Delayed gastric emptying following pancreaticoduodenectomy: Incidence, risk factors, and healthcare utilization

Table 1 Delayed gastric emptying classification based on International Study Group of Pancreatic Surgery definition

DGE grade	NGT required	Unable to tolerate solids orally by	Vomiting/distention	Use of prokinetics
A	4-7 d or reinsertion > POD 3	POD 7	±	±
B	8-14 d or reinsertion > POD 7	POD 14	+	+
C	14 d or reinsertion > POD 14	POD 21	+	+

Adapted from Wente et al[18]. NGT: Nasogastric tube; POD: Post-operative day; DGE: Delayed gastric emptying.

Table 2 Demographic and clinical characteristics of overall study population and patients with or without delayed gastric emptying

	Overall (n = 276)	No DGE group (n = 227)	DGE Group (n = 49)	P values
Age	63.2 ± 11.92	62.9 ± 11.95	64.6 ± 11.77	0.348
Gender				0.339
Male	135 (48.9%)	108 (47.6%)	27 (55.1%)
Female	141 (51.1%)	119 (52.4%)	22 (44.9%)
Co-morbid conditions
HTN	147 (53.3%)	119 (52.4%)	28 (57.1%)	0.568
COPD	13 (4.7%)	11 (4.8%)	2 (4.1%)	1
DM	67 (24.3%)	58 (25.6%)	9 (18.4%)	0.288
CRI	8 (2.9%)	6 (2.6%)	2 (4.1%)	0.635
History of pancreatitis	42 (15.2%)	36 (15.9%)	6 (12.2%)	0.557
History of ETOH use	122 (44.2%)	102 (44.9%)	20 (40.8%)	0.702
History of tobacco use	57 (20.7%)	49 (21.6%)	8 (16.3%)	0.390
BMI (mean ± SD)	26.7 ± 7.1	27.1 ± 7.28	25.6 ± 6.91	0.226
Presenting symptoms
Weight loss	140 (50.7%)	115 (50.7%)	25 (51.0%)	0.921
Anorexia	29 (10.5%)	24 (10.6%)	5 (10.2%)	0.873
Early satiety	17 (6.2%)	16 (7.0%)	1 (2.0%)	0.323
Nausea	83 (30.1%)	74 (32.6%)	9 (18.4%)	0.058
Vomiting	43 (15.6%)	40 (17.6%)	3 (6.1%)	0.048
Jaundice	122 (44.2%)	103 (45.4%)	19 (38.8%)	0.419
Preop albumin	4.0 ± 0.60	4.0 ± 0.59	3.8 ± 0.62	0.038
Preop total bilirubin	2.5 ± 4.29	2.7 ± 4.49	1.8 ± 3.11	0.139
Preop hemoglobin	12.8 ± 1.85	12.8 ± 1.87	12.7 ± 1.76	0.734
Preop Cr > 1.2	40 (14.5%)	31 (13.7%)	9 (18.4%)	0.378

DGE: Delayed gastric emptying; HTN: Hypertension; COPD: Chronic obstructive pulmonary disease; DM: Diabetes mellitus; CRI: Chronic renal insufficiency; ETOH: Ethanol; BMI: Body mass index; Preop: Pre-operative; Cr: Creatinine.

Table 3 Operative and pathology details

	Overall (n = 276)	No DGE group (n = 227)	DGE group (n = 49)	P values
ASA class				0.398
1	1 (0.4%)	1 (0.4%)	0 (0.0%)
2	78 (28.3%)	59 (26.0%)	19 (38.8%)
3	172 (62.3%)	144 (63.4%)	28 (57.1%)
4	16 (5.8%)	14 (6.2%)	2 (4.1%)
Operative time	452.1 ± 100.6	450.0 ± 100.87	461.6 ± 99.7	0.467
Procedure performed				0.169
Classic	55 (19.9%)	49 (21.6%)	6 (12.2%)
Pylorus-preserving	221 (80.1%)	178 (78.4%)	43 (87.8%)
EBL	515.7 ± 571.4	509.3 ± 533.59	544.0 ± 722.99	0.702
Transfusions	49 (17.8%)	37 (16.3%)	12 (24.5%)	0.178
Pancreas texture				0.264
Soft	144 (52.2%)	115 (50.7%)	29 (59.2%)
Firm/hard	121 (64.8%)	103 (45.4%)	18 (36.7%)
PD size	4.2 ± 2.29	4.3 ± 2.21	4.1 ± 2.65	0.612
PD anastomotic stent	117 (42.4%)	99 (43.6%)	18 (36.7%)	0.377
Vein resection	41 (14.9%)	34 (15.0%)	7 (14.3%)	0.902
Pathological diagnosis
PDAC	118 (42.8%)	103 (45.4%)	15 (30.6%)	0.058
Neuroendocrine	12 (4.3%)	11 (4.8%)	1 (2.0%)	0.383
Ampullary	38 (13.8%)	30 (13.2%)	8 (16.3%)	0.567
Cystic	41 (14.9%)	32 (14.1%)	9 (18.4%)	0.446
Pancreatitis	33 (12.0%)	28 (12.3%)	5 (10.2%)	0.677
Cholangiocarcinoma	7 (2.5%)	5 (2.2%)	2 (4.1%)	0.807
Other	27 (9.8%)	18 (7.9%)	9 (18.4%)	0.026
Fistula risk score
Negative (0 points)	34 (12.4%)	28 (12.4%)	6 (12.2%)	0.861
Low (1-2 points)	62 (22.6%)	58 (25.7%)	4 (8.2%)	0.008
Moderate (3-6 points)	138 (50.2%)	106 (46.9%)	32 (65.3%)	0.020
High (7-10 points)	30 (10.9%)	24 (10.6%)	6 (12.2%)	0.741

DGE: Delayed gastric emptying; ASA: American Society of Anesthesiologists; EBL: Estimated blood loss; PD: Pancreatic duct; PDAC: Pancreatic ductal adenocarcinoma.

Table 4 Rates of selected graded 90-d complication rates

	Overall (n = 276)	No DGE group (n = 227)	DGE group (n = 49)	P values
Frequency of other complications (any grade)
Patients with 0 complications	157 (56.9%)	157 (69.2%)	0 (0.0%)	< 0.001
Patients with 1 complication	51 (18.5%)	42 (18.5%)	9 (18.4%)	0.982
Patients with 2 complications	42 (15.2%)	18 (7.9%)	24 (49.0%)	< 0.001
Patients with 3 complications	11 (4.0%)	5 (2.2%)	6 (12.2%)	0.005
Patients with 4 complications	8 (2.9%)	5 (2.2%)	3 (6.1%)	0.153
Patients with ≥ 5 complications	7 (2.5%)	0 (0.0%)	7 (14.3%)	< 0.001
Severity of complications
Patients with any complication ≥ Grade 3	60 (21.7%)	38 (16.7%)	22 (44.9%)	< 0.001
Patients with any complication ≥ Grade 2	84 (30.4%)	47 (20.7%)	37 (75.5%)	< 0.001
Patients with any complication ≥ Grade 1	119 (43.1%)	70 (30.8%)	49 (100.0%)	< 0.001
90-d mortality	6 (2.2%)	4 (1.8%)	2 (4.1%)	0.289
Re-operations	12 (4.3%)	10 (4.4%)	2 (4.1%)	1
Readmissions	40 (14.5%)	33 (14.5%)	7 (14.3%)	1
Pancreatic fistula	64 (23.2%)	43 (18.9%)	21 (42.9%)	0.001
Grade A	39 (14.1%)	29 (12.8%)	10 (20.4%)
Grade B	19 (6.9%)	11 (4.8%)	8 (16.3%)
Grade C	6 (2.2%)	3 (1.3%)	3 (6.1%)
Bile leak	4 (1.4%)	1 (0.4%)	3 (6.1%)	0.019
Wound infection	20 (7.2%)	12 (5.3%)	8 (16.3%)	0.013
Wound dehiscence	3 (1.1%)	1 (0.4%)	2 (4.1%)	0.082
Intra-abdominal abscess	17 (6.2%)	9 (4.0%)	8 (16.3%)	0.012
Line infection	2 (0.7%)	2 (0.9%)	0 (0.0%)	0.033
Clostridium difficile	4 (1.4%)	1 (0.4%)	3 (6.1%)	0.019
Benign fluid collection	5 (1.8%)	2 (0.9%)	3 (6.1%)	0.041
Pneumonia	9 (3.3%)	5 (2.2%)	4 (8.2%)	0.056
Urinary tract infection	10 (3.6%)	5 (2.2%)	5 (10.2%)	0.018
Respiratory failure	9 (3.3%)	3 (1.3%)	6 (12.2%)	0.001
Encephalopathy	5 (1.8%)	1 (0.4%)	4 (8.2%)	0.004
Arrhythmia	16 (5.8%)	6 (2.6%)	10 (20.4%)	< 0.001
MI	4 (1.4%)	3 (1.3%)	1 (2.0%)	0.545
DVT	2 (0.7%)	2 (0.9%)	0 (0%)	1
PE	2 (0.7%)	2 (0.9%)	0 (0%)	1
Hemorrhage	4 (1.4%)	3 (1.3%)	1 (2.0%)	0.545
Renal failure	5 (1.8%)	3 (1.3%)	2 (4.1%)	0.216
Hepatic failure	1 (0.4%)	0 (0.0%)	1 (2.0%)	0.182
SMV/PV Thrombosis	8 (2.9%)	6 (2.6%)	2 (4.1%)	0.635

DGE: Delayed gastric emptying; MI: Myocardial infarction; DVT: Deep venous thrombosis; PE: Pulmonary embolism; SMV/PV: Superior mesenteric vein, portal vein.

Table 5 Multivariate analysis of the characteristics of patients with Pancreaticoduodenectomy

	Odds ratio (95%CI)	P value
Pancreatic fistula	3.39 (1.35-8.52)	0.009
Intra-abdominal abscess	1.51 (1.03-2.22)	0.035
PDAC diagnosis	1.01 (0.524-1.94)	0.982
Moderate/high FRS	0.99 (0.98-1.01)	0.463

PDAC: Pancreatic ductal adenocarcinoma; FRS: Fistula risk score.