (4.39 cm versus 4.95 cm, P=.009). CONCLUSION A small-diameter stapler is a risk factor for gastric stasis in the early postoperative period, whereas a large-diameter stapler is a risk factor for gastritis and bile reflux in the early postoperative period and for esophagitis in the late postoperative period. Thus, a small-diameter circular stapler has more advantages over a large-diameter circular stapler. It also enables a reliable anastomosis through a smaller incision and easy handling of the stapler during anastomosis.
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Affiliation(s)
- Min-Kyoon Kim
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
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20
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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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21
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Hochwald SN, Grobmyer SR, Hemming AW, Curran E, Bloom DA, Delano M, Behrns KE, Copeland EM, Vogel SB. Braun enteroenterostomy is associated with reduced delayed gastric emptying and early resumption of oral feeding following pancreaticoduodenectomy. J Surg Oncol 2010; 101:351-5. [PMID: 20112274 DOI: 10.1002/jso.21490] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Morbidity rates following pancreaticoduodenectomy (PD) remain high with delayed gastric emptying (DGE) and slow resumption of oral diet contributing to increased postoperative length of stay. A Braun enteroenterostomy has been shown to decrease bile reflux following gastric resection. We hypothesize that addition of Braun enteroenterostomy during PD would reduce the sequelae of DGE. METHODS From our PD database, patients were identified that underwent classic PD with partial gastrectomy from 2001 to 2006. All patients with reconstruction utilizing a single loop of jejunum at the University of Florida Shands Hospital were reviewed. Demographics, presenting signs and symptoms, pathologic diagnoses, and postoperative morbidity were compared in those patients undergoing reconstruction with an additional Braun enteroenterostomy (n = 70) to those not undergoing a Braun enteroenterostomy (n = 35). RESULTS Patients undergoing a Braun had NG tubes removed earlier (Braun: 2 days, no Braun: 3 days, P = 0.002) and no significant change in postoperative vomiting (Braun: 27%, no Braun: 37%, P = 0.37) or NG tube reinsertion rates (Braun: 17%, no Braun: 29%, P = 0.21). Median postoperative day with tolerance of oral liquids (Braun: 5, no Braun: 6, P = 0.01) and solid diets (Braun: 7, no Braun: 9, P = 0.01) were significantly sooner in the Braun group. DGE defined by two criteria including the inability to have oral intake by postoperative day 10 (Braun: 10%, no Braun: 26%, P < 0.05) and the international grading criteria (grades B and C, Braun: 7% vs. no Braun: 31%, P = 0.003) were significantly reduced in those undergoing the Braun procedure. In addition, the median length of stay (Braun: 10 days, no Braun: 12 days, P < 0.05) was significantly reduced in those undergoing the Braun procedure. The rate of pancreatic anastomotic failure was similar in the two groups (Braun: 17% vs. no Braun: 14%, P = 0.79). Median bile reflux was 0% in those undergoing a Braun. CONCLUSIONS The present study suggests that Braun enteroenterostomy can be safely performed in patients undergoing PD and may reduce the indicence of DGE and its sequelae. Further studies of Braun enteroenterostomy in larger randomized trials of patients undergoing PD are warranted.
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Affiliation(s)
- Steven N Hochwald
- Division of Surgical Oncology and Endocrine Surgery, University of Florida College of Medicine, Gainesville, Florida 32610, USA.
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Nikfarjam M, Kimchi ET, Gusani NJ, Shah SM, Sehmbey M, Shereef S, Staveley-O'Carroll KF. A reduction in delayed gastric emptying by classic pancreaticoduodenectomy with an antecolic gastrojejunal anastomosis and a retrogastric omental patch. J Gastrointest Surg 2009; 13:1674-82. [PMID: 19548039 DOI: 10.1007/s11605-009-0944-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 06/03/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) continues to be a major cause of morbidity following pancreaticoduodenectomy (PD). A change in the method of reconstruction following PD was instituted in an attempt to reduce the incidence DGE. METHODS Patients undergoing PD from January 2002 to December 2008 were reviewed and outcomes determined. Pylorus-preserving pancreaticoduodenectomy (PPPD) with a retrocolic duodenojejunal anastomosis (n = 79) or a classic PD with a retrocolic gastrojejunostomy (n = 36) was performed prior to January 2008. Thereafter, a classic PD with an antecolic gastrojejunal anastomosis and placement of a retrogastric vascular omental patch was undertaken (n = 36). RESULTS A statistically significant decrease in DGE was noted in the antecolic group compared to the entire retrocolic group (14% vs 40%; p = 0.004) and compared to patients treated by classic PD with a retrocolic anastomosis alone (14% vs 39%; p = 0.016). On multivariate analysis, the only modifiable factor associated with reduced DGE was the antecolic technique with an omental patch, odds ratio (OR) 0.3 (confidence interval (CI) 0.1-0.8) p = 0.022. Male gender was associated with an increased risk of DGE with OR 2.3 (CI 1.1-4.8) p = 0.026. CONCLUSION A classic PD combined with an antecolic anastomosis and retrogastric vascular omental patch results in a significant reduction in DGE.
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Affiliation(s)
- Mehrdad Nikfarjam
- Liver, Pancreas and Foregut Unit, Department of Surgery, Penn State College of Medicine, Hershey, PA 17033-0850, USA.
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Iqbal N, Lovegrove R, Tilney H, Abraham A, Bhattacharya S, Tekkis P, Kocher H. A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: A meta-analysis of 2822 patients. Eur J Surg Oncol 2008; 34:1237-45. [DOI: 10.1016/j.ejso.2007.12.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Accepted: 12/17/2007] [Indexed: 02/06/2023] Open
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Mochiki E, Asao T, Kuwano H. Gastrointestinal motility after digestive surgery. Surg Today 2007; 37:1023-32. [PMID: 18030561 DOI: 10.1007/s00595-007-3525-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 02/17/2007] [Indexed: 12/11/2022]
Abstract
Gastrointestinal (GI) motility dysfunction is a common complication of any abdominal surgical procedure. During fasting, the upper GI tract undergoes a cyclic change in motor activity, called the interdigestive migrating motor contraction (IMC). The IMC is divided into four phases, with phase III having the most characteristic activity. After digestive surgery, GI motility dysfunction shows a lack of a fed response, less phase II activity, more frequent phase III activity of the IMC, and some phase III activity migrating orally. Postoperative symptoms have been related to motor disturbances, such as interrupted or retrograde phase III or low postprandial activity. The causes of GI disorder are autonomic nervous dysfunction and GI hormone disruptions. The administration of a motilin agonist can induce earlier phase III contractions in the stomach after pancreatoduodenectomy. For nervous dysfunction, an inhibitory sympathetic reflux is likely to be important in postoperative motility disorders. Until recently, treatment for gut dysmotility has consisted of nasogastric suction, intravenous fluids, and observation; however, more effective treatment methods are being reported. Recent discoveries have the potential to decrease postoperative gut dysmotility remarkably after surgery.
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Affiliation(s)
- Erito Mochiki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, Japan
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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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Räty S, Sand J, Lantto E, Nordback I. Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy. J Gastrointest Surg 2006; 10:1131-9. [PMID: 16966032 DOI: 10.1016/j.gassur.2006.05.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Revised: 05/03/2006] [Accepted: 05/08/2006] [Indexed: 01/31/2023]
Abstract
The aim of this study was to prospectively analyze the possible association of delayed gastric emptying and postoperative pancreatic complications after pancreaticoduodenectomy. Although hospital mortality after pancreaticoduodenectomy is minimal, morbidity is still high; delayed gastric emptying is one of the most frequent complications. Thirty-nine consecutive patients undergoing pancreaticoduodenectomy were included in this study: 14 females and 25 males (median age 65 years; range, 7-82). Delayed gastric emptying was defined as the need for a nasogastric tube or recurrent vomiting that prevented normal feeding on the 10th postoperative day. Blood analysis was performed on postoperative days 4, 6, and 10; Gastrografin examination on day 6; CT scan on days 2 and 5; and drain amylases were measured on day 5. Pancreatitis was defined as pancreatitis changes in CT scan interpreted by an experienced radiologist without knowing other data. Pancreatic fistula was defined according to the recent international recommendations. We had no mortality. Twelve patients (31%) developed delayed gastric emptying. Surgical (9/12 vs. 5/27; P = 0.001) but not medical complications occurred more often in the delayed gastric emptying group. Of the single complications, postoperative CT-detected pancreatitis (6/12 vs. 4/27; P = 0.03) and postoperative pancreatic fistula (5/12 vs. 1/27; P = 0.0007) were significantly associated with delayed gastric emptying compared with the patients without delayed gastric emptying. This pancreatitis was already detected in CT scan on day 2 in most patients (6/10, 60%). In delayed gastric emptying patients, the only parameters in blood analysis that differed significantly from patients without this complication were serum amylase activity (mean +/- SEM, 715 +/- 205 vs. 152 +/- 70 IU/L; P = 0.02), blood leukocyte count (16 +/- 2 vs. 9 +/- 0.6 x 10(9)/L; P = 0.007) and serum C-reactive protein (CRP) concentration (144 +/- 28 vs. 51 +/- 14 mg/L, P = 0.01). Postoperative pancreatic (subclinical) fistula was also associated with postoperative pancreatitis (6/10 vs. 0/29; P = 0.003). Preoperative coronary artery disease (OR = 16; 95% CI, 1.0-241; P = 0.05) and soft pancreatic texture at operation (OR = 9; 95% CI, 1.4-52; P = 0.02) were significant risk factors for the development of postoperative pancreatitis. The diagnosis of delayed gastric emptying after pancreaticoduodenectomy often follows postoperative pancreatitis. Delayed gastric emptying is also associated with postoperative pancreatic fistula, for which this pancreatitis seems to be a risk factor. Preoperative coronary artery disease and soft texture of the pancreas are significant risk factors for postoperative CT-detected pancreatitis.
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Affiliation(s)
- Sari Räty
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
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Yi SQ, Ru F, Ohta T, Terayama H, Naito M, Hayashi S, Buhe S, Yi N, Miyaki T, Tanaka S, Itoh M. Surgical anatomy of the innervation of pylorus in human and Suncus murinus, in relation to surgical technique for pylorus-preserving pancreaticoduodenectomy. World J Gastroenterol 2006; 12:2209-16. [PMID: 16610023 PMCID: PMC4087648 DOI: 10.3748/wjg.v12.i14.2209] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [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
AIM: To clarify the innervation of the antro-pyloric region in humans from a clinico-anatomical perspective.
METHODS: The stomach, duodenum and surrounding structures were dissected in 10 cadavers, and immersed in a 10mg/L solution of alizarin red S in ethanol to stain the peripheral nerves. The distribution details were studied to confirm innervations in the above areas using a binocular microscope. Similarly, innervations in 10 Suncus murinus were examined using the method of whole-mount immunohistochemistry.
RESULTS: The innervation of the pyloric region in humans involved three routes: One arose from the anterior hepatic plexus via the route of the suprapyloric/supraduodenal branch of the right gastric artery; the second arose from the anterior and posterior gastric divisions, and the third originated from the posterior-lower region of the pyloric region, which passed via the infrapyloric artery or retroduodenal branches and was related to the gastroduodenal artery and right gastroepiploic artery. For Suncus murinus, results similar to those in humans were observed.
CONCLUSION: There are three routes of innervation of the pyloric region in humans, wherein the route of the right gastric artery is most important for preserving pyloric region innervation. Function will be preserved by more than 80% by preserving the artery in pylorus-preserving pancreaticoduodenectomy (PPPD). However, the route of the infrapyloric artery should not be disregarded. This route is related to several arteries (the right gastroepiploic and gastroduodenal arteries), and the preserving of these arteries is advantageous for preserving pyloric innervation in PPPD. Concurrently, the nerves of Latarjat also play an important role in maintaining innervation of the antro-pyloric region in PPPD. This is why pyloric function is not damaged in some patients when the right gastric artery is dissected or damaged in PPPD.
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Affiliation(s)
- Shuang-Qin Yi
- Department of Anatomy, Tokyo Medical University, Shinjuku-ku, Tokyo 160-8402, Japan.
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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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Niedergethmann M, Shang E, Farag Soliman M, Saar J, Berisha S, Willeke F, Post S. Early and enduring nutritional and functional results of pylorus preservation vs classic Whipple procedure for pancreatic cancer. Langenbecks Arch Surg 2006; 391:195-202. [PMID: 16491403 DOI: 10.1007/s00423-005-0015-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Accepted: 10/18/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIMS There have been many supportive data that the pylorus-preserving pancreatoduodenectomy (PPPD) might be equal to the classic Whipple pancreatoduodenectomy (PD) in terms of oncological radicality. However, few reports are available on the early postoperative and enduring functional changes, nutritional status, body composition, and quality of life years after surgery. The aim of this study was to compare nutritional and functional results of the different techniques in a retrospective evaluation and prospective cohort study. PATIENTS AND METHODS In May 1998, the standard surgical approach in the Department of Surgery, University-Hospital Mannheim, changed from PD to PPPD. The early postoperative and enduring functional changes, quality of life, oncological radicality, and nutritional status after years were compared between 128 patients after PD and 111 patients after PPPD. In a retrospective manner, the intra- and postoperative course was evaluated. In survivors, we prospectively analyzed the functional, nutritional, and oncological outcomes after 54 months (mean) in PD and after 24 months (mean) in PPPD patients. RESULTS The PPPD and PD groups did not differ according to age, gender, preoperative condition, or tumor localization. The PPPD group demonstrated favorable results (p<0.05) for operation time (PPPD 341+/-74 vs PD 386+/-89 min), blood loss (793+/-565 vs 1,000+/-590 ml), blood transfusions (416+/-691 vs 653+/-776 ml), delayed gastric emptying (6 vs 13%), and hospital stay (20 vs 24 days). However, a possible bias has to be mentioned since more T4 stages were diagnosed in the PD group (3 vs 11%), and even more extended (venous) resections were performed in the PD group (7 vs 24%). Morbidity (32 vs 30%) and mortality (5 vs 3%) did not differ between the two groups. After 24 months (PPPD, n=22) and 54 months (PD, n=16), there was no difference in global quality of life in recurrence-free patients. While the preoperative body weight was reached after 4 months (median) in the PPPD group, it was reached after 6 months (p<0.05) in the PD group. Bioelectrical impedance analysis (BIA) revealed a significantly (p<0.05) lower total body water (55 vs 60%) and significantly higher total body fat (26 vs 18%) in PPPD than in PD patients. Long-term follow-up showed no significant statistical differences in survival between both groups. CONCLUSION Besides favorable postoperative outcome in specific aspects and equal oncological outcome of PPPD, pylorus preservation seems to have advantages in enduring functional and nutritional status years after surgery for pancreatic cancer.
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Affiliation(s)
- Marco Niedergethmann
- Department of Surgery, University-Hospital Mannheim, University of Heidelberg, 68135, Mannheim, Germany.
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Strömmer L, Räty S, Hennig R, Adrian TE, Friess H, Böttiger Y, Stanaitis J, Nordback I, Sand J, Arnelo U. Delayed gastric emptying and intestinal hormones following pancreatoduodenectomy. Pancreatology 2005; 5:537-44. [PMID: 16110252 DOI: 10.1159/000086544] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Accepted: 02/23/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Delayed gastric emptying (DGE) is frequently reported in patients following pancreatoduodenectomy (PD). The present study tested the hypothesis that gastrointestinal hormones known to effect gastric emptying contribute to DGE in patients after PD. METHODS Patients with (delayed, n = 9) or without clinical signs of DGE (non-delayed, n = 22) after PD were investigated. Plasma concentrations of motilin, glucagon-like peptide-1 (GLP-1), neurotensin, and peptide YY (PYY) and the gastric emptying rate (GER), assessed by the paracetamol absorption method were measured after a liquid meal on postoperative day 11. RESULTS Days with a nasogastric tube (p < 0.01), days until solid food was tolerated (p < 0.05), and hospital stay (p < 0.001) were increased in delayed compared to non-delayed patients. The total and incremental integrated peptide responses of motilin and GLP-1 were similar, but the responses of neurotensin and PYY were reduced, in delayed compared to non-delayed patients, whether considered on clinical grounds or by measured GER (p < 0.05-0.005). CONCLUSION Neurotensin and PYY slow the rate of gastric emptying in humans. Therefore, our findings suggest that reduced hormone responses were the consequence of DGE arising from delayed delivery of nutrients to the distal intestine where the endocrine cells secrete neurotensin and PYY reside.
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Katagiri F, Itoh H, Takeyama M. Effects of erythromycin on plasma gastrin, somatostatin, and motilin levels in healthy volunteers and postoperative cancer patients. Biol Pharm Bull 2005; 28:1307-10. [PMID: 15997121 DOI: 10.1248/bpb.28.1307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Erythromycin, an antibiotic agent, is known to be a motilin receptor agonist. Motilin is a peptide hormone that regulates gastric motility. One of the gastrointestinal motility regulatory factors has been assumed to be the induction of changes in the levels of peptides (gastrin, somatostatin and motilin) in plasma. We have elucidated the effects of erythromycin by examining changes in the plasma levels of gastroinitestinal peptides. In this study, we investigated the effects of erythromycin on the plasma levels of gastrointestinal peptides (somatostatin, motilin, and gastrin) in healthy volunteers and patients with delayed gastric emptying (DGE). After a single oral administration, erythromycin caused a significant increase in plasma gastrin-like immunoreactive substance (IS) levels at 60 min. But the agent did not alter the levels of somatostatin- and motilin-IS. DGE is the most frequent postoperative complication after pylorus-preserving pancreatoduodenectomy. Molitin is assumed to be one important factor that influences DGE. We also examined the effects of erythromycin on the plasma motilin-IS levels of postoperative patients. The plasma motilin-IS levels were increased after 1 week of oral administration of erythromycin compared with preadministration. These results suggest that the pharmacologic effects of erythromycin in promoting gastric emptying are closely related to changes in plasma motilin-IS levels.
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Tran KTC, Smeenk HG, van Eijck CHJ, Kazemier G, Hop WC, Greve JWG, Terpstra OT, Zijlstra JA, Klinkert P, Jeekel H. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 2004; 240:738-45. [PMID: 15492552 PMCID: PMC1356476 DOI: 10.1097/01.sla.0000143248.71964.29] [Citation(s) in RCA: 282] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE A prospective randomized multicenter study was performed to assess whether the results of pylorus-preserving pancreaticoduodenectomy (PPPD) equal those of the standard Whipple (SW) operation, especially with respect to duration of surgery, blood loss, hospital stay, delayed gastric emptying (DGE), and survival. SUMMARY BACKGROUND DATA PPPD has been associated with a higher incidence of delayed gastric emptying, resulting in a prolonged period of postoperative nasogastric suctioning. Another criticism of the pylorus-preserving pancreaticoduodenectomy for patients with a malignancy is the radicalness of the resection. On the other hand, PPPD might be associated with a shorter operation time and less blood loss. METHODS A prospective randomized multicenter study was performed in a nonselected series of 170 consecutive patients. All patients with suspicion of pancreatic or periampullary tumor were included and randomized for a SW or a PPPD resection. Data concerning patients' demographics, intraoperative and histologic findings, as well as postoperative mortality, morbidity, and follow-up up to 115 months after discharge, were analyzed. RESULTS There were no significant differences noted in age, sex distribution, tumor localization, and staging. There were no differences in median blood loss and duration of operation between the 2 techniques. DGE was observed equally in the 2 groups. There was only a marginal difference in postoperative weight loss in favor of the standard Whipple procedure. Overall operative mortality was 5.3%. Tumor positive resection margins were found for 12 patients of the SW group and 19 patients of the PPPD group (P < 0.23). Long-term follow-up showed no significant statistical differences in survival between the 2 groups (P < 0.90). CONCLUSIONS The SW and PPPD operations were associated with comparable operation time, blood loss, hospital stay, mortality, morbidity, and incidence of DGE. The overall long-term and disease-free survival was comparable in both groups. Both surgical procedures are equally effective for the treatment of pancreatic and periampullary carcinoma.
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Affiliation(s)
- Khe T C Tran
- Department of General Surgery, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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Sugiyama M, Abe N, Ueki H, Masaki T, Mori T, Atomi Y. A new reconstruction method for preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. Am J Surg 2004; 187:743-6. [PMID: 15191869 DOI: 10.1016/j.amjsurg.2003.10.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2003] [Revised: 10/17/2003] [Indexed: 12/28/2022]
Abstract
BACKGROUND With the aim of preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy (PPPD), we devised a new reconstruction method in which the pancreas and the bile duct are anastomosed to the proximal jejunum brought through the transverse mesocolon, and the duodenum is antecolically anastomosed to the jejunum below the mesocolon. The right gastric artery is divided in order to place the stomach, the duodenum, and the jejunum in a straight line. METHODS Thirty patients underwent PPPD with the new reconstruction method (n = 12) or the conventional method (all anastomoses performed retrocolically; n = 18). Early and late complications were compared between the two groups. RESULTS Delayed gastric emptying occurred respectively in 1 patient (8%) and 13 patients (72%) operated on by the new and conventional method (P <0.001). The incidences of other complications did not differ significantly between the two groups. CONCLUSIONS The new reconstruction method may prevent delayed gastric emptying after PPPD.
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Affiliation(s)
- Masanori Sugiyama
- First Department of Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan.
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Horstmann O, Markus PM, Ghadimi MB, Becker H. Pylorus preservation has no impact on delayed gastric emptying after pancreatic head resection. Pancreas 2004; 28:69-74. [PMID: 14707733 DOI: 10.1097/00006676-200401000-00011] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Delayed gastric emptying (DGE) has been specifically attributed to pylorus-preserving pancreaticoduodenectomy (PPPD). As PPPD has been shown to be comparable with the classic Kausch-Whipple pancreaticoduodenectomy (KWPD) in terms of oncological radicality, DGE has advanced to be the leading argument for hemigastrectomy in PD. METHODS A prospective, nonrandomized comparison of patients undergoing PPPD (n = 113), KWPD (n = 19), and duodenum-preserving, pancreatic head resection (DPPHR, n = 18) for various diseases was performed. First, groups were analyzed with regard to structural similarity; then, they were compared with special emphasis on DGE and other postoperative complications. Finally, further prognostic factors were sought that had an impact on DGE. RESULTS The PPPD group was comparable with the KWPD group, but not to the DPPHR population. The in-clinic course after DPPHR compared favorably with PPPD as well as KWPD, and, here, no DGE occurred. The overall morbidity rates of PPPD and KWPD were comparable; 1 patient died in hospital (mortality rate, 0.7%). The gastric tube after PPPD and KWPD could be withdrawn at a median of 2 and 3 days, respectively, a liquid diet was started after 4 and 5 days, respectively, and a full diet was tolerated after 10 days each (n.s.). DGE was distributed evenly among PPPD (12%) and KWPD patients (21%, n.s.), and it was noted almost exclusively when other postoperative complications were present (P < 0.0001). No further prognostic factors influencing DGE could be identified. CONCLUSION Pylorus preservation does not increase the frequency of DGE. DGE almost exclusively occurs as a consequence of other postoperative complications. Therefore, DGE should not be used as an argument to advocate hemigastrectomy in PPPD.
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Affiliation(s)
- Olaf Horstmann
- Department of Surgery, University Clinic, Göttingen, Germany.
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Park YC, Kim SW, Jang JY, Ahn YJ, Park YH. Factors influencing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. J Am Coll Surg 2003; 196:859-65. [PMID: 12788421 DOI: 10.1016/s1072-7515(03)00127-3] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is the most frequent postoperative complication after pylorus-preserving pancreatoduodenectomy (PPPD). This study was undertaken to determine which factors influence the development of DGE after PPPD. STUDY DESIGN We studied 150 consecutive patients who underwent PPPD performed by one surgeon between 1996 and 2000. The variables analyzed were age, gender, diagnosis, laboratory data, operative time, transfusion, preoperative cholangitis, and complications. The operative factors included were route of the afferent jejunal limb (retromesenteric versus antemesenteric), type of pancreatoenteric anastomosis, and preservation of the right gastric artery. DGE was defined as nasogastric drainage for more than 10 days or delay of regular diet until 14 days postoperatively. RESULTS Univariate analysis showed preoperative cholangitis, intraabdominal complication, and the jejunal reconstruction method were significantly associated with DGE. Preservation of the right gastric artery was not associated with gastric emptying ability. Multivariate analysis by logistic regression showed that DGE was significantly more frequent among patients with preoperative cholangitis (15 of 36 [41.7%] versus 19 of 114 [16.7%], p=0.0031), postoperative intraabdominal complications (15 of 36 [41.7%] versus 10 of 114 [8.8%], p = 0.0001), and in the retromesenteric group (33 of 104 [31.7%] versus 3 of 46 [6.5%], p = 0.0174). CONCLUSIONS Preoperative cholangitis and postoperative leakage problems affect gastric emptying after PPPD during the early postoperative period. The retromesenteric route is not recommended for pancreato- and biliary-enteric anastomosis. We speculate that retromesenteric passage of afferent jejunum can cause venous congestion and bowel edema, which can in turn retard the recovery of jejunal peristalsis at the duodenojejunostomy site resulting in disturbance from food passage.
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Affiliation(s)
- Yoon-Chan Park
- Department of Surgery, Seoul National University College of Medicine, Clinical Research Institute, Seoul National University Hospital, South Korea
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Murakami H, Suzuki H, Nakamura T. Pancreatic fibrosis correlates with delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy with pancreaticogastrostomy. Ann Surg 2002; 235:240-5. [PMID: 11807364 PMCID: PMC1422420 DOI: 10.1097/00000658-200202000-00012] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To show that residual pancreatitis delays gastric emptying, the authors used surgical specimens and studied gastric stasis after pylorus-preserving pancreaticoduodenectomy (PPPD). SUMMARY BACKGROUND DATA Delayed gastric emptying is a leading cause of complications after PPPD, occurring in 30% of patients. The pathogenesis of delayed gastric emptying remains unclear. METHODS Surgical specimens of the pancreas from 25 patients undergoing PPPD and pancreaticogastrostomy were collected and examined by microscopy according to progressive pancreatic fibrosis and divided into three groups: no fibrosis, periductal fibrosis, and intralobular fibrosis. The authors then measured gastric output from the nasogastric tube, pancreatic output from the pancreatic tube, and the time until patients tolerated a solid diet. RESULTS Pancreatic juice output was significantly related to the degree of pathologic findings, and gastric output was inversely related to them. A significant prolongation of postoperative solid diet tolerance correlated with increased pancreatic fibrosis and gastric fluid production. CONCLUSIONS Pancreatic fibrosis and increased gastric fluid production correlate with delayed gastric emptying after PPPD with pancreaticogastrostomy.
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Ohwada S, Satoh Y, Kawate S, Yamada T, Kawamura O, Koyama T, Yoshimura S, Tomizawa N, Ogawa T, Morishita Y. Low-dose erythromycin reduces delayed gastric emptying and improves gastric motility after Billroth I pylorus-preserving pancreaticoduodenectomy. Ann Surg 2001; 234:668-74. [PMID: 11685031 PMCID: PMC1422092 DOI: 10.1097/00000658-200111000-00013] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To test the hypothesis that early and low doses of erythromycin reduce the incidence of early delayed gastric emptying (DGE) and induce phase 3 of the migratory motor complex in the stomach after Billroth I pylorus-preserving pancreaticoduodenectomy (PPPD). SUMMARY BACKGROUND DATA Delayed gastric emptying is a leading cause of complications after PPPD, occurring in up to 50% of patients. High doses of erythromycin (200 mg) accelerate gastric emptying after pancreaticoduodenectomy and reduce the incidence of DGE, although they induce strong contractions that do not migrate to the duodenum. METHODS Thirty-one patients were randomly assigned to either the erythromycin or control groups. The patients received erythromycin lactobionate (1 mg/kg) every 8 hours, or H2-receptor antagonists and gastrokinetic drugs from days 1 to 14 after surgery. On postoperative day 30, gastroduodenal motility was recorded in 14 patients. RESULTS Preoperative, intraoperative, and postoperative factors were comparable in the erythromycin and control groups. The erythromycin group had a shorter duration of nasogastric drainage, earlier resumption of eating, and a 75% reduction in the incidence of DGE. Erythromycin was an independent influence on nasogastric tube removal, and preservation of the right gastric vessels was a significant covariate. Low doses of erythromycin induced phase 3 of the migratory motor complex and phase 3-like activity, with the same characteristics as spontaneous phase 3, in 86% of patients: two had quiescent stomachs and the others had spontaneous phase 3 or phase 3-like activity. CONCLUSIONS Low doses of erythromycin reduced the incidence of DGE by 75% and induced phase 3 of the migratory motor complex after Billroth I PPPD. Low doses of erythromycin are preferable to high doses in the unfed period after PPPD.
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Affiliation(s)
- S Ohwada
- Second Department of Surgery, Gunma University Faculty of Medicine, Maebashi, Japan.
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Abstract
After resection of the head of the pancreas, the distal remnant is typically telescoped into the jejunum. Recently, pancreaticogastrostomy has re-emerged as a useful alternative, as the anastomosis is easy and without tension. The results of pancreaticogastrostomy in 10 consecutive patients is reviewed, as is the literature of both the technique and the physiology of the procedure. In the current series, mean +/- SEM age was 65 +/- 2.3 years. Extended pancreaticoduodenectomy was performed in two patients, pylorus-preserving in eight. Mean tumor size was 3.9 +/- 1.1 cm (range, 1.5-7.5 cm), mean operative time was 6.5 +/- 0.5 hours. Intraoperatively, 7.6 +/- 0.8 L of fluid was given, only two patients were transfused. The mean length of stay was 9.4 +/- 1.8 days. There were no anastomotic leaks, no deaths, and two patients developed temporary gastric ileus. There are now 841 pancreaticogastrostomies reported in the literature, with a leak rate of 3.1% and a death rate of 2.6%. Pancreaticogastrostomy is easy to perform, safe, and useful even after extended Whipple.
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Affiliation(s)
- M E Zenilman
- Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10461, USA.
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Le Blanc-Louvry I, Ducrotté P, Peillon C, Testart J, Denis P, Michot F, Tenière P. Upper jejunal motility after pancreatoduodenectomy according to the type of anastomosis, pancreaticojejunal or pancreaticogastric. J Am Coll Surg 1999; 188:261-70. [PMID: 10065815 DOI: 10.1016/s1072-7515(98)00309-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The goal of this study was to compare upper jejunal motor patterns after Billroth II pancreatoduodenectomy according to the type of pancreatic anastomosis (pancreaticojejunostomy [PJA] or pancreaticogastrostomy [PGA]) and the presence or absence of postoperative symptoms. STUDY DESIGN Manometric recordings during fasting and after a 750-kcal meal were performed in the afferent limb in 12 patients (7 PJA, 5 PGA) and in the efferent limb in 15 other patients (7 PJA, 8 PGA) with a postoperative delay of 15+/-6 days and 3.9+/-2.2 months respectively. Patient data were compared to those of 20 healthy controls. RESULTS During fasting, the 2 main abnormal findings were a higher incidence (p < 0.05) and a slower migration velocity (p < 0.01) of incomplete phase III by comparison with that recorded in controls. No difference for phase III was observed between the 2 surgical procedures regardless of recording site. Trimebutine, 100 mg intravenously, induced a phase III in 89% (24 of 27) of the patients. Delay of motor response varied from 5 to 10 minutes without difference between the recording site; it was less than 2 minutes in 100% of controls. Trimebutine-induced phase III showed similar propagation abnormalities to the spontaneous phase III. Duration of the fed pattern (p < 0.001) and motor index (p < 0.001) were significantly lower than in controls after the meal, in both limbs, whatever the type of anastomosis. Differences between the 2 surgical procedures were a slower migration velocity of phase III (p < 0.01) and a lower postmeal motor index (p < 0.05) in the efferent limb after PJA than after PGA. Nine of 27 patients were symptomatic. In these 9 patients, mean phase III migration velocity was slower (p < 0.001), and mean area under the postprandial curve was higher (p < 0.01) than in asymptomatic patients. Propagated clusters of contractions were only found in symptomatic patients and in the afferent limb. CONCLUSIONS Pancreatoduodenectomy is associated with significant motor disturbances, mainly slower phase III and a reduced fed pattern, in the upper jejunum, at least during the first 3 postoperative months. Few motor differences were observed between PGA and PJA pancreatic anastomosis. A lesser occurrence of postsurgical motor anomalies does not appear to be an argument for preferring PGA to PJA.
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Matsunaga H, Tanaka M, Naritomi G, Yokohata K, Yamaguchi K, Chijiwa K. Effect of leucine 13-motilin (KW5139) on early gastric stasis after pylorus-preserving pancreatoduodenectomy. Ann Surg 1998; 227:507-12. [PMID: 9563538 PMCID: PMC1191305 DOI: 10.1097/00000658-199804000-00010] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To test a hypothesis that exogenously administered motilin would improve early gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD). SUMMARY BACKGROUND DATA Prolonged gastric stasis is a frequent complication after PPPD. We demonstrated that this might at least in part be attributable to delayed recovery of phase III activity of the gastric migrating motor complex due to low concentrations of plasma motilin caused by resection of the duodenum. METHODS Ten patients with a mean age of 54 years (range, 33-70) who underwent PPPD were studied. An assembly of manometric tubes was placed in the gastric antrum and jejunum (neoduodenum) at surgery. A gastrostomy tube was added for drainage and volume measurements of the gastric juice. After baseline recording, saline as a placebo was given intravenously on day 14 and 0.5 microg/kg of KW5139 (leucine-13 motilin) was given on days 17 and 18 every 2 hours, 6 times a day. The daily volume of gastric juice output and a gastric motility index were measured. RESULTS The mean period until the first appearance of phase III activity in the stomach was 41 +/- 2 days. The injection of saline did not change the gastric motility index (7.3 +/- 1.1 to 7.1 +/- 1.3 mmHg; p = 0.72). In contrast, motilin resulted in a significant increase in the gastric motility index (7.5 +/- 1.0 to 17.7 +/- 2.0 mmHg; p < 0.001). The saline injection produced no change in the daily gastric juice output (1175 +/- 140 to 1393 +/- 193 mL; p = 0.09). Motilin significantly decreased the gastric juice output (1387 +/- 157 to 934 +/- 142 mL; p = 0.01). CONCLUSIONS These data indicate that KW5139 is a safe and effective prokinetic drug for the treatment of early gastric stasis after PPPD.
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Affiliation(s)
- H Matsunaga
- Department of Surgery 1, Kyushu University Faculty of Medicine, Fukuoka, Japan
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van Berge Henegouwen MI, van Gulik TM, Moojen TM, Boeckxstaens GE, Gouma DJ. Gastrointestinal motility after pancreatoduodenectomy. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1998. [PMID: 9515753 DOI: 10.1080/003655298750026552] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pancreatoduodenectomy (PD) is a major surgical procedure which is accompanied by a high morbidity of between 30 and 50%. A large part of this morbidity is caused by delayed gastric emptying (DGE), which is reported to have an incidence of between 30 and 40% and is associated with prolonged hospital stay. Several pathophysiological mechanisms are thought to cause this complication. Peroperative trauma of the pylorus and the occurrence of intra-abdominal abscesses play a role. Neuronal changes and disruption of the gastrointestinal (GI) intramural nervous plexus may be especially important regarding the pivotal role of the duodenum in the initiation and coordination of antroduodenal motor activity. Another important factor is the postoperative administration of enteral nutrition. Recently, it was demonstrated that cyclic enteral nutrition through a catheter jejunostomy led to a faster return to normal diet and shorter hospital stay than patients on continuous enteral nutrition; this might be partly caused by continuously elevated cholecystokinin levels. The effect of prokinetic agents has not been studied extensively, but a beneficial action on the return of postoperative gastric function after gastrointestinal surgery seems limited.
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van Berge Henegouwen MI, Akkermans LM, van Gulik TM, Masclee AA, Moojen TM, Obertop H, Gouma DJ. Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy. Ann Surg 1997; 226:677-85; discussion 685-7. [PMID: 9409567 PMCID: PMC1191138 DOI: 10.1097/00000658-199712000-00005] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The effect of a cyclic versus a continuous enteral feeding protocol on postoperative delayed gastric emptying, start of normal diet, and hospital stay was assessed in patients undergoing pylorus-preserving pancreatoduodenectomy (PPPD). SUMMARY BACKGROUND DATA Delayed gastric emptying occurs in approximately 30% of patients after PPPD and causes prolonged hospital stay. Enteral nutrition through a catheter jejunostomy is used to provide postoperative nutritional support. Enteral infusion of fats and proteins activates neurohumoral feedback mechanisms and therefore can potentially impair gastric emptying and prolong postoperative gastroparesis. METHODS From September 1995 to December 1996, 72 consecutive patients underwent PPPD at the Academic Medical Center, Amsterdam. Fifty-seven patients were included and randomized for either continuous (CON) jejunal nutrition (0-24 hr; 1500 kCal/24 hr) or cyclic (CYC) enteral nutrition (6-24 hr; 1125 kCal/18 hr). Both groups had an equal caloric load of 1 kCal/min. The following parameters were assessed: days of nasogastric intubation, days of enteral nutrition, days until normal diet was tolerated orally, and hospital stay. On postoperative day 10, plasma cholecystokinin (CCK) levels were measured during both feeding protocols. RESULTS Nasogastric intubation was 9.1 days in the CON group (n = 30) and 6.7 days in the CYC group (n = 27) (not statistically significant). First day of normal diet was earlier for the CYC group (15.7 vs. 12.2 days, p < 0.05). Hospital stay was shorter in the CYC group (21.4 vs. 17.5 days, p < 0.05). CCK levels were lower in CYC patients, before and after feeding, compared with CON patients (p < 0.05). CONCLUSIONS Cyclic enteral feeding after PPPD is associated with a shorter period of enteral nutrition, a faster return to a normal diet, and a shorter hospital stay. Continuously high CCK levels could be a cause of prolonged time until normal diet is tolerated in patients on continuous enteral nutrition. Cyclic enteral nutrition is therefore the feeding regimen of choice in patients after PPPD.
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Müller MW, Friess H, Beger HG, Kleeff J, Lauterburg B, Glasbrenner B, Riepl RL, Büchler MW. Gastric emptying following pylorus-preserving Whipple and duodenum-preserving pancreatic head resection in patients with chronic pancreatitis. Am J Surg 1997; 173:257-63. [PMID: 9136776 DOI: 10.1016/s0002-9610(96)00402-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND After pylorus-preserving Whipple (PPW), delayed gastric emptying (DGE) is reported in up to 50% of these patients. We analyzed gastric emptying and hormonal adaptation of cholecystokinin (CCK), pancreatic polypeptide (PP), and gastrin following two surgical procedures for chronic pancreatitis (CP): the PPW and the duodenum-preserving pancreatic head resection (DPPHR). METHODS Ten patients underwent DPPHR and 10 underwent PPW for CP. Preoperatively and 10 days and 6 months postoperatively, gastric emptying (paracetamol absorption test) and CCK, gastrin, and PP were measured using a test meal stimulation. RESULTS The area under the serum paracetamol time curve for 0 to 120 minutes (AUC) showed no preoperative difference. Ten days postoperatively, the AUC was significantly reduced (P <0.05) after PPW but not after DPPHR. Six months postoperatively, AUC was comparable with the preoperative findings in DPPHR and PPW. The integrated 180-minute PP release was significantly reduced 10 days and 6 months postoperatively in both groups. The integrated 180-minute CCK release was decreased 10 days after PPW, but failed to be significant (P = 0.053). Gastrin levels were postoperatively unchanged. CONCLUSION Following DPPHR we found no delay in gastric emptying. In contrast, DGE occurs early after PPW. Our data may help explain the slower recovery in PPW patients with regard to weight gain and relief from pain, which may be due to the functional alteration of gastric emptying and motility after this type of surgery.
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Affiliation(s)
- M W Müller
- Department of General Surgery, University of Ulm, Germany
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Abstract
Pancreaticoduodenectomy remains a formidable procedure, with low mortality rates in experienced hands. Postoperative complications following pancreaticoduodenectomy are common, and their prompt recognition and appropriate management are of great importance in contributing to a successful outcome for the majority of patients.
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Affiliation(s)
- C J Yeo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Yeo CJ, Barry MK, Sauter PK, Sostre S, Lillemoe KD, Pitt HA, Cameron JL. Erythromycin accelerates gastric emptying after pancreaticoduodenectomy. A prospective, randomized, placebo-controlled trial. Ann Surg 1993; 218:229-37; discussion 237-8. [PMID: 8103982 PMCID: PMC1242953 DOI: 10.1097/00000658-199309000-00002] [Citation(s) in RCA: 292] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE This study tested the hypothesis that erythromycin, a motilin agonist, reduces the incidence of early DGE after pancreaticoduodenectomy. SUMMARY BACKGROUND DATA Delayed gastric emptying (DGE) is a leading cause of morbidity after pancreaticoduodenectomy, occurring in up to 40% of patients. The pathogenesis of DGE has been speculated to involve factors such as peritonitis from anastomotic leaks, ischemia to the antropyloric muscles, and gastric atony in response to resection of the duodenal pacemaker or reduction in circulating motilin levels. METHODS Between November 1990 and January 1993, 118 patients undergoing pancreaticoduodenectomy completed this prospective, randomized, placebo-controlled trial. The patients received either 200 mg of intravenous erythromycin lactobionate every 6 hours (n = 58), or an identical volume of 0.9% saline (n = 60) from the third to tenth postoperative days. On the tenth postoperative day, a dual phase radionuclide gastric emptying study was performed. RESULTS The erythromycin and control groups were comparable regarding multiple preoperative, intraoperative, and postoperative factors. The erythromycin group had a 37% reduction in the incidence of DGE (19% vs. 30%), a significantly reduced (p < 0.05) need to reinsert a nasogastric tube for DGE (6 vs. 15 patients), and a significantly reduced (p < 0.01) per cent retention of liquids at 30 minutes and solids at 30, 60, 90, and 120 minutes. No major adverse reactions to erythromycin were observed. CONCLUSIONS Erythromycin is a safe, inexpensive drug that significantly accelerates gastric emptying after pancreaticoduodenectomy and reduces the incidence of DGE by 37%. These data support the use of erythromycin to decrease early DGE after pancreaticoduodenectomy.
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Affiliation(s)
- C J Yeo
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Tanaka M, Dalton RR, Smith CD, Van Lier Ribbink JA, Sarr MG. The role of myoneural and luminal continuity in the coordination of canine gastroduodenal patterns of motility. J Surg Res 1992; 53:588-95. [PMID: 1494292 DOI: 10.1016/0022-4804(92)90259-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Our aim was to determine the role of intrinsic myoneural and enteric luminal continuity in the coordination of gastric and duodenal motility patterns. Three groups of dogs were prepared: five dogs with an intact gastrointestinal tract served as a Control group; four dogs had transection and reanastomosis of the duodenum 0.5 cm distal to the pylorus (Pyloric Transection group); and seven dogs had identical proximal duodenal transection, but with oversewing of duodenum and pylorojejunostomy to a Roux-en-Y limb (Roux-en-Y group). In the Control and Pyloric Transection groups, the gastric and intestinal MMCs were similar in appearance, the cycle durations (x +/- SEM) were not different (134 +/- 19 vs 111 +/- 26 min, respectively; P > 0.05), and the times between the start of gastric and duodenal Phase III (gastroduodenal latency) were similar (6 +/- 1 vs 10 +/- 3 min; P > 0.05). In the Roux-en-Y group, MMCs also occurred in six of seven dogs but tended to have a longer cycle duration (176 +/- 19 min) and a more variable gastroduodenal latency (23 +/- 15 min). Plasma motilin concentration, measured only in the Roux-en-Y group, was greater during Phase III in the stomach and duodenum than during Phases I or II (P < 0.05). Feeding inhibited the gastric and duodenal MMCs in all groups, but the duodenal MMC returned earlier in the Roux-en-Y group. The Roux-en-Y jejunal limb exhibited a postprandial pattern in only seven of 14 studies.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M Tanaka
- Department of Surgery, Mayo Medical School, Rochester, Minnesota 55905
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Quigley EM, Spanta AD, Rose SG, Lof J, Thompson JS. Long-term effects of jejunoileal autotransplantation on myoelectrical activity in canine small intestine. Dig Dis Sci 1990; 35:1505-17. [PMID: 2253537 DOI: 10.1007/bf01540569] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We studied the longitudinal effects of autotransplantation on the motor function of the jejunoileum. By performing the autotransplantation procedure in a manner similar to that employed for allotransplantation, we sought to examine the long-term effects of both extrinsic denervation and the operative procedure itself on small intestinal motor function. Although initially disrupted, interdigestive myoelectrical activity demonstrated progressive organization: 88% of migrating myoelectrical complexes in animals studied between 12 and 20 months following autotransplantation demonstrated each phase of the complex in normal sequence. Longitudinal studies of several parameters of myoelectrical activity provided further evidence of progressive organization and entrainment of motor functions within the denervated intestine. Several abnormal myoelectrical patterns were observed within the autotransplanted segment, however, and coordination of either slow wave or phase III activity with the proximal innervated intestine did not recover with time. The major component of the myoelectrical response to feeding was permanently impaired with a delayed onset and shortened duration of the fed response. We conclude that the extrinsically denervated intestine recovers the ability to generate and organize all phases of the MMC but demonstrates permanent impairment of the major motor response to food. However, anoxic and cooling damage to enteric nerves and muscle, incurred during the autotransplantation procedure, may explain the persistence of abnormal motor patterns and impaired myoelectrical conduction and could play an important role, additional to that of extrinsic denervation, in the long-term motor function of the allotransplanted intestine.
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Affiliation(s)
- E M Quigley
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-2000
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Tanaka M, Sarr MG, Van Lier Ribbink JA. Gastrointestinal motor patterns: motilin as a coordinating factor. J Surg Res 1989; 47:325-31. [PMID: 2770290 DOI: 10.1016/0022-4804(89)90143-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Our aim was to further define the role of neural and hormonal control of upper gastrointestinal motility patterns. In five dogs, the stomach and duodenum were separated enterically by transecting and oversewing the proximal duodenum and by anastomosing a Roux-en-Y jejunal limb to the pylorus. Five intact dogs served as controls. After recovery, motility was recorded on four or more occasions during fasting and after feeding. Plasma was sampled for motilin radioimmunoassay. In three Roux-en-Y dogs, motilin (0.1 microgram/kg iv) was administered. We found in the Roux-en-Y group that the characteristic MMC occurred in the stomach, duodenum, and jejunal limb, but the jejunal MMC had a much shorter period (P less than 0.005). Gastric and duodenal MMCs were coordinated temporally and were associated with peaks in plasma motilin concentration. Jejunal MMCs had no apparent association with plasma motilin. Feeding disrupted the gastric and duodenal MMC and decreased plasma motilin, but inhibited the jejunal MMC in only 6 of 12 experiments. Exogenous motilin induced a "premature" MMC in the stomach, duodenum, and jejunum. This study suggests that (1) enteric neural continuity and/or luminal continuity are not necessary for coordination of gastric and duodenal motor patterns, and (2) post-prandial inhibition of the duodenal MMC may not depend on the presence of ingested nutrient in the duodenum. Hormonal factors, possibly motilin, may play a role in initiation and coordination of gastric and duodenal motor patterns.
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Affiliation(s)
- M Tanaka
- Department of Surgery and Gastroenterology Research Unit, Mayo Medical School, Rochester, Minnesota 55905
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