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Jiménez-Romero C, de Juan Lerma A, Marcacuzco Quinto A, Caso Maestro O, Alonso Murillo L, Rioja Conde P, Justo Alonso I. Risk factors for delayed gastric emptying after pancreatoduodenectomy: a 10-year retrospective study. Ann Med 2025; 57:2453076. [PMID: 39817563 PMCID: PMC11740295 DOI: 10.1080/07853890.2025.2453076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Revised: 12/06/2024] [Accepted: 12/20/2024] [Indexed: 01/18/2025] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication of pancreatoduodenectomy (PD) and is associated with prolonged hospital stay, readmission, increased hospital costs and decreased quality of life. However, the pathophysiology of DGE remains unclear. METHODS This is a retrospective study of patients who underwent PD for pancreatic or periampullary tumours. All these patients were operated between January 2012 and February 2023. The patients were divided into four groups according to the development of DGE after PD: No DGE, DGE grade A, DGE grade B and DGE grade C. The groups were compared in terms of outcomes and complications. We also analysed the preoperative and perioperative risk factors for DGE development. RESULTS Between January 2012 and February 2023, a total of 250 patients underwent PD. These patients were divided into four groups: No DGE (n = 152); DGE grade A (n = 42); DGE grade B (n = 45); and DGE grade C (n = 11). The incidence of the postoperative pancreatic fistulas (POPFs) grade B/C was significantly higher in the DGE grade C group (p < .001), and the rates of post-pancreatectomy haemorrhage (p = .004) and reoperation (p < .001) were significantly higher in the DGE grade B/C groups. A significantly higher rate of grade III-IV Clavien-Dindo complications (p < .001), longer intensive care unit (p < .001) and longer hospital stays (p < .001) were observed in the DGE grade C group; and 90-day mortality (p < .001) and morbidity (p < .001) were significantly higher in the DGE grade B/C groups. Multivariate analysis demonstrated that the POPF grade B/C was a risk factor of DGE grade B/C (OR: 9.147; 95%CI: 4.125-20.281; p < .001). CONCLUSIONS POPF B/C is a risk factor for grade B/C DGE. Prevention of surgical complications and early treatment could contribute to the decreased incidence of DGE.
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Affiliation(s)
- Carlos Jiménez-Romero
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Agustín de Juan Lerma
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Oscar Caso Maestro
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Laura Alonso Murillo
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Paula Rioja Conde
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Iago Justo Alonso
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
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Duan P, Sun L, Kou K, Li XR, Zhang P. Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2024; 23:449-457. [PMID: 37980179 DOI: 10.1016/j.hbpd.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 10/31/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE. DATA SOURCES Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles. RESULTS In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE. CONCLUSIONS Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.
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Affiliation(s)
- Peng Duan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Lu Sun
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Kai Kou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Xin-Rui Li
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, China
| | - Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China.
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Huang K, Qian T, Chen W, Bai X, Gao S, Shen Y, Zhang M, Ma T, Liang T. Clinical Significance and Risk Factors of Nonalcoholic Fatty Liver Diseases After Whipple Procedure. J Surg Res 2024; 302:706-714. [PMID: 39214062 DOI: 10.1016/j.jss.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 05/30/2024] [Accepted: 07/01/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION The etiology and management of nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD) remain unclear. This study aimed to investigate the risk factors and outcomes of NAFLD after PD (PD-NAFLD). METHODS Patients who underwent PD at our institution between June 2019 and September 2021 were enrolled in the study. The clinical manifestations and outcomes of the patients with PD-NAFLD were evaluated. Multivariable analysis was used to identify risk factors for PD-NAFLD. RESULTS Of the 407 patients enrolled, PD-NAFLD was identified in 54 (13.2%). The median time of onset of PD-NAFLD was 72.5 (51.5-171.25) d postoperatively. Twenty-four patients (44.4%) recovered completely within 36 mo postoperatively. Adjuvant chemotherapy was administered in 147 malignant cases, and patients with PD-NAFLD encountered delay or discontinuation of chemotherapy more frequently than those without PD-NAFLD (55.9% versus 30.1%, P = 0.006). Multivariable analysis identified female sex, high body mass index, and neoadjuvant chemotherapy as independent risk factors for PD-NAFLD. CONCLUSIONS PD-NAFLD is a common complication of PD. Female sex, high body mass index, and neoadjuvant chemotherapy may be associated with the development of PD-NAFLD. PD-NAFLD may interrupt the delivery of adjuvant chemotherapy in patients with malignant tumors.
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Affiliation(s)
- Kaiquan Huang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Qian
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yan Shen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China.
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China; Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China; Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China; Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China; Cancer Center, Zhejiang University, Hangzhou, China.
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Christodoulidis G, Kouliou MN, Koumarelas KE, Argyriou K, Karali GA, Tepetes K. Billroth II anastomosis combined with brown anastomosis reduce reflux gastritis in gastric cancer patients. World J Methodol 2024; 14:89709. [PMID: 38577202 PMCID: PMC10989415 DOI: 10.5662/wjm.v14.i1.89709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/21/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The surgeon performing a distal gastrectomy, has an arsenal of reconstruction techniques at his disposal, Billroth II among them. Braun anastomosis performed during a Billroth II procedure has shown evidence of superiority over typical Billroth II, in terms of survival, with no impact on postoperative morbidity and mortality. AIM To compare Billroth II vs Billroth II and Braun following distal gastrectomy, regarding their postoperative course. METHODS Patients who underwent distal gastrectomy during 2002-2021, were separated into two groups, depending on the surgical technique used (Billroth II: 74 patients and Billroth II and Braun: 28 patients). The daily output of the nasogastric tube (NGT), the postoperative day that NGT was removed and the day the patient started per os feeding were recorded. Postoperative complications were at the same time noted. Data were then statistically analyzed. RESULTS There was difference in the mean NGT removal day and the mean start feeding day. Mean total postoperative NGT output was lower in Braun group (399.17 mL vs 1102.78 mL) and it was statistically significant (P < 0.0001). Mean daily postoperative NGT output was also statistically significantly lower in Braun group. According to the postoperative follow up 40 patient experienced bile reflux and alkaline gastritis from the Billroth II group, while 9 patients who underwent Billroth II and Braun anastomosis were presented with the same conditions (P < 0.05). CONCLUSION There was evidence of superiority of Billroth II and Braun vs typical Billroth II in terms of bile reflux, alkaline gastritis and NGT output.
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Affiliation(s)
| | | | | | - Konstantinos Argyriou
- Department of Gastroenterology, University Hospital of Larissa, Larissa 41334, Greece
| | | | - Konstantinos Tepetes
- Department of General Surgery, University Hospital of Larissa, Larissa 41110, Greece
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Pathak N, Naidu CS, Routh D, Rao PP, Sharma S, Singh AK, Ranjan P, Trehan V, Gaur A, Kulkarni SV. The Effect of Braun’s Enteroenterostomy on Delayed Gastric Emptying in Binding Pancreaticogastrostomy Following Pancreaticoduodenectomy: a Comparative Study and Review of Literature. Indian J Surg 2022; 84:471-475. [DOI: 10.1007/s12262-021-03223-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/10/2021] [Indexed: 02/05/2023] Open
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Komokata T, Nuruki K, Tada N, Imada R, Aryal B, Kaieda M, Sane S. An invaginated pancreaticogastrostomy following subtotal stomach-preserving pancreaticoduodenectomy: A prospective observational study. Asian J Surg 2021; 44:1510-1514. [PMID: 33865665 DOI: 10.1016/j.asjsur.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/04/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Postoperative pancreatic fistula (POPF) leads to life-threatening complications after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) often adopted as a reconstruction technique after PD to prevent POPF. Delayed gastric emptying (DGE) following PD is the most common complication that compromises the quality of life. Subtotal stomach-preserving PD (SSPPD) preserves the pooling ability of the stomach and minimize the occurrence of DGE. This study aimed to describe our PG technique following SSPPD and evaluate the perioperative outcomes. METHODS The study included patients who underwent PG following SSPPD from August 2013 to July 2020 at our institution. An invaginated PG was performed by one-layer eight interrupted sutures with a lost stent. Patients' demographics and perioperative outcomes were documented. RESULTS This technique was applied in 72 patients with a median age of 75 years. The median operative time was 342 min. The clinically relevant POPF, DGE and post-pancreatectomy hemorrhage was 4 (5.6%), 5 (6.9%), and 10 (13.9%), respectively. Although the drain fluid amylase concentration on postoperative day 3 was significantly higher in clinically relevant POPF (CR-POPF) positive group (median, 2006 U/L vs. 74 U/L in CR-POPF negative group, p = 0.002), none of the risk factors including disease pathology, pancreatic duct diameter, texture of pancreas and excessive blood loss were significantly associated with CR-POPF. Other morbidity ≥ Clavien-Dindo classification II occurred in 29 patients (40.3%). The 90-days operative mortality was two (2.8%). CONCLUSIONS This novel method of one-layer invaginated PG following SSPPD is safe and dependable procedure with acceptable morbidity and mortality.
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Affiliation(s)
- Teruo Komokata
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan.
| | - Kensuke Nuruki
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Nobuhiro Tada
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Ryo Imada
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Bibek Aryal
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Mamoru Kaieda
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Soji Sane
- Department of Surgery, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
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A Systematic Review and Network-Meta-Analysis of Gastro-Enteric Reconstruction Techniques Following Pancreatoduodenectomy to Reduce Delayed Gastric Emptying. World J Surg 2021; 44:2314-2322. [PMID: 32166469 DOI: 10.1007/s00268-020-05459-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION This network meta-analysis aimed to identify the reconstruction technique associated with lowest rates of DGE following pancreatoduodenectomy (PD) from randomised controlled trials (RCTs). METHODS A systematic literature search of PubMed, Embase and MEDLINE databases was carried out using the PRISMA framework to identify all RCTs comparing reconstruction techniques of gastrojejunostomy after PD, with overall DGE as the primary endpoint. The primary outcome measure was overall DGE. Secondary outcomes were grade B/C DGE, duration of nasogastric tube, time to solid food intake, overall and grade B/C pancreatic fistula, bile leaks, reoperation, length of hospital stay and in-hospital mortality. RESULTS The search strategy identified eight RCTs including 761 patients. Six RCTs compared antecolic (n = 291 patients) and retrocolic Billroth II (n = 289 patients) reconstruction (n = 6 studies), and two RCTs compared antecolic Billroth II (n = 92 patients) and Roux-en-Y (n = 89 patients) reconstruction. Overall, antecolic Billroth II ranked best for overall and grade B/C DGE, bile leak, surgical site infection, length of stay and in-hospital mortality. Roux-en-Y was best for overall and grade B/C pancreatic fistula. CONCLUSION Antecolic Billroth II gastroenteric reconstruction is associated with the lowest rates of delayed gastric emptying after PD amongst the currently available techniques of gastrojejunostomy reconstructions.
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Gunadi, Munandar MA, Fauzi AR, Simanjaya S, Damayanti W. Gastric stricture following corrosive agent ingestion: A case report. Int J Surg Case Rep 2020; 75:539-542. [PMID: 32994146 PMCID: PMC7567050 DOI: 10.1016/j.ijscr.2020.09.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/07/2020] [Accepted: 09/07/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Gastric stricture due to corrosive ingestion is a rare cause of obstruction in the upper gastrointestinal tract in children. However, only a few reports highlight the management of the stricture of the gastric antrum and pylorus, i.e. gastric outlet obstruction (GOO) due to corrosive ingestion, particularly in children. PRESENTATION OF CASE We report a 1-year-old male who presented with chief complaints of upper abdominal pain and profuse vomiting after accidentally ingesting sulfuric acid one month prior. On physical examination, minimal epigastric distension was found. Endoscopic examination showed oesophagitis, erosive gastritis, multiple gastric ulcers and suspicion of pyloric stricture. We decided to perform an exploratory laparotomy and found severe strictures from the major curvature to the gastric pylorus. Subsequently, we conducted gastrojejunostomy and Braun anastomosis. The patient was discharged on the eighth postoperative day uneventfully. DISCUSSION Endoscopy is a reliable technique for assessing upper digestive tract mucous membranes after caustic agent ingestion because it helps in making a definitive diagnosis, especially to define the anatomic location and injury severity. The timing and type of surgery for GOO is controversial. We performed Braun anastomosis in addition to gastrojejunostomy because of several advantages over other surgical methods. CONCLUSION We recommend choosing an appropriate supporting examination to precisely diagnose gastric stricture due to corrosive ingestion. Gastojejunostomy and Braun anastomosis show a good outcome for gastric stricture due to corrosive ingestion, particularly in children.
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Affiliation(s)
- Gunadi
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia.
| | - Mukhamad Arif Munandar
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Aditya Rifqi Fauzi
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Susan Simanjaya
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
| | - Wahyu Damayanti
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, 55281, Indonesia
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Learning Curve From 450 Cases of Robot-Assisted Pancreaticoduocectomy in a High-Volume Pancreatic Center: Optimization of Operative Procedure and a Retrospective Study. Ann Surg 2019; 274:e1277-e1283. [PMID: 31651533 DOI: 10.1097/sla.0000000000003664] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We aimed to describe our experience and the learning curve of 450 cases of robot-assisted pancreaticoduodenectomy (RPD) and optimize the surgical process so that our findings can be useful for surgeons starting to perform RPD. SUMMARY BACKGROUND DATA Robotic surgical systems were first introduced 20 years ago. Pancreaticoduodenectomy (PD) is a challenging surgery because of its technical difficulty. RPD may overcome some of these difficulties. METHODS The medical records of 450 patients who underwent RPD between May 2010 and December 2018 at the Shanghai Ruijin Hospital were retrospectively analyzed. Operative times and estimated blood loss (EBL) were analyzed and the learning curve was determined. A cumulative sum (CUSUM) analysis was used to identify the inflexion points. Other postoperative outcomes, postoperative complications, and long-term follow-up were also analyzed. RESULTS Operative time improved gradually over time from 405.4 ± 112.9 minutes (case 1-50) to 273.6 ± 70 minutes (case 301-350) (P < 0.001). EBL improved from 410 ± 563.5 mL (case 1-50) to 149.0 ± 103.3 mL (case 351-400) (P < 0.001). According to the CUSUM curve, there were 3 phases in the RPD learning curve. The inflexion points were around cases 100 and 250. The incidence of pancreatic leak in the last 350 cases was significantly lower than that in the first 100 cases (30.0% vs 15.1%, P = 0.003). CONCLUSIONS RPD is safe and feasible for selected patients. Operative and oncologic outcomes were much improved after experience of 250 cases. Our optimization of the surgical process may have also contributed to this. Future prospective and randomized studies are needed to confirm our results.
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Jung JP, Zenati MS, Dhir M, Zureikat AH, Zeh HJ, Simmons RL, Hogg ME. Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy. JAMA Surg 2019; 153:918-927. [PMID: 29998288 DOI: 10.1001/jamasurg.2018.2089] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Technical proficiency at robotic pancreaticoduodenectomy (RPD) and video assessment are promising tools for understanding postoperative outcomes. Delayed gastric emptying (DGE) remains a major driver of cost and morbidity after pancreaticoduodenectomy. Objective To determine if technical variables during RPD are associated with postoperative DGE. Design, Setting, and Participants A retrospective study was conducted of technical assessment performed in all available videos (n = 192) of consecutive RPDs performed at a single academic institution from October 3, 2008, through September 27, 2016. Exposures Video review of gastrojejunal anastomosis during RPD. Main Outcomes and Measures Delayed gastric emptying was classified according to International Study Group of Pancreatic Surgery criteria. Video analysis reviewed technical variables specific in the construction of the gastrojejunal anastomosis. Using multivariate analysis, DGE was correlated with known patient variables and technical variables, individually and combined. Results Of 410 RPDs performed, video was available for 192 RPDs (80 women and 112 men; mean [SD] age, 65.7 [11.1] years). Delayed gastric emptying occurred in 41 patients (21.4%; grade A, 15; grade B, 14; and grade C, 12). Patient variables contributing to DGE on multivariate analysis were advanced age (odds ratio [OR] 1.11; 95% CI, 1.05-1.16; P < .001), small pancreatic duct size (OR, 0.84; 95% CI, 0.72-0.98; P = .03), and postoperative pseudoaneurysm (OR, 17.29; 95% CI, 2.34-127.78; P = .005). However, technical variables contributing to decreased DGE on multivariate analysis included the flow angle (within 30° of vertical) between the stomach and efferent jejunal limb (OR, 0.25; 95% CI, 0.08-0.79; P = .02), greater length of the gastrojejunal anastomosis (OR, 0.40; 95% CI, 0.20-0.77; P = .006), and a robotic-sewn anastomosis (robotic suture vs stapler: OR, 0.30; 95% CI, 0.09-0.95; P = .04). Conclusions and Relevance This study examines modifiable technical factors through the use of review of video obtained at the time of operation and suggests ways by which the surgical construction of the gastrojejunal anastomosis during RPD may reduce the incidence of DGE as a framework for prospective quality improvement.
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Affiliation(s)
- Jae Pil Jung
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mazen S Zenati
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mashaal Dhir
- Department of Surgery, State University of New York Upstate Medical University, Syracuse
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard L Simmons
- Division of Surgical Research, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Schorn S, Demir IE, Vogel T, Schirren R, Reim D, Wilhelm D, Friess H, Ceyhan GO. Mortality and postoperative complications after different types of surgical reconstruction following pancreaticoduodenectomy-a systematic review with meta-analysis. Langenbecks Arch Surg 2019; 404:141-157. [PMID: 30820662 DOI: 10.1007/s00423-019-01762-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 02/06/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy/PD is a technically demanding pancreatic resection. Options of surgical reconstruction include (1) the child reconstruction defined as pancreatojejunostomy/PJ followed by hepaticojejunostomy/HJ and the gastrojejunostomy/GJ "the standard/s-Child," (2) the s-child reconstruction with an additional Braun enteroenterostomy "BE-Child," or (3) Isolated-Roux-En-Y-pancreaticojejunostomy "Iso-Roux-En-Y," in which the pancreas anastomosis is reconstructed in a separate loop after the GJ. Yet, the impact of these reconstruction methods on patients' outcome has not been sufficiently compared in a systematic manner. METHODS A systematic review and meta-analysis were conducted according to the Preferred-Reporting-Items-for-Systematic-review-and-Meta-Analysis/PRISMA-guidelines by screening Pubmed/Medline, Scopus, Cochrane Library and Web-of-Science. Articles meeting predefined criteria were extracted and meta-analysis was performed. RESULTS Nineteen studies were identified comparing BE-Child or Isolated-Roux-En-Y vs. s-Child. Compared to s-Child neither BE-Child (p = 0.43) nor Iso-Roux-En-Y (p = 0.94) displayed an impact on postoperative mortality, whereas BE-Child showed less postoperative complications (p = 0.02). BE-Child (p = 0.15) and Iso-Roux-En-Y (p = 0.61) did not affect postoperative pancreatic fistula/POPF in general, but BE-Child was associated with a decrease of clinically relevant POPF (p = 0.005), clinically relevant delayed gastric emptying/DGE B/C (p = 0.004), bile leaks (p = 0.01), and hospital stay (p = 0.06). BE-Child entailed also an increased operation time (p = 0.0002) with no impact on DGE A/B/C, hemorrhage, surgical site infections and pulmonary complications. CONCLUSION BE-Child is associated with a decreased risk for postoperative complications, particularly a decreased risk for clinically relevant DGE, POPF, and bile leaks, whereas Iso-Roux-En-Y does not seem to affect the clinical course after PD. Therefore, BE seems to be a valuable surgical method to improve patients' outcome after PD.
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Affiliation(s)
- Stephan Schorn
- School of Medicine, Klinikum rechts der Isar, Department of Surgery, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Ihsan Ekin Demir
- School of Medicine, Klinikum rechts der Isar, Department of Surgery, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Thomas Vogel
- School of Medicine, Klinikum rechts der Isar, Department of Surgery, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rebekka Schirren
- School of Medicine, Klinikum rechts der Isar, Department of Surgery, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Daniel Reim
- School of Medicine, Klinikum rechts der Isar, Department of Surgery, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Dirk Wilhelm
- School of Medicine, Klinikum rechts der Isar, Department of Surgery, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Helmut Friess
- School of Medicine, Klinikum rechts der Isar, Department of Surgery, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Güralp Onur Ceyhan
- School of Medicine, Klinikum rechts der Isar, Department of Surgery, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
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12
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Zhou Y, Hu B, Wei K, Si X. Braun anastomosis lowers the incidence of delayed gastric emptying following pancreaticoduodenectomy: a meta-analysis. BMC Gastroenterol 2018; 18:176. [PMID: 30477442 PMCID: PMC6258435 DOI: 10.1186/s12876-018-0909-5] [Citation(s) in RCA: 8] [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: 08/08/2017] [Accepted: 11/14/2018] [Indexed: 12/19/2022] Open
Abstract
Background Delayed gastric emptying (DGE) is one of the most frequent complications following pancreaticoduodenectomy. This meta-analysis aimed to evaluate the impact of Braun enteroenterostomy on DGE following pancreaticoduodenectomy. Methods A systematic review of the literature was performed to identify relevant studies. Statistical analysis was carried out using Review Manager software 5.3. Results Eleven studies involving 1672 patients (1005 in Braun group and 667 in non-Braun group) were included in the meta-analysis. Braun enteroenterostomy was associated with a statistically significant reduction in overall DGE (odds ratios [OR] 0.32, 95% confidence intervals [CI] 0.24 to 0.43; P <0.001), clinically significant DGE (OR 0.27, 95% CI 0.15 to 0.51; P <0.001), bile leak (OR 0.50, 95% CI 0.29 to 0.86; P = 0.01), and length of hospital stay (weighted mean difference -1.66, 95% CI -2.95 to 00.37; P = 0.01). Conclusions Braun enteroenterostomy minimizes the rate and severity of DGE following pancreaticoduodenectomy.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University, Xiamen, China.
| | - Bin Hu
- Department of Clinical Laboratory Medicine, First affiliated Hospital of Xiamen University, Xiamen, China
| | - Kongyuan Wei
- Department of General Surgery, First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaoying Si
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University, Xiamen, China
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Addition of Mesh Reinforcement for Pancreatic Stump and Braun Enteroenterostomy after Pancreaticoduodenectomy: A Single Institution Experience. Am Surg 2018. [DOI: 10.1177/000313481808400320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The morbidity rate after pancreaticoduodenectomy (PD) remains high and a modified digestive reconstruction may affect the postoperative complications. We investigated a new modification of PD by adding mesh reinforcement for the pancreatic stump and Braun enteroenterostomy with the aim of reducing postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE), respectively. From November 2010 to April 2015, 81 consecutive patients who underwent modified PD were retrospectively reviewed. The clinically relevant POPF and DGE rates were 4.9 and 6.1 per cent, respectively. The overall mortality rate was 2.4 per cent. The incidence of overall postoperative complications was 46.9 per cent, with 17.2 per cent considered as major complications (Clavien grades 3–5). The median postoperative length of hospital stay was 17 days (range 10–119 days). For patients who had major complications, median postoperative length of hospital stay increased significantly (22 vs 13 days, P = 0.001), as compared with those patients with no complications. The new modified digestive reconstruction after PD seems safe and reliable with low clinically relevant POPF and DGE rates. Further prospective controlled trials are essential to support these results.
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Kobayashi S, Koizumi S, Hatori T, Segami K, Hoshino H, Otsubo T. The Vertical Array Reconstruction Technique in Pylorus-Preserving Pancreatoduodenectomy. Dig Surg 2018; 35:469-473. [PMID: 29316561 DOI: 10.1159/000485847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/27/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND/AIMS We describe a new reconstruction method of duodenojejunal anastomosis, the "vertical array reconstruction" (VAR) technique, following pylorus-preserving pancreatoduodenectomy (PPPD). METHODS The VAR technique aligns the stomach, duodenum, and jejunal loop vertically along the body's longitudinal axis. It was performed in 120 consecutive patients (between June 2008 and October 2015) who underwent PPPD. We evaluated the incidence of delayed gastric emptying (DGE). RESULTS The incidence of DGE was 1.7% (n = 2). The proposed clinical grading classified these 2 cases of DGE as grade B. There was no DGE related to pancreatic fistula. The median duration to starting a solid diet was 3 days (range 3-5 days). The median operative time was 450 min (range 391-550 min). CONCLUSION The VAR technique allows the upper digestive tract to be aligned linearly and can minimize the risk of DGE after PPPD.
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Affiliation(s)
- Shinjiro Kobayashi
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Satoshi Koizumi
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takashi Hatori
- International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Kouhei Segami
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hiroyuki Hoshino
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takehito Otsubo
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
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Tsutaho A, Nakamura T, Asano T, Okamura K, Tsuchikawa T, Noji T, Nakanishi Y, Tanaka K, Murakami S, Kurashima Y, Ebihara Y, Shichinohe T, Ito YM, Hirano S. Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Pancreaticoduodenectomy: Result of a Propensity Score Matching. J Gastrointest Surg 2017; 21:1635-1642. [PMID: 28819791 DOI: 10.1007/s11605-017-3540-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common morbidities of pancreaticoduodenectomy (PD). The aim of this study was to clarify whether the incidence of DGE can be reduced by side-to-side gastric greater curvature-to-jejunal anastomosis in subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). METHODS The clinical data of 253 patients who had undergone PD were examined. Of a total of 188 patients who had undergone SSPPD, a gastrojejunostomy (GJ) was performed with end-to-side anastomosis in 87 patients (SSPPD-ETS group), and a GJ was performed with a greater curvature side-to-jejunal side anastomosis in 101 patients (SSPPD-STS group). After propensity score matching, the matched cohort consisted of 74 patients in each group. The postoperative data were evaluated according to the International Study Group of Pancreatic Surgery grade of DGE. RESULTS The total incidence of DGE was 9.4% in the SSPPD-ETS group and 4% in the SSPPD-STS group, with no significant difference (p = 0.1902). A significant difference was observed between the two groups in the incidence of DGE grade C (p = 0.0426). CONCLUSIONS The incidence of total DGE was not reduced statistically in the STS group compared with the ETS group, but reduced DGE grade C. Side-to-side anastomosis might be associated with a reduced incidence of DGE grade C.
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Affiliation(s)
- Akio Tsutaho
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan.
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yoichi M Ito
- Department of Biostatistics, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
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Panwar R, Pal S. The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int 2017; 16:353-363. [PMID: 28823364 DOI: 10.1016/s1499-3872(17)60037-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 02/03/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence. DATA SOURCE We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles. RESULTS Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0-100%; median: 18.7%) and 14.3% (range: 1.8%-58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Braun's entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies. CONCLUSIONS ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.
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Affiliation(s)
- Rajesh Panwar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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17
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Murata Y, Tanemura A, Kato H, Kuriyama N, Azumi Y, Kishiwada M, Mizuno S, Usui M, Sakurai H, Isaji S. Superiority of stapled side-to-side gastrojejunostomy over conventional hand-sewn end-to-side gastrojejunostomy for reducing the risk of primary delayed gastric emptying after subtotal stomach-preserving pancreaticoduodenectomy. Surg Today 2017; 47:1007-1017. [PMID: 28337543 PMCID: PMC5493708 DOI: 10.1007/s00595-017-1504-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/25/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND PURPOSE Delayed gastric emptying (DGE) is the most common complication following pancreaticoduodenectomy (PD). The clinical efficacy of stapled side-to-side anastomosis using a laparoscopic stapling device during alimentary reconstruction in PD is not well understood and its superiority over conventional hand-sewn end-to-side anastomosis remains controversial. The objective of this study was to evaluate the effectiveness of the stapled side-to-side anastomosis in preventing the development of DGE after PD. METHODS The subjects of this retrospective study were 137 patients who underwent pancreaticoduodenectomy, as subtotal stomach-preserving pancreaticoduodenectomy (SSPPD; n = 130), or conventional whipple procedure (n = 7) with Child reconstruction, between January 2010 and May 2014. The patients were divided into two groups according to whether they had had a stapled side-to-side anastomosis (SA group; n = 57) or a conventional hand-sewn end-to-side anastomosis (HA group; n = 80). RESULTS SA reduced the operative time (SA vs. HA: 508 vs. 557 min, p = 0.028) and the incidence of delayed gastric emptying (SA vs. HA: 21.1 vs. 46.3%, p = 0.003) and was associated with shorter hospitalization (SA vs. HA: 33 vs. 39.5 days, p = 0.007). In this cohort, SA was the only significant factor contributing to a reduction in the incidence of DGE (p = 0.002). CONCLUSIONS Stapled side-to-side gastrojejunostomy reduced the operative time and the incidence of DGE following PD with Child reconstruction, thereby also reducing the length of hospitalization.
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Affiliation(s)
- Yasuhiro Murata
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Akihiro Tanemura
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Kato
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naohisa Kuriyama
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yoshinori Azumi
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masashi Kishiwada
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masanobu Usui
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Sakurai
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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18
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Glowka TR, Webler M, Matthaei H, Schäfer N, Schmitz V, Kalff JC, Standop J, Manekeller S. Delayed gastric emptying following pancreatoduodenectomy with alimentary reconstruction according to Roux-en-Y or Billroth-II. BMC Surg 2017; 17:24. [PMID: 28320386 PMCID: PMC5359898 DOI: 10.1186/s12893-017-0226-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 03/16/2017] [Indexed: 02/06/2023] Open
Abstract
Background Delayed gastric emptying (DGE) remains the most frequent complication following pancreatoduodenectomy (PD) with published incidences as high as 61%. The present study investigates the impact of bowel reconstruction techniques on DGE following classic PD (Whipple-Kausch procedure) with pancreatogastrostomy (PG). Methods We included 168 consecutive patients who underwent PD with PG with either Billroth II type (BII, n = 78) or Roux-en-Y type reconstruction (ReY, n = 90) between 2004 and 2015. Excluded were patients with conventional single loop reconstruction after pylorus preserving procedures. DGE was classified according to the 2007 International Study Group of Pancreatic Surgery definition. Patients were analyzed regarding severity of DGE, morbidity and mortality, length of hospital stay and demographic factors. Results No difference was observed between BII and ReY regarding frequency of DGE. Overall rate for clinically relevant DGE was 30% (ReY) and 26% (BII). BII and ReY did not differ in terms of demographics, morbidity or mortality. DGE significantly prolongs ICU (four vs. two days) and hospital stay (20.5 vs. 14.5 days). Risk factors for DGE development are advanced age, retrocolic reconstruction, postoperative hemorrhage and major complications. Conclusions The occurrence of DGE can not be influenced by the type of alimentary reconstruction (ReY vs. BII) following classic PD with PG. Old age and major complications could be identified as important risk factors in multivariate analysis. Trial registration German Clinical Trials Register (DRKS) DRKS00011860. Registered 14 March 2017.
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Affiliation(s)
- Tim R Glowka
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
| | - Markus Webler
- Department of Orthopedic and Trauma Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Hanno Matthaei
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Nico Schäfer
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Volker Schmitz
- Department of Gastroenterology, St. Marienwörth Hospital, Mühlenstr. 39, 55543, Bad Kreuznach, Germany
| | - Jörg C Kalff
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
| | - Jens Standop
- Department of Surgery, Maria Stern Hospital, Am Anger 1, 53424, Remagen, Germany
| | - Steffen Manekeller
- Department of Surgery, University of Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany
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Barreto SG, Windsor JA. Does the Ileal Brake Contribute to Delayed Gastric Emptying After Pancreatoduodenectomy? Dig Dis Sci 2017; 62:319-335. [PMID: 27995402 DOI: 10.1007/s10620-016-4402-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/29/2016] [Indexed: 12/18/2022]
Abstract
Delayed gastric emptying (DGE) represents a significant cause for morbidity following pancreatoduodenectomy (PD). At a time when no specific and universally effective therapy exists to treat these patients, elucidating other potential (preventable or treatable) mechanisms for DGE is important. The aim of the manuscript was to test the hypothesis that ileal brake contributes to DGE in PD patients receiving jejunal tube feeding by systematically reviewing experimental and clinical literature. A series of clinically relevant questions were framed related to the potential role of the ileal brake in development of DGE post-PD and formed the basis of targeted literature searches. A comprehensive search of major reference databases from January 1980 to June 2015 was carried out which included human and animal studies. The ileal brake is a feedback loop neurally mediated by the vagus and sympatho-adrenergic pathways and hormonally by gut peptides including glucagon-like peptide-1, peptide YY (PYY), and neurotensin. The most potent stimulus for this inhibitory reflex is intra-ileal fat. There is evidence to indicate the role of an inhibitory reflex (on gastric emptying) mediated by PYY and CCK which, in turn, are stimulated by nutrient delivery into the distal small intestine providing indirect support to the role of ileal brake in post-PD DGE. The ileal brake is a likely factor contributing to DGE post-PD. While there has been no study to directly test this hypothesis, there is compelling indirect evidence to support it. Designing a trial that would answer such a question appears to be the most appropriate way forward.
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Affiliation(s)
- Savio G Barreto
- Hepatobiliary and Oesophagogastric Unit, Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, SA, Australia
| | - John A Windsor
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand.
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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20
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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; 23:364-372. [PMID: 27038406 DOI: 10.1002/jhbp.349] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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.
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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
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21
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Huang MQ, Li M, Mao JY, Tian BL. Braun enteroenterostomy reduces delayed gastric emptying: A systematic review and meta-analysis. Int J Surg 2015; 23:75-81. [PMID: 26384836 DOI: 10.1016/j.ijsu.2015.09.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 08/26/2015] [Accepted: 09/07/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND It remains controversial whether the additional Braun enteroenterostomy (BEE) is necessary in decreasing delayed gastric emptying (DGE) following pancreaticoduodenectomy (PD). This meta-analysis aims to assess the efficacy of the additional BEE in reducing DGE after PD. METHODS PubMed, EMBASE, Science Citation Index and The Cochrane Library were searched to identify relevant studies. Articles published before May 15, 2015 comparing BEE with traditional gastrojejunostomy during PD were selected. The evaluated end points consist of intro-operative outcomes as well as postoperative complications. RESULTS Seven observational clinical studies that recruited 1401 patients were included. This meta-analysis indicated that the occurrence of DGE was lower in Braun group (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.15 to 0.60; P = 0.0007). Overall morbidity (OR, 0.61; 95%CI, 0.47 to 0.80; P = 0.0003) and the length of hospital stay (LOS) (weighted mean difference [WMD], -1.80; 95%CI, -3.4 to -0.18; p = 0.03) were also in favor of the Braun group. However, Braun group had no advantage over Non-Braun group in terms of intra-operative blood loss, mortality, pancreatic fistula, bile Leakage and intra-abdominal abscess. CONCLUSION The additional of BEE plays an important role in reducing DGE, overall morbidity and LOS.
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Affiliation(s)
- Ming-quan Huang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mou Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jing-yu Mao
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bo-le Tian
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.
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Xu B, Zhu YH, Qian MP, Shen RR, Zheng WY, Zhang YW. Braun Enteroenterostomy Following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015; 94:e1254. [PMID: 26266356 PMCID: PMC4616697 DOI: 10.1097/md.0000000000001254] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Pancreaticoduodenectomy (PD) holds high postoperative morbidity. How to resolve this issue is challenged. An additional anastomosis (Braun enteroenterostomy) following PD may decrease the postoperative morbidity, but holds conflicting results. The objective of this study is to investigate the advantages and disadvantages of Braun enteroenterostomy in PD.Clinical studies compared perioperative outcomes between the Braun group and the non-Braun group following PD before December 21, 2014 were retrieved and filtered from PubMed, EMBASE, Web of Science, the Cochrane Library, and Chinese electronic databases (VIP database, WanFang database, and CNKI database). Relevant data were extracted according to predesigned sheets. Blood loss, operating time, and postoperative mortality and morbidity were evaluated using odds ratio (OR), weighted mean difference, or standard mean difference (SMD).Ten studies concerning 1614 patients were included. No significant differences between the Braun and the non-Braun group were identified in mortality (OR: 0.65, 95% confidence interval [CI]: 0.26-1.60), intraoperative blood loss (SMD: -0.035, 95% CI: -0.253 to 0.183), postoperative pancreatic fistula (POPF) (OR: 0.67, 95% CI: 0.35-1.67), bile leakage (OR: 0.537, 95% CI: 0.287-1.004), postoperative gastrointestinal hemorrhage (OR: 1.17, 95% CI: 0.578-2.385), intraabdominal abscesses (OR: 0.793, 95% CI: 0.444-1.419), wound complications (OR: 0.806, 95% CI: 0.490-1.325), and hospital stay (SMD: -0.098, 95% CI: -0.23 to 0.033). Braun enteroenterostomy extended operating time (SMD: 0.39, 95% CI: 0.02-0.78), but it was associated with lower reoperation rate (OR: 0.380, 95% CI: 0.149-0.968), lower morbidity rate (OR: 0.66, 95% CI: 0.49-0.91), lower clinically relevant delayed gastric emptying (Grades B and C) (OR: 0.375, 95% CI: 0.164-0.858), lower nasogastric tube reinsertion (OR: 0.436, 95% CI: 0.232-0.818), and less postoperative vomiting (OR: 0.444, 95% CI: 0.262-0.755).Braun enteroenterostomy can be safely performed during PD. It is beneficial for patients and could be recommended in PD from the current published data.PROSPERO registration number: CRD42015016198.
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Affiliation(s)
- Bin Xu
- From the Department of General Surgery, Shanghai 10th People's Hospital, Tongji University School of Medicine, Shanghai, China (BX, Y-HZ, M-PQ, R-RS); Department of Clinical Laboratory, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang, China (Y-WZ); and Department of Surgical Intensive Care Unit, Zhongshan Hospital, Fudan University, Shanghai, China (W-YZ)
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