|
1
|
Kato T, Ono Y, Oba A, Sato T, Ito H, Inoue Y, Saiura A, Takahashi Y. Treatment Strategy of Pancreas-Sparing Distal Duodenectomy for Distal Duodenal Malignancies with Adjustable Dissection Levels According to Disease Progression (with Video). World J Surg 2023; 47:1752-1761. [PMID: 36941481 DOI: 10.1007/s00268-023-06981-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Pancreas-sparing distal duodenectomy (PSDD) is a favorable option for distal duodenal neoplasms, and its procedure, including the extent of lymphadenectomy, should be modified according to the malignancy of the tumor. However, there are no coherent reports on the details of this procedure or long-term outcomes after each resection. METHODS This study included 24 patients who underwent PSDD at our institution between January 2009 and October 2020. Patients were divided into two groups according to the tumor progression: nine with (Lv-II) and fifteen without (Lv-I) mesopancreas dissection. Postoperative outcomes were compared between the two groups. RESULTS Two groups had similar operation times, blood loss, hospital stay, and the rate of delayed gastric emptying (DGE): 40% versus 44%. There were no Clavien-Dindo classification ≥ III complications in the Lv-II group. The Lv-II group had a larger number of examined lymph nodes (median: 29), and three (33%) patients had lymph node metastasis. No local recurrence was observed, although two patients in the Lv-II group had liver metastasis. The 5-year overall survival rates of the Lv-I and Lv-II groups were 100% and 78%, respectively. None of the patients had an impaired nutrition status after one year of surgery, and no rehospitalization was observed in either group. CONCLUSION Although PSDD with or without mesopancreas dissection entailed a high risk of DGE, this procedure showed favorable long-term outcomes and may be an alternative to pancreatoduodenectomy in patients with distal duodenal neoplasms.
Collapse
Affiliation(s)
- Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| |
Collapse
|
|
2
|
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.
Collapse
|
|
3
|
Is delayed gastric emptying associated with pylorus ring preservation in patients undergoing pancreaticoduodenectomy? Asian J Surg 2020; 44:137-142. [PMID: 32951961 DOI: 10.1016/j.asjsur.2020.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/OBJECTIVE A high incidence of delayed gastric emptying (DGE) is observed in patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). However, DGE incidence after pancreaticoduodenectomy varied because of heterogeneity in surgical techniques, number of surgeons, and DGE definition. This study aimed to evaluate the difference in the incidence of DGE following PpPD and pylorus-resecting pancreaticoduodenectomy (PrPD) and to analyze the risk factor of DGE by a single surgeon to determine whether pylorus preservation was the main factor of DGE. METHODS This retrospective study included 115 patients who underwent PpPD (with pylorus ring preservation) and PrPD (without pylorus ring preservation) with laparotomy by a single surgeon at a tertiary center. RESULTS The overall incidence of DGE was 23.1%. For comparison, 20 patients (39.2%) in the PpPD group and 5 patients (8.8%) in the PrPD group had DGE, showing a significant difference (p < 0.001). On univariate analysis, hypertension, PpPD, operation time, intraoperative bleeding, packed red blood cell transfusion ≥500 mL, and clinically relevant postoperative pancreatic fistula were associated with DGE. Multivariate analysis identified pylorus preservation and clinically relevant postoperative pancreatic fistula as risk factors for DGE. CONCLUSION Compared with PpPD, PrPD significantly reduced the incidence of DGE.
Collapse
|
|
4
|
Kim DH, Hong SC, Jang JY, Cho JK, Ju YT, Lee YJ, Jung EJ, Jeong SH, Park TJ, Kim JY, Kwag SJ, Park JH, Jeong CY. Comparing the surgical outcomes of stapled anastomosis versus hand-sewn anastomosis of duodenojejunostomy in pylorus-preserving pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:245-251. [PMID: 31501813 PMCID: PMC6728254 DOI: 10.14701/ahbps.2019.23.3.245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/21/2019] [Accepted: 04/30/2019] [Indexed: 12/28/2022] Open
Abstract
Backgrounds/Aims This study is to evaluate the perioperative outcomes of the duodenojejunostomy (DJ) procedure in pylorus preserving pancreaticoduodenectomy (PPPD). Methods In this study, as noted between 2010 and 2018, there were 77 PPPDs which were performed at our hospital by one surgeon. We began the circular stapled method from 2014, and continue with this procedure for the aforementioned surgeries including and up to today. The clinical data for the study were collected retrospectively to compare clinical outcomes of the two methods, the circular stapled anastomosis and the hand - sewn anastomosis. Results There were 34 patients in a circular stapled group, and 43 in a hand-sewn group as identified for this study. The delayed gastric emptying (DGE) occurred in 6 (17.64%) patients in the circular stapled group, and 10 (23.3%) in the hand-sewn group (p=0.547). It is noted that there was a serum albumin level measured on the 14th day after the operation, which was significantly high in the circular stapled group (3.41±0.47 (g/dl) vs 2.92±0.39 (g/dl), p<0.001). There were no significant differences in terms of the incidence of postoperative complications (58.8% vs 58.1%, p=0.952) and mortality rates (5.9% vs 0, p=0.192) among the patient participants in this study. Conclusions We conclude that using a circular stapler for the DJ procedure in PPPDs do not increase the development of a DGE, and is also helpful for the benefit of the patient's nutritional status going forward during recovery from the operation.
Collapse
Affiliation(s)
- Dong-Hwan Kim
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Soon-Chan Hong
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jae-Yool Jang
- Department of General Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Jin-Kyu Cho
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young-Tae Ju
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young-Joon Lee
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Eun-Jung Jung
- Department of General Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Sang-Ho Jeong
- Department of General Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Tae-Jin Park
- Department of General Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Ju-Yeon Kim
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Seung-Jin Kwag
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji-Ho Park
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chi-Young Jeong
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| |
Collapse
|
|
5
|
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.
Collapse
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
| |
Collapse
|
|
6
|
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.
Collapse
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
| |
Collapse
|
|
7
|
Gagnière J, Le Roy B, Veziant J, Pereira B, Narayan RR, Pezet D, Buc E, Dupré A. Pancreaticoduodenectomy with right gastric vessels preservation: impact on intraoperative and postoperative outcomes. ANZ J Surg 2018; 89:E147-E152. [PMID: 30497109 DOI: 10.1111/ans.14956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/27/2018] [Accepted: 10/07/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Sympathetic denervation of the antropyloric area combined with relative devascularization from division of the right gastric vessels (RGV) during pancreaticoduodenectomy (PD) could predispose to delayed gastric emptying (DGE). Therefore, some authors advocated for RGV preservation (RGVP), where feasibility and utility for the prevention of post-operative DGE have never been investigated. METHODS From 2011 to 2014, patients who underwent classic Whipple PD (CWPD, n = 34), standard pylorus-preserving PD (PPPD, n = 44) or PPPD with RGVP (n = 22) were retrospectively analysed. RESULTS RGVP was not possible in 12% of the cases because of an intraoperative injury of the RGV. There was no difference between CWPD, standard PPPD and PPPD with RGVP in terms of intraoperative blood loss, operative time, number of lymph node harvested and resection margins. Post-operative morbidity and mortality were comparable between the three groups, including rate (27%, 34% and 32%, P = 0.77) and severity of DGE, delay in removing nasogastric tube and use of prokinetics. Hospital stay was similar in all the compared groups. CONCLUSION This is the first study comparing post-operative outcomes after PPPD with RGVP, standard PPPD and CWPD. Although feasible and safe, RGVP during PPPD appeared to offer no obvious clinical benefit in terms of preventing post-operative complications, especially DGE.
Collapse
Affiliation(s)
- Johan Gagnière
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.,U1071 Inserm/Clermont Auvergne University, Clermont-Ferrand, France
| | - Bertrand Le Roy
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Julie Veziant
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics, Délégation à la Recherche Clinique et à l'Innovation, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Raja R Narayan
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Denis Pezet
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.,U1071 Inserm/Clermont Auvergne University, Clermont-Ferrand, France
| | - Emmanuel Buc
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélien Dupré
- Department of Surgery, Léon Bérard Cancer Center, Lyon, France
| |
Collapse
|
|
8
|
Klaiber U, Probst P, Büchler MW, Hackert T. Pylorus preservation pancreatectomy or not. Transl Gastroenterol Hepatol 2017; 2:100. [PMID: 29264438 DOI: 10.21037/tgh.2017.11.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is the treatment of choice for various benign and malignant tumors of the pancreatic head or the periampullary region, and the only hope for cure in patients with cancer at this side. While it has been associated with high morbidity and mortality rates in the last century, its centralization in specialized institutions together with refinements in the operative technique and better management of postoperative complications have made PD a standardized, safe procedure. Besides the classic Whipple procedure including distal gastrectomy, two variations of PD with or without pylorus resection, but preservation of the entire stomach in either procedure exist today. Pylorus-preserving PD has gained wide acceptance as standard procedure and is being performed by an increasing number of pancreatic surgeons. After its oncological adequacy was questioned initially, pylorus-preserving PD was shown to be equivalent to the classic Whipple procedure regarding tumor recurrence and long-term survival. Moreover, operation time and blood loss were shown to be reduced in the pylorus-preserving procedure and benefits in nutritional status and quality of life were observed. However, preservation of the pylorus has been suggested to result in an increased incidence of postoperative delayed gastric emptying (DGE). In this context, pylorus-resecting PD has become popular especially in Japan with the aim to prevent DGE by removal of the pylorus but preservation of the stomach. In contrast to positive results from early studies, latest high-quality randomized controlled trial (RCT) data show that pylorus resection does not reduce DGE compared to the pylorus-preserving operation. Non-superiority of pylorus resection was also confirmed in current meta-analysis on this topic. This article summarizes the existing evidence on PD with or without pylorus preservation and derives recommendations for daily practice.
Collapse
Affiliation(s)
- Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
|
9
|
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.
Collapse
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
| |
Collapse
|
|
10
|
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.
Collapse
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
| |
Collapse
|
|
11
|
Hwang HK, Lee SH, Han DH, Choi SH, Kang CM, Lee WJ. Impact of Braun anastomosis on reducing delayed gastric emptying following pancreaticoduodenectomy: a prospective, randomized controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:364-72. [PMID: 27038406 DOI: 10.1002/jhbp.349] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The present study investigates the clinical impact of Braun anastomosis on delayed gastric emptying (DGE) after pylorus-preserving pancreaticoduodenectomy (PPPD). METHODS From February 2013 to June 2014, 60 patients were recruited for this randomized controlled trial. The incidence of DGE and its risk factors were analyzed according to whether or not Braun anastomosis was used after PPPD. RESULTS Thirty patients were respectively enrolled in No-Braun group and Braun group. A comparative analysis between the two groups showed no differences in sex, diagnosis, operation time, hospital stay, or postoperative complications, including pancreatic fistula. Overall DGE developed in eight patients (26.7%) in the Braun group and in 14 patients (46.7%) in the No-Braun group (P = 0.108). However, clinically relevant DGE (grades B and C) was marginally more frequent in the No-Braun group (23.3% vs. 3.3%, P = 0.052). In a multivariable analysis, No-Braun anastomosis was an independent risk factor for developing clinically relevant DGE (odds ratio = 16.489; 95% confidence interval: 1.287-211.195; P = 0.031). CONCLUSION The overall DGE occurrence was not different between the two groups. However, No-Braun anastomosis was an independent risk factor for developing clinically relevant DGE.
Collapse
Affiliation(s)
- Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Sung Hwan Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Dai Hoon Han
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Sung Hoon Choi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea.
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| |
Collapse
|
|
12
|
Weledji EP, Enoworock G, Mokake M, Sinju M. How Grim is Pancreatic Cancer? Oncol Rev 2016; 10:294. [PMID: 27471581 PMCID: PMC4943093 DOI: 10.4081/oncol.2016.294] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/12/2016] [Accepted: 06/29/2016] [Indexed: 12/16/2022] Open
Abstract
Pancreatic ductal carcinoma continues to be the most lethal malignancy with rising incidence. It is the fourth most common cause of cancer death in the western world due to its low treatment success rate. In addition, because of its rapid growth and silent course, diagnosis is often only established in the advanced stages. As one of the most aggressive malignancies, the treatment of this disease is a great challenge to clinicians. This paper reviewed the natural history of pancreatic cancer, the current clinical practice and the future in pancreatic cancer management.
Collapse
Affiliation(s)
| | | | - Martin Mokake
- Department of Surgery and Obstetrics and Gynaecology, University of Buea, Cameroon
| | - Motaze Sinju
- Department of Surgery and Obstetrics and Gynaecology, University of Buea, Cameroon
| |
Collapse
|
|
13
|
Delayed gastric emptying after pylorus preserving pancreaticoduodenectomy—does gastrointestinal reconstruction technique matter? Am J Surg 2016; 211:810-9. [DOI: 10.1016/j.amjsurg.2015.10.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 10/23/2015] [Accepted: 10/28/2015] [Indexed: 01/04/2023]
|
|
14
|
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.
Collapse
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
| |
Collapse
|
|
15
|
Skipenko OG, Bedzhanjan K, Shatverjan D, Bagmet K, Chardarov K. [Prevention of gastrostasis after pancreaticoduodenal resection: new technique of gastroenterostomy]. Khirurgiia (Mosk) 2015:17-30. [PMID: 26081183 DOI: 10.17116/hirurgia2015417-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It was performed a retrospective comparative analysis of treatment results of 113 patients with pancreatic head and periampular cancer. The main group consisted of 58 patients in whom pancreaticoduodenal resection was performed according to an original technique of Russian Scientific Center of Surgery. Control group included 55 patients who underwent end-to-side gastrojejunostomy reconstruction. We have analyzed immediate postoperative complications in 2 groups without taking into consideration nosological forms of the disease. Pancreaticojejunostomy failure was diagnosed postoperatively in 5 (8.6%) patients in main group and in 10 (18.2%) patients in control group. There was no hepaticoentero- and gastroenterostomy failure in patients who underwent new technique of gastrojejunostomy while these events were observed in 8 (14.5%) and 3 (5.5%) patients respectively in control group. Mortality was 1.7% (n=1) in main group and 5.5% (n=3) in control group (p=0.29). Mild degree of gastrostasis (A class) was observed in 54 (93.7%) patients of main group and in 34 (61.8%) patients of control group (p=0.0004). There was B class of gastrostasis in 4 (6.9%) patients of main group. Severe gastrostasis (C class) was not revealed in any observation. In control group B class of gastrostasis was diagnosed in 14 (25.5%) patients, severe degree - in 7 (12.7%) patients. Univariant analysis showed hemotransfusion (p=0.037), pancreatic fistula (p=0.001), enteric fistula (p=0.005) and reconstruction technique (p=0.00004) as predictors of gastrostasis. Multivariant analysis defined pancreatic fistula (p=0.01), enteric fistula (p=0.04) and reconstruction technique (p=0.001) as significant predictors of gastrostasis. Thus, our study revealed significant decreasing gastrostasis incidence in case of original technique in comparison with conventional anastomosis, as well as demonstrated effect of anastomoses failure on augmentation of gastrostasis frequency after pancreaticoduodenal resection. Further randomized investigations are necessary to confirm our results.
Collapse
Affiliation(s)
- O G Skipenko
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Bedzhanjan
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - D Shatverjan
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Bagmet
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Chardarov
- acad. B.V. Petrovskiy Russian Research Surgery Center
| |
Collapse
|
|
16
|
Yang J, Wang C, Huang Q. Effect of Billroth II or Roux-en-Y Reconstruction for the Gastrojejunostomy After Pancreaticoduodenectomy: Meta-analysis of Randomized Controlled Trials. J Gastrointest Surg 2015; 19:955-63. [PMID: 25788119 DOI: 10.1007/s11605-015-2751-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 01/08/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES This study aimed to compare Billroth II with Roux-en-Y reconstruction after pancreaticoduodenectomy (PD). METHODS A literature search was carried out to identify all randomized controlled trials (RCTs) comparing postoperative complications of Billroth II versus Roux-en-Y reconstruction following PD published from 1 January 1990 to 31 August 2014. Pooled risk ratios (RRs) with 95 % confidence intervals (CIs) were calculated using fixed effects or random effects models RESULTS In total, three RCTs with 470 patients were included. Using International Study Group of Pancreatic Surgery (ISGPS) definitions, incidences of delayed gastric emptying (DGE) [grades B and C (3.9 versus 12.9 %; RR 0.30, 95 % CI 0.11-0.79; P = 0.01), DGE grade C (0.7 versus 9.6 %; RR 0.11, 95 % CI 0.02-0.61; P = 0.01)] were significantly lower in the Billroth II group than in the Roux-en-Y group, as was the length of hospital stay (weighted mean difference -4.72, 95 % CI -8.91, -0.53; P = 0.03). CONCLUSIONS Meta-analysis revealed that the incidence of DGE (grades B and C) after PD can be decreased by using Billroth II rather than Roux-en-Y reconstruction.
Collapse
Affiliation(s)
- Ji Yang
- Department of General Surgery, Affiliated Provincial Hospitalof Anhui Medical University, Hefei, 230001, China,
| | | | | |
Collapse
|
|
17
|
Is antisecretory therapy after pancreatoduodenectomy necessary? Meta-analysis and contemporary practices of pancreatic surgeons. J Gastrointest Surg 2015; 19:604-12. [PMID: 25691111 DOI: 10.1007/s11605-015-2765-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 01/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Marginal ulcer (MU) is a well-described complication of pancreatoduodenectomy (PD) whose incidence remains unclear. Gastric antisecretory medications likely attenuate the risk of marginal ulceration after PD; however, the true relationship between antisecretory medication and marginal ulceration after PD is not precisely known. The aims of this study were to document the incidence of MU after PD, identify any relationship between MU and gastric antisecretory medication, and survey current practice of MU prophylaxis among experienced pancreatic surgeons. METHODS the MEDLINE, EMBASE, Cochrane Central Registrar of Controlled Trials, and Cochrane Database of Systematic Reviews databases were searched from their inception to May 2014 for abstracts documenting ulceration after pancreatoduodenectomy. Two reviewers independently graded abstracts for inclusion in this review. Contemporary practice was assessed through a four-question survey distributed globally to 200 established pancreatic surgeons. RESULTS After a review of 208 abstracts, 54 studies were graded as relevant. These represented a cohort of 212 patients with marginal ulcer after PD (n = 4794). A meta-analysis of the included references shows mean incidence of ulceration after PD of 2.5% (confidence interval (CI) 1.8-3.2%) with a median time to diagnosis of 15.5 months. Pylorus preservation was associated with a MU rate of 2.0% (CI 1.0-2.9%), while "classic" PD procedures report an overall rate of 2.6% (CI 1.6-3.6%). Documented use of postoperative antisecretory medication was associated with a reduced rate of 1.4% (CI 0.1-1.7%). One hundred forty-four of 200 (72%) surveys were returned, from which it was determined that 92% of pancreatic surgeons have dealt with this complication, and 86% routinely prescribe prophylactic antisecretory medication after PD. CONCLUSIONS The incidence of MU after PD is 2.5% with a median time to occurrence of 15.5 months postoperatively. Gastric antisecretory medication prescription may affect the incidence of MU. The majority of pancreatic surgeons surveyed have encountered MU after PD; most (86%) routinely prescribe prophylactic gastric antisecretory medication.
Collapse
|
|
18
|
Bell R, Pandanaboyana S, Shah N, Bartlett A, Windsor JA, Smith AM. Meta-analysis of antecolic versus retrocolic gastric reconstruction after a pylorus-preserving pancreatoduodenectomy. HPB (Oxford) 2015; 17:202-8. [PMID: 25267428 PMCID: PMC4333780 DOI: 10.1111/hpb.12344] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/28/2014] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) is a common complication after a pylorus-preserving pancreatoduodenectomy (PPPD) and is associated with significant morbidity. This study determines whether DGE is affected by antecolic (AC) or retrocolic (RC) reconstruction after a PPPD. METHOD An electronic search was performed of the MEDLINE, EMBASE and PubMed databases to identify all articles related to this topic. Pooled risk ratios (RR) were calculated for categorical outcomes, and mean differences (MD) for secondary continuous outcomes using the fixed-effects and random-effects models for meta-analysis. RESULTS Nine studies including 878 patients met the inclusion criteria. DGE was lower with an AC reconstruction RR 0.31 [0.12, 0.78] Z = 2.47 (P = 0.010). Length of stay (LOS) MD -4 days [-7.63, -1.14] Z = 2.65 (P = 0.008) and days to commence a solid diet MD -5 days [-6.63, -3.15] Z = 5.50 (P ≤ 0.000) were also significantly in favour of the AC group. There was no difference in the incidence of pancreatic fistula, intra-abdominal collection/bile leak or mortality between the two groups. CONCLUSION AC reconstruction after PPPD is associated with a lower incidence of DGE. Time to oral intake was significantly shorter with AC reconstruction, with a reduced hospital stay.
Collapse
Affiliation(s)
- Richard Bell
- Department of HPB Surgery, St James University HospitalLeeds, UK
| | - Sanjay Pandanaboyana
- Department of HPB Surgery, St James University HospitalLeeds, UK,Correspondence, Sanjay Pandanaboyana, Department of HPB and Transplant Surgery, ICU Offices, Level 3 Bexley Wing, St James Hospital, Beckett Street, Leeds LS7 9TF, UK. Tel.: 113 2433144. Fax: +44 (0)113 2448182. E-mail:
| | - Nehal Shah
- Department of HPB Surgery, St James University HospitalLeeds, UK
| | - Adam Bartlett
- HPB/Upper GI Unit, Department of General Surgery, Auckland City HospitalAuckland, New Zealand
| | - John A Windsor
- HPB/Upper GI Unit, Department of General Surgery, Auckland City HospitalAuckland, New Zealand
| | - Andrew M Smith
- Department of Pancreatic Surgery, St James University HospitalLeeds, UK
| |
Collapse
|
|
19
|
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.
Collapse
Affiliation(s)
- Go Sato
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | | | | | | | | | | |
Collapse
|
|
20
|
Cao SS, Lin QY, He MX, Zhang GQ. Effect of antecolic versus retrocolic reconstruction for gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A meta-analysis. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Shuang-Shuang Cao
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Qi-Yuan Lin
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Man-Xi He
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Guang-Quan Zhang
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| |
Collapse
|
|
21
|
Parmar AD, Sheffield KM, Vargas GM, Pitt HA, Kilbane EM, Hall BL, Riall TS. Factors associated with delayed gastric emptying after pancreaticoduodenectomy. HPB (Oxford) 2013; 15:763-72. [PMID: 23869542 PMCID: PMC3791115 DOI: 10.1111/hpb.12129] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 04/10/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The factors associated with delayed gastric emptying (DGE) after a pancreaticoduodenectomy (PD) are not definitively known. METHODS From November 2011 through to May 2012, data were prospectively collected on 711 patients undergoing a pancreaticoduodenectomy or total pancreatectomy as part of the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project. Bivariate and multivariate models were employed to determine the factors that predicted DGE. RESULTS In the 711 patients, the overall rate of DGE was 20.1%. In a bivariate analysis, intra-operative factors such as pylorus-preservation (47.1% versus 43.7%, P = 0.40), intra-operative drain placement (85.5%, versus 85.1%, P = 0.91) and an antecolic compared with a retrocolic gastrojejunostomy (60.1% versus 65.1%, P = 0.26) were not different between the DGE and no DGE groups. Pancreatic fistula formation (31.2% versus 10.1%), post-operative sepsis (21.7% versus 7.0%), organ space surgical site infection (SSI) (23.9% versus 7.9%), need for percutaneous drainage (23.0% versus 10.6%) and reoperation (10.6% versus 3.1%) were higher in patients with DGE (P < 0.0001). In a multivariable model, only pancreatic fistula, post-operative sepsis and reoperation were independently associated with DGE. DISCUSSION In this multicentre study, only post-operative complications were associated with DGE. Neither pylorus preservation nor route of enteric reconstruction (antecolic versus retrocolic) was associated with delayed gastric emptying.
Collapse
Affiliation(s)
- Abhishek D Parmar
- Departments of Surgery, The University of Texas Medical Branch, Galveston, TX, USA; The University of California, San Francisco-East Bay, Oakland, CA, USA
| | | | | | | | | | | | | |
Collapse
|
|
22
|
Effect of billroth II or Roux-en-Y reconstruction for the gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled study. Ann Surg 2013; 257:938-42. [PMID: 23579543 DOI: 10.1097/sla.0b013e31826c3f90] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Delayed gastric emptying (DGE) is one of the major complications after pancreaticoduodenectomy (PD), occurring in 14% to 61% of cases. There have been no studies that compare the incidence of DGE in terms of the reconstruction method of gastrojejunostomy performed in subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). The objective of this study was to evaluate the superiority of Billroth II (B-II) to Roux-en Y (R-Y) reconstruction on decreasing the incidence of delayed gastric emptying DGE after SSPPD by a prospective randomized controlled trial. METHODS Between April 2008 and August 2011, 101 patients who underwent SSPPD for pancreatic head or periampullary diseases were randomly allocated to B-II reconstruction (n = 52) and R-Y reconstruction (n = 49) groups. The primary endpoint was incidence of DGE. RESULTS DGE occurred in 5.7% of patients in the B-II group and in 20.4% of patients in the R-Y group (P = 0.028). Patients in the B-II group had a significantly shorter hospital stay after operation than patients in the R-Y group (31.6 ± 15.0 days vs. 41.4 ± 20.5 days, P = 0.037). In terms of postoperative complications, the incidence of pancreatic fistula was significantly higher in patients with DGE (38.5%) than in patients without DGE (14.8%) (P = 0.037). CONCLUSION It is suggested that the incidence of DGE after SSPPD can be decreased by using B-II rather than R-Y reconstruction for gastrojejunostomy.(Clinical Trials Registry, UMIN-CTR: http://www.umin.ac.jp/ctr/, ref no. UMIN000003535).
Collapse
|
|
23
|
Muscogiuri G, Mezza T, Prioletta A, Sorice GP, Clemente G, Sarno G, Nuzzo G, Pontecorvi A, Holst JJ, Giaccari A. Removal of duodenum elicits GLP-1 secretion. Diabetes Care 2013; 36:1641-6. [PMID: 23393218 PMCID: PMC3661831 DOI: 10.2337/dc12-0811] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the effect of removal of the duodenum on the complex interplay between incretins, insulin, and glucagon in nondiabetic subjects. RESEARCH DESIGN AND METHODS For evaluation of hormonal secretion and insulin sensitivity, 10 overweight patients without type 2 diabetes (age 61 ± 19.3 years and BMI 27.9 ± 5.3 kg/m(2)) underwent a mixed-meal test and a hyperinsulinemic-euglycemic clamp before and after pylorus-preserving pancreatoduodenectomy for ampulloma. RESULTS All patients experienced a reduction in insulin (P = 0.002), C-peptide (P = 0.0002), and gastric inhibitory peptide (GIP) secretion (P = 0.0004), while both fasting and postprandial glucose levels increased (P = 0.0001); GLP-1 and glucagon responses to the mixed meal increased significantly after surgery (P = 0.02 and 0.031). While changes in GIP levels did not correlate with insulin, glucagon, and glucose levels, the increase in GLP-1 secretion was inversely related to the postsurgery decrease in insulin secretion (R(2) = 0.56; P = 0.012) but not to the increased glucagon secretion, which correlated inversely with the reduction of insulin (R(2) = 0.46; P = 0.03) and C-peptide (R(2) = 0.37; P = 0.04). Given that the remaining pancreas presumably has preserved intraislet anatomy, insulin secretory capacity, and α- and β-cell interplay, our data suggest that the increased glucagon secretion is related to decreased systemic insulin. CONCLUSIONS Pylorus-preserving pancreatoduodenectomy was associated with a decrease in GIP and a remarkable increase in GLP-1 levels, which was not translated into increased insulin secretion. Rather, the hypoinsulinemia may have caused an increase in glucagon secretion.
Collapse
Affiliation(s)
- Giovanna Muscogiuri
- Division of Endocrinology and Metabolic Diseases, Università Cattolica del Sacro Cuore, Rome, Italy.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
24
|
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.
Collapse
|
|
25
|
Enteral nutrition reduces delayed gastric emptying after standard pancreaticoduodenectomy with child reconstruction. J Gastrointest Surg 2012; 16:1004-11. [PMID: 22258876 DOI: 10.1007/s11605-012-1821-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/04/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication following pancreaticoduodenectomy (PD). Our retrospective study aimed to evaluate the influence of enteral nutrition (EN) on DGE incidence after standard PD with antrectomy and Child reconstruction. METHODS We retrospectively analyzed 275 consecutive patients who underwent standard PD between January 2000 and September 2009. Patients operated on after January 2005 received EN (EN group, n = 152) until total oral alimentation. Patients operated on prior to 2005 did not receive EN (control group, n = 123) and were orally fed after removing the nasogastric tube. Primary endpoint was the incidence of DGE according to the International Study Group of Pancreatic Surgery criteria. Secondary endpoints were the incidence of any other complications. RESULTS The incidence of DGE was 26% vs. 38% (p = 0.04) in the EN and control groups, respectively, with 17% vs. 19% for grade B DGE (NS) and 9% vs. 19% for grade C DGE (p = 0.02). The differences in DGE did not significantly decrease the duration of stay (18 ± 11 vs. 19 ± 13 days; NS). Postpancreatectomy hemorrhage was significantly reduced in the EN group (8% vs. 20%, p = 0.008), with the incidence of postoperative pancreatic fistula being similar in both groups (15% vs. 12%; NS). Using multivariate analysis, EN (p = 0.047, OR = 0.559 [0.315; 0.994]), operative time (p < 0.001, OR = 1.007 [1.003; 1.010]), and patient age (p = 0.014, OR = 1.031 [1.006; 1.057]) were independent factors affecting the incidence of DGE. CONCLUSIONS EN reduces DGE and postpancreatectomy hemorrhage after PD.
Collapse
|
|
26
|
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.
Collapse
Affiliation(s)
- Yong Hoon Kim
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Keimyung University School of Medicine, Daegu, Korea
| |
Collapse
|
|
27
|
Hornez E, Beyer L, Bourgouin S, Calvary R, Monchal T, Moutardier V, Orsonni P, Berdah S. Routine gastrostomy tube for gastric decompression in 55 consecutive pylorus-conserving pancreatoduodenectomy: retrospective analysis of the efficacy and tolerance. Clin Res Hepatol Gastroenterol 2011; 35:597-9. [PMID: 21664214 DOI: 10.1016/j.clinre.2011.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 04/20/2011] [Indexed: 02/04/2023]
|
|
28
|
Kurahara H, Shinchi H, Maemura K, Mataki Y, Iino S, Sakoda M, Ueno S, Takao S, Natsugoe S. Delayed gastric emptying after pancreatoduodenectomy. J Surg Res 2011; 171:e187-92. [PMID: 22001182 DOI: 10.1016/j.jss.2011.08.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 07/27/2011] [Accepted: 08/01/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antecolic reconstruction after pylorus-preserving pancreatoduodenectomy (PPPD) has been reported to decrease the incidence of delayed gastric emptying (DGE), which is one of the main postoperative complications. Subtotal stomach-preserving PD (SSPPD), in which duodenum and pylorus ring were removed, was introduced for the purpose of decreasing the incidence of DGE. This prospective randomized control study was performed to assess whether antecolic reconstruction decreases the incidence of DGE compared with retrocolic reconstruction after SSPPD. MATERIALS AND METHODS Forty-six patients were enrolled in this trial between May 2007 and June 2010. Twenty-two and 24 patients were randomized for the retrocolic and antecolic groups, respectively. The primary endpoint was DGE incidence. RESULTS The overall incidence of DGE in the retrocolic group was significantly higher than that in the antecolic group (50% versus 20.8%, P=0.0364). In particular, this difference was most striking in the incidence of DGE grade B/C (27.3% versus 4.2%, P=0.0234). Furthermore, patients in the retrocolic group required significantly longer time to full resumption of diet compared with the antecolic group. No significant difference was observed in other postoperative complications between the two groups. CONCLUSION Antecolic reconstruction, and not retrocolic reconstruction, decreases DGE incidence after SSPPD.
Collapse
Affiliation(s)
- Hiroshi Kurahara
- Department of Surgical Oncology and Digestive Surgery, Graduate School of Medical Sciences, Kagoshima University, Kagoshima, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
|
29
|
Pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: the clinical impact of a new surgical procedure; pylorus-resecting pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:755-61. [DOI: 10.1007/s00534-011-0427-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
|
30
|
Sasaki M, Okamoto H, Johtatsu T, Kurihara M, Iwakawa H, Tanaka T, Shiomi H, Naka S, Kurumi Y, Tani T. Resting energy expenditure in patients undergoing pylorus preserving pancreatoduodenectomies for bile duct cancer or pancreatic tumors. J Clin Biochem Nutr 2011. [PMID: 21562636 DOI: 10.3164/jcbn.10.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We measured the energy expenditure weekly in patients undergoing a pylorus preserving pancreatoduodenectomy for bile duct cancer or pancreatic tumors. Twelve patients (5 women and 7 men; mean age 70.1 years) were enrolled in this study, and their resting energy expenditure levels were determined by indirect calorimetry. In these patients, a significant correlation was observed between the measured resting energy expenditures and the predicted resting energy expenditures calculated by the Harris-Benedict equation. The resting energy expenditures measured before surgery were almost the same as the predicted resting energy expenditures (measured resting energy expenditure: 22.4 ± 3.9 kcal/kg/day vs predicted resting energy expenditure: 21.7 ± 2.0 kcal/kg/day). The measured resting energy expenditure/predicted resting energy expenditure ratio, which reflects the stress factor, was 1.02 ± 0.10. After the pylorus preserving pancreatoduodenectomy, a significant increase in energy expenditure was observed, and the measured resting energy expenditure was 25.7 ± 3.5 kcal/kg/day on postoperative day 7 and 25.4 ± 4.9 kcal/kg/day on postoperative day 14. The measured resting energy expenditure/predicted resting energy expenditure ratio was 1.16 ± 0.14 on postoperative day 7, and 1.16 ± 0.18 on postoperative day 14 respectively. In conclusion, patients undergoing a pylorus preserving pancreatoduodenectomy showed a hyper-metabolic status as evaluated by their measured resting energy expenditure/predicted resting energy expenditure ratio. From our observations, we recommend that nutritional management based on 30 kcal/body weight/day (calculated by the measured resting energy expenditure×activity factor 1.2-1.3) may be optimal for patients undergoing a pylorus preserving pancreatoduodenectomy.
Collapse
Affiliation(s)
- Masaya Sasaki
- Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
31
|
Post M, Wrzesinski M, Klek R, Lubikowski J, Wojcicki M. Pancreatoduodenectomy with subtotal stomach-preserving and uncut Roux reconstruction. ACTA ACUST UNITED AC 2011; 47:1-4. [PMID: 21540612 DOI: 10.1159/000326947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 02/24/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Pylorus-preserving pancreatoduodenectomy (PD) has become the therapy of choice for resectable tumors located in the head of the pancreas and periampullary region. In addition, a distal gastrectomy may still be required for tumors located in the dorsal part of the pancreatic head or when there is evidence of proximal duodenal invasion. This may lead to postoperative complications, including gastric dumping, marginal ulceration, and bile reflux gastritis. This study reports on the postoperative course following subtotal stomach-preserving PD with the uncut Roux reconstruction diverting biliary and pancreatic secretions from the gastric remnant. METHODS A technique combining subtotal stomach-preserving PD with the uncut Roux reconstruction was applied in 10 patients. The postoperative clinical follow-up data are reviewed, and clinical criteria of biliary gastric reflux and gastritis were evaluated. RESULTS The postoperative course was uneventful in 4 patients and complicated in 6 patients. Delayed gastric emptying occurred in 3 patients. No deaths occurred in the postoperative period. One patient suffered from occasional nausea with abdominal discomfort for which endoscopy and cholescintigraphy were performed. Endoscopy confirmed complete occlusion of the afferent jejunal limb and showed marginal ulceration within the gastrojejunal anastomosis. Cholescintigraphy showed signs of enterogastric reflux. The check-up endoscopy following typical antisecretory therapy revealed complete ulcer healing. Four patients died of tumor recurrence 6, 7, 8, and 12 months following surgery. CONCLUSION This pilot study suggests that the uncut Roux reconstruction may represent a good alternative to gastrointestinal reconstruction following PD. Further studies including the determination of intragastric bile acid concentration and radionuclide isotope scanning in a larger number of patients are warranted.
Collapse
Affiliation(s)
- M Post
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of General and Transplant Surgery, M. Curie Hospital, Szczecin, Poland
| | | | | | | | | |
Collapse
|
|
32
|
Sasaki M, Okamoto H, Johtatsu T, Kurihara M, Iwakawa H, Tanaka T, Shiomi H, Naka S, Kurumi Y, Tani T. Resting energy expenditure in patients undergoing pylorus preserving pancreatoduodenectomies for bile duct cancer or pancreatic tumors. J Clin Biochem Nutr 2011; 48:183-6. [PMID: 21562636 PMCID: PMC3082071 DOI: 10.3164/jcbn.10-83] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 08/07/2010] [Indexed: 02/06/2023] Open
Abstract
We measured the energy expenditure weekly in patients undergoing a pylorus preserving pancreatoduodenectomy for bile duct cancer or pancreatic tumors. Twelve patients (5 women and 7 men; mean age 70.1 years) were enrolled in this study, and their resting energy expenditure levels were determined by indirect calorimetry. In these patients, a significant correlation was observed between the measured resting energy expenditures and the predicted resting energy expenditures calculated by the Harris-Benedict equation. The resting energy expenditures measured before surgery were almost the same as the predicted resting energy expenditures (measured resting energy expenditure: 22.4 ± 3.9 kcal/kg/day vs predicted resting energy expenditure: 21.7 ± 2.0 kcal/kg/day). The measured resting energy expenditure/predicted resting energy expenditure ratio, which reflects the stress factor, was 1.02 ± 0.10. After the pylorus preserving pancreatoduodenectomy, a significant increase in energy expenditure was observed, and the measured resting energy expenditure was 25.7 ± 3.5 kcal/kg/day on postoperative day 7 and 25.4 ± 4.9 kcal/kg/day on postoperative day 14. The measured resting energy expenditure/predicted resting energy expenditure ratio was 1.16 ± 0.14 on postoperative day 7, and 1.16 ± 0.18 on postoperative day 14 respectively. In conclusion, patients undergoing a pylorus preserving pancreatoduodenectomy showed a hyper-metabolic status as evaluated by their measured resting energy expenditure/predicted resting energy expenditure ratio. From our observations, we recommend that nutritional management based on 30 kcal/body weight/day (calculated by the measured resting energy expenditure×activity factor 1.2–1.3) may be optimal for patients undergoing a pylorus preserving pancreatoduodenectomy.
Collapse
Affiliation(s)
- Masaya Sasaki
- Division of Clinical Nutrition, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
33
|
Pylorus Ring Resection Reduces Delayed Gastric Emptying in Patients Undergoing Pancreatoduodenectomy. Ann Surg 2011; 253:495-501. [DOI: 10.1097/sla.0b013e31820d98f1] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
|
34
|
Evers DJ, Smeenk RM, Bottenberg PD, van Werkhoven ED, Boot H, Verwaal VJ. Effect of preservation of the right gastro-epiploic artery on delayed gastric emptying after cytoreductive surgery and HIPEC: a randomized clinical trial. Eur J Surg Oncol 2011; 37:162-7. [PMID: 21216560 DOI: 10.1016/j.ejso.2010.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 11/30/2010] [Accepted: 12/06/2010] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a main complication with unknown origin after a cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS-HIPEC). The aim of this study was to investigate if preservation of the right gastro-epiploic artery (GEA) during standard omentectomy would have a positive effect on gastric emptying after CRS-HIPEC. METHODS Forty-two patients subjected to a CRS-HIPEC were randomized into two groups perioperatively before performing an omentectomy: in Group I (N = 21) omentectomy was performed with preservation of the GEA; in Group II (N = 21) omentectomy was performed with resection of the GEA. The primary endpoint was the number of days to full oral intake of solid food. Secondary endpoints were number of days to intended occlusion of gastrostomy catheter and total hospital admission time. RESULTS No significant differences were discovered between both groups in any of the study endpoints after CRS-HIPEC. No significant differences were observed in patient or operation characteristics between the randomized groups. CONCLUSIONS No association was demonstrated between preservation of the gastro-epiploic artery during omentectomy and gastric emptying after CRS-HIPEC. The extensive intestinal manipulation or the heated intra-peritoneal chemotherapy during surgery are more plausible causes of this phenomenon. This clinical trial was registered in the Netherlands at the Central Committee on Research involving Human Subjects (CCMO) under registration number P06.0301L.
Collapse
Affiliation(s)
- D J Evers
- Department of Surgery, The Netherlands Cancer Institute NKI-AVL, Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
|
35
|
Ziegler KM, Nakeeb A, Pitt HA, Schmidt CM, Bishop SN, Moreno J, Matos JM, Zyromski NJ, House MG, Madura JA, Howard TJ, Lillemoe KD. Pancreatic surgery: evolution at a high-volume center. Surgery 2010; 148:702-9; discussion 709-10. [PMID: 20797743 DOI: 10.1016/j.surg.2010.07.029] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 07/15/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Advances in imaging, minimally invasive techniques, and regionalization have changed pancreatic surgery. Therefore, the aims of this report are to determine whether the pancreatic operations or the spectrum of disease have evolved at a high-volume center. METHODS From 1996 through 2009, 2,004 pancreatic operations were performed at Indiana University Hospital. The operations, pathology, and outcomes for 1996-2003 were compared with 2004-2009. RESULTS In 2004-2009, more operations/year were performed (215 vs 89; P < .01) and patients were older (58.8 years vs 55.8 years; P < .01). In recent years, more pancreatoduodenectomies (55.0% vs 50.4%) and fewer pancreatojejunostomies (6.2% vs 12.6%) and Beger/Frey procedures (2.6% vs 4.8%) were performed (P < .05). In 2004-2009, pylorus preservation (81.1% vs 64.4%), laparoscopic distal pancreatectomy (33.9% vs 0%), and splenic preservation (25.3% vs 2.2%) were carried out more frequently (P < .001). Pathology review revealed more tumors (68.8% vs 60.4%) and less pancreatitis (29.2% vs 34.4%; P < .01). Thirty-day mortality improved from 2.5% to 1.8%. CONCLUSION At a high-volume pancreatic surgery center, the number and age of the patients, the percentage of pancreatic resections, preservation of the pylorus and spleen as well as laparoscopic procedures, and the percentage of patients with tumors all have increased, whereas the outcomes continued to improve.
Collapse
Affiliation(s)
- Kathryn M Ziegler
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
36
|
Kwok KH, Rizk J, Coleman M, Fenton-Lee D. Pancreaticoduodenectomy - outcomes from an Australian institution. ANZ J Surg 2010; 80:605-8. [DOI: 10.1111/j.1445-2197.2010.05348.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
|
37
|
Lee SE, Jang JY, Hwang DW, Lee KU, Kim SW. Clinical efficacy of organ-preserving pancreatectomy for benign or low-grade malignant potential lesion. J Korean Med Sci 2010; 25:97-103. [PMID: 20052354 PMCID: PMC2800014 DOI: 10.3346/jkms.2010.25.1.97] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Accepted: 03/01/2009] [Indexed: 11/20/2022] Open
Abstract
The clinical usefulness of organ-preserving pancreatectomy is not well established due to technical difficulty and ambiguity of functional merit. The purpose of this study is to evaluate the clinical efficacy of organ-preserving pancreatectomy such as duodenum-preserving resection of the head of the pancreas (DPRHP), pancreatic head resection with segmental duodenectomy (PHRSD), central pancreatectomy (CP) and spleen-preserving distal pancreatectomy (SPDP). Between 1995 and 2007, the DPRHP were performed in 14 patients, the PHRSD in 16 patients, the CP in 13 patients, and the SPDP in 45 patients for preoperatively diagnosed benign lesions or tumors with low-grade malignant potential. The clinical outcomes including surgical details, postoperative complications and long-term functional outcomes were compared between organ-preserving pancreatectomy and conventional pancreatectomy group. Major postoperative complications constituted the following: bile duct stricture (7.1% [1/14]) in DPRHP, delayed gastric emptying (31.2% [5/16]) in PHRSD, pancreatic fistula (21.4% [3/14]) in CP. There were no significant differences in postoperative complications and long-term functional outcomes between two groups. Organ-preserving pancreatectomy is associated with tolerable postoperative complications, and good long-term outcome comparing to conventional pancreatectomy. Organ-preserving pancreatectomy could be alternative treatment for benign or low-grade malignant potential lesion of the pancreas or ampullary/parapapillary duodenum.
Collapse
Affiliation(s)
- Seung Eun Lee
- Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Dae Wook Hwang
- Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Kuhn Uk Lee
- Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| |
Collapse
|
|
38
|
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.
Collapse
Affiliation(s)
- Mehrdad Nikfarjam
- Liver, Pancreas and Foregut Unit, Department of Surgery, Penn State College of Medicine, Hershey, PA 17033-0850, USA.
| | | | | | | | | | | | | |
Collapse
|
|
39
|
Chijiiwa K, Imamura N, Ohuchida J, Hiyoshi M, Nagano M, Otani K, Kai M, Kondo K. Prospective randomized controlled study of gastric emptying assessed by (13)C-acetate breath test after pylorus-preserving pancreaticoduodenectomy: comparison between antecolic and vertical retrocolic duodenojejunostomy. ACTA ACUST UNITED AC 2008; 16:49-55. [PMID: 19083149 DOI: 10.1007/s00534-008-0004-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2007] [Accepted: 01/16/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND/PURPOSE To examine whether vertical retrocolic duodenojejunostomy is superior to antecolic duodenojejunostomy with respect to gastric emptying in a prospective, randomized, controlled study of patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). METHODS Thirty-five patients undergoing PpPD between March 2005 and July 2007 were enrolled in the study. All provided informed consent. During PpPD, the patients were randomly assigned to either the antecolic (antecolic group, n = 17) or vertical retrocolic route (vertical retrocolic group, n = 18) just before the reconstruction. Each patient ingested (13)C-acetate in a liquid meal before surgery and on postoperative day (POD) 30. Gastric emptying variables (Tmax, T1/2) were determined and compared between groups. RESULTS Clinical delayed gastric emptying, defined as an inability of patients to take in an appropriate amount of solid food orally by POD 14, was found in 1 of 17 patients (6%) in the antecolic group and in 4 of 18 patients (22%) in the vertical retrocolic group, but the difference was not significant (P = 0.34). Tmax and T1/2 on POD 30 were prolonged in both groups in comparison to preoperative levels, but no significant difference was found between the two groups. Follow-up examinations revealed that gastric emptying had recovered to the preoperative level by POD 30 in approximately 80% of the patients, regardless of the reconstruction route. CONCLUSIONS Vertical retrocolic duodenojejunostomy does not seem to offer an advantage with respect to gastric emptying.
Collapse
Affiliation(s)
- Kazuo Chijiiwa
- Department of Surgical Oncology and Regulation of Organ Function, Miyazaki University School of Medicine, Kiyotake, Miyazaki, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
|
40
|
Duodenum-preserving Pancreatic Head Resection Versus Pancreatoduodenectomy for Surgical Treatment of Chronic Pancreatitis. Ann Surg 2008; 247:950-61. [DOI: 10.1097/sla.0b013e3181724ee7] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
|
41
|
Fang WL, Shyr YM, Su CH, Chen TH, Wu CW, Lui WY. Comparison between pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy. J Formos Med Assoc 2007; 106:717-27. [PMID: 17908661 DOI: 10.1016/s0929-6646(08)60033-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/PURPOSE Pancreatic leakage is a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) has been reported to be associated with a lower pancreatic leakage rate and morbidity rate than pancreaticojejunostomy (PJ). This study compared the preoperative characteristics, surgical risk factors, intraoperative parameters, and postoperative outcome between PJ and PG. METHODS From March 1992 to March 2005, a comparative study between PJ and PG for patients with periampullary lesions undergoing PD was conducted. A total of 377 consecutive patients underwent PD. Among them, 188 patients underwent PJ and 189 underwent PG. RESULTS The overall mortality, morbidity and pancreatic leakage following PD were 5%, 45.1% and 10.6%, respectively. The mortality, morbidity and pancreatic leakage were 8.9%, 56.4% and 17.6% in the PJ group, and 2.1%, 33.9% and 3.7% in the PG group (p < 0.001). Mean operative time was 9.3 hours versus 6.7 hours (p < 0.001), mean blood loss was 1032 mL versus 891 mL (p = 0.064) and mean hospital stay was 34.8 days versus 26.1 days (p < 0.001) in the PJ and PG groups, respectively. PJ, soft pancreas, pancreatic duct stenting, low surgical volume (< 20) and age (> 65 years) were identified as risk factors for pancreatic leakage, while PJ, soft pancreas, pancreatic duct stenting and low surgical volume (< 20) were four significant risk factors for surgical morbidity. Further, PJ, pancreatic leakage, low surgical volume (< 20) and age (> 65 years) were identified to be surgical risk factors for mortality. CONCLUSION PG is a safer method than PJ following PD as a significantly lower rate of pancreatic leakage, surgical morbidity and mortality, shorter operation time, and shorter postoperative hospital stay are reported.
Collapse
Affiliation(s)
- Wen-Liang Fang
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | | |
Collapse
|
|
42
|
Kawamoto M, Konomi H, Kobayashi K, Shimizu S, Yamaguchi K, Tanaka M. Type of gastrointestinal reconstruction affects postoperative recovery after pancreatic head resection. ACTA ACUST UNITED AC 2007; 13:336-43. [PMID: 16858546 DOI: 10.1007/s00534-005-1085-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2005] [Accepted: 11/10/2005] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE The postoperative recovery of gastric motility with various reconstructions after pancreatic head resection has been reported. However, little is known about this recovery after pancreatic head resection with segmental duodenectomy (PHRSD). Some have attributed gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD) to tube gastrostomy, but its effect on gastric motility has not been investigated. In this study, the postoperative recovery after PHRSD and PPPD, and gastric motility with and without gastrostomy after PPPD were investigated. METHODS We analyzed the first appearance of gastric phase III motility, postoperative systemic status, and body weight (BW; n = 32). The Imanaga PPPD and PHRSD were compared because the procedures differ only in the length of the remaining duodenum. Traverso and Roux-en-Y PPPDs were compared because the two procedures are similar except for the creation of gastrostomy. RESULTS (1) Times to first appearance of gastric phase III motility and BW recovery were significantly better after PHRSD than after the Imanaga PPPD (P < 0.05). (2) Times to first gastric phase III motility and resumption of a regular diet as well as periods of gastric sump tube use and postoperative hospital stay were significantly shorter after the Roux-en-Y than after the Traverso PPPD (P < 0.05). CONCLUSIONS Preservation of as long a portion of the duodenum as possible, the choice of a Roux-en-Y duodenojejunostomy, and the avoidance of peritoneal fixation of the gastric wall may be factors that improve the recovery of gastric motility and BW after pancreatic head resection.
Collapse
Affiliation(s)
- Masahiko Kawamoto
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka 812-8582, Japan
| | | | | | | | | | | |
Collapse
|
|
43
|
Ohtsuka T, Tanaka M, Miyazaki K. Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy. ACTA ACUST UNITED AC 2006; 13:218-24. [PMID: 16708298 DOI: 10.1007/s00534-005-1067-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Accepted: 10/26/2005] [Indexed: 12/20/2022]
Abstract
The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreatoduodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.
Collapse
Affiliation(s)
- Takao Ohtsuka
- Department of Surgery, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | | | | |
Collapse
|
|
44
|
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.
Collapse
|
|
45
|
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.
Collapse
Affiliation(s)
- Dimitrios Lytras
- 1st Department of Surgery, Agia Olga Hospital, 3-5 Agias Olgas Street, 14233 Nea Ionia, Greece
| | | | | | | | | | | | | |
Collapse
|
|
46
|
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.
Collapse
Affiliation(s)
- Sari Räty
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | | | | | | |
Collapse
|
|
47
|
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.
Collapse
Affiliation(s)
- Shuang-Qin Yi
- Department of Anatomy, Tokyo Medical University, Shinjuku-ku, Tokyo 160-8402, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
48
|
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.
Collapse
Affiliation(s)
- Marco Niedergethmann
- Department of Surgery, University-Hospital Mannheim, University of Heidelberg, 68135, Mannheim, Germany.
| | | | | | | | | | | | | |
Collapse
|
|
49
|
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.
Collapse
|
|
50
|
Gerdes B, Ramaswamy A, Bartsch DK, Rothmund M. Peripyloric lymph node metastasis is a rare condition in carcinoma of the pancreatic head. Pancreas 2005; 31:88-92. [PMID: 15968254 DOI: 10.1097/01.mpa.0000168221.97967.98] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Pylorus preserving pancreatoduodenectomy (PPPD) was introduced to achieve a better functional result compared with the conventional Kausch-Whipple procedure (PD). In PPPD, peripyloric and perigastric lymphatic tissue is not removed compared with PD. The aim of this prospective study was to identify the frequency of peripyloric and perigastric lymph node metastases in ductal adenocarcinoma of the pancreatic head (PC). METHODS Fifty specimens following Kausch-Whipple procedure including partial gastric resection for PC were analyzed for peripyloric and perigastric lymph node metastases by a standardized clearing technique. All lymph nodes of the specimens were counted, discriminating between those not removed ("group A") and those removed ("group B") in pylorus preserving resection of the pancreatic head. Additionally, the duodenal wall and paraduodenal tissue at a potential duodenal resection margin 2 cm distal of the pylorus were investigated histologically. RESULTS Three of the 50 specimens (6%) carried peripyloric lymph node metastases, whereas 32 of the 50 specimens (64%) contained lymph node metastases in total. Four of 362 group A and 90 of 748 group B lymph nodes showed metastatic spread of the carcinoma. The 4 lymph node metastases in group A could be identified exclusively in 88 peripyloric lymph nodes but in none of the 274 perigastric lymph nodes at the lesser or greater curvature. In 2 of the 3 patients with peripyloric lymph node metastases, these lymph nodes were the only lymph nodes with metastatic involvement in the entire specimen. In 1 specimen, a small tumor nest of less than 2 mm in diameter was detected at a distance of less than 1 mm to the pylorus, although pyloric involvement was not suspected intraoperatively. The potential PPPD resection margin of the duodenal wall was not infiltrated by intramural tumor spread in any specimen. CONCLUSION In a minority of 6%, PC metastasizes in peripyloric lymph nodes. Lymph nodes of the lesser and greater curvature of the stomach are not involved in patients with PC. Thus, we conclude by the data of this prospective study that the limited benefits of the extended lymph node dissection in a conventional Kausch-Whipple resection are far outweighed by the disadvantages construed by this procedure.
Collapse
Affiliation(s)
- Berthold Gerdes
- Department of Surgery, Philipps-University of Marburg, Marburg, Germany.
| | | | | | | |
Collapse
|