Pylorus-preserving pancreaticoduodenectomy with complete preservation of the pyloroduodenal blood supply and innervation

Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy

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.

A new technique of duodenojejunostomy may reduce the rate of delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: The growth factor technique (with video)

BACKGROUND

Despite various technical modifications, delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy. DGE results in longer hospital stay, higher cost, lower quality of life, and delay of adjuvant therapy. We have developed a modified duodenojejunostomy technique to reduce the incidence of DGE. Here we evaluate our 4-year experience with this technique.

METHODS

This study evaluated consecutive patients who underwent pylorus-preserving pancreatoduodenectomy using the growth factor technique. It consists of performing a posterior seromuscular running suture with a zigzag stitch that stretches the jejunum and allows future growth of the anastomosis. This results in a longer jejunal opening. The angles at the edge of the duodenum are cut to accommodate the duodenal opening to the longer jejunum (the growth factor). The anterior seromuscular layer is then performed with interrupted sutures to accommodate the larger anastomosis. These patients were compared with a cohort of patients (n = 103) before the introduction of this new technique using propensity score matching.

RESULTS

134 patients underwent pylorus-preserving pancreatoduodenectomy. Delayed gastric emptying occurred in only three patients (2.2%), one grade B and two grade C. Compared with the 103 patients in the control group with standard technique, the incidence of DGE was significantly higher (11.6%; P = 0.00318). The median hospital stay was also statistically longer in the control group (P = 0.048704). A similar trend was observed in the matched cohort; the proportion of patients who developed DGE was significantly (P = 0.005) lower in the growth factor technique group (2.1% vs. 12.9%). Hospital stay was significantly longer in the standard group (P = 0.008), and patients operated on with the standard technique resumed feeding later than those with the growth factor technique.

CONCLUSIONS

This study demonstrated that the new technique of duodenojejunostomy can reduce the incidence and severity of DGE and allow earlier hospital discharge. Comparative studies are still needed to confirm these preliminary results.

Pylorus-preserving versus Pylorus-resecting: Impact on dynamic changes of nutrition and body composition in pancreatic cancer patients before and after pancreatoduodenectomy

OBJECTIVES

To investigate if different methods of pancreatoduodenectomy (with or without pyloric preservation) would have different impacts on postoperative nutrition and body composition changes among pancreatic cancer patients.

METHODS

Demographic and clinicopathological data, perioperative data were collected, body composition (e.g. skeletal muscle cross-sectional area [CSA], visceral fat area [VFA]) were evaluated with abdominal CT before and after surgery. Sarcopenia patients' proportion changes were also recorded.

RESULTS

The hospital stay in the PRPD group was significantly less than that in the PPPD group (p < 0.05). A significant difference was found in CSA, skeletal muscle index (SMI), VFA, VFA/CSA and albumin (ALB) in both groups between preoperative, 3, and 12 months after surgery. The loss of visceral fat in the PRPD group was more prominent than that in the PPPD group at 3 months and 12 months after surgery (p < 0.05). VFA/CSA was higher in the PPPD group than in the PRPD group (3 months: p < 0.05, 12 months: p < 0.001). The proportion of sarcopenic patients increased significantly over time in the PPPD and PRPD groups (p < 0.001).

CONCLUSIONS

Postoperative CSA and VFA continued to significantly decrease in both PPPD and PRPD groups, while the incidence of sarcopenia continued to increase. Compared with PRPD, PPPD has a protective effect on visceral fat. PPPD may contribute to better maintaining visceral fat mass and blood ALB levels. CT quantification can be an objective and effective method to evaluate the nutritional status of pancreatic cancer patients during the pre- and postoperative period and can provide a useful objective basis for guiding clinical treatment.

Intraoperative endoluminal pyloromyotomy for reduction of delayed gastric emptying after pylorus preserving partial pancreaticoduodenectomy (PORRIDGE trial): study protocol for a randomised controlled trial

Background

Pylorus-preserving pancreaticoduodenectomy (ppPD) is a standard surgical procedure for the treatment of resectable neoplasms of the periampullary region. One of the most common postoperative complications after ppPD is delayed gastric emptying (DGE) which reduces quality of life, prevents a timely return to a solid oral diet and prolongs the length of hospital stay. In a retrospective analysis, intraoperative endoluminal pyloromyotomy was associated with a reduced rate of DGE. The aim of this study is to investigate the effect of intraoperative endoluminal pyloromyotomy on postoperative DGE after ppPD in a randomised and controlled setting.

Methods

This randomised trial features parallel group design with a 1:1 allocation ratio and a superiority hypothesis. Patients with a minimum age of 18 years and an indication for ppPD are eligible to participate in this study and will be randomised intraoperatively to receive either endoluminal pyloromyotomy or atraumatic stretching of the pylorus. The sample size calculation (n=64 per study arm) is based on retrospective data. The primary endpoint is the rate of DGE within 30 days. Secondary endpoints are quality of life, operation time, estimated blood loss, length of hospital stay, morbidity and mortality.

Discussion

DGE after ppPD is a common complication with an incomplete understood aetiology. Prevention of DGE could improve outcomes and enhance quality of life after one of the most common procedures in pancreatic surgery. This trial will expand the existing evidence on intraoperative pyloromyotomy, and the results will provide additional data on a simple surgical technique that could reduce the incidence of postoperative DGE.

Trial registration

German Clinical Trials RegisterDRKS00013503. Registered on 27 December 2017.

Vascular surgery in liver resection

Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.

Previous upper abdominal surgery is a risk factor for nasogastric tube reinsertion after pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy without subsequent nasogastric tube management has not been widely adopted due to delayed gastric emptying, the specific and frequent morbidity associated with this surgical procedure. We assessed the feasibility of pancreaticoduodenectomy without use of nasogastric tubes and the risk factors for subsequent nasogastric tube reinsertion.

METHODS

We retrospectively reviewed 465 patients who underwent pancreaticoduodenectomy at a single institution between 2010 and 2019. Primary endpoint was the rate of nasogastric tube reinsertion. Logistic regression analysis was used to determine independent risk factors of nasogastric tube reinsertion and delayed gastric emptying.

RESULTS

The rate of nasogastric tube reinsertion was 10.1% (47/465). The rate of delayed gastric emptying was 9.5% (44/465). Logistic regression analysis identified 4 independent risk factors for nasogastric tube reinsertion: male sex (odds ratio = 4.42; 95% confidence interval 1.50-13.0, P = .007), comorbidity of cardiac ischemia (odds ratio = 3.04; 95% confidence interval 1.05-8.79, P = .041), preoperative cholangitis or cholecystitis (odds ratio = 2.21; 95% confidence interval 1.02-4.76, P = .044), and previous upper abdominal surgery (odds ratio = 8.34; 95% confidence interval 3.07-22.7, P < .001). Independent risk factors for delayed gastric emptying were male sex (odds ratio = 3.20; 95% confidence interval 1.11-9.21, P = .031), comorbidity of cardiac ischemia (odds ratio = 3.81; 95% confidence interval 1.34-10.8, P = .012), concomitant organ resection (odds ratio = 3.99; 95% confidence interval 1.10-14.4, P = .035), and previous upper abdominal surgery (odds ratio = 7.21; 95% confidence interval 2.68-19.4, P < .001).

CONCLUSION

Pancreaticoduodenectomy without use of nasogastric tubes is feasible, but patients with previous upper abdominal surgery require careful postoperative nasogastric tube management.

Effect of Billroth-II versus Roux-en-Y reconstruction for gastrojejunostomy after pancreaticoduodenectomy on delayed gastric emptying: A meta-analysis of randomized controlled trials

BACKGROUND/PURPOSE

Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). The aim of the present meta-analysis was to evaluate the effect of Billroth-II(B-II) versus Roux-en-Y (R-Y) reconstruction for gastrojejunostomy on DGE after PD.

METHODS

A systematic literature search was performed using the electronic database MEDLINE (via PubMed and OVID), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) of the Cochrane Library to select pertinent randomized controlled trials (RCTs) on this topic from January 1990 to January 2020. The primary outcome was identified as postoperative DGE. Subgroup analysis was established to compare the incidence of grade B and C DGE. Software Revman 5.3 was used for the statistical analysis, summary statistics were calculated using fixed effect model or random effect model.

RESULTS

Five RCTs including a total of 612 patients were eligible for this meta-analysis. The incidence of grade B and C DGE was significantly lower with the B-II reconstruction than with the R-Y reconstruction (8.0% vs. 14.8%, OR = 0.49, 95% CI: 0.26-0.95, P = 0.03) and the B-II reconstruction took a shorter operation time (WMD=-7.18, 95% CI: [-13.09, -1.27], P = 0,02). No statistically significant difference was found between the two reconstruction methods in terms of the incidence of postoperative pancreatic fistula (POPF), bile leak, intra-abdominal abscess, postoperative pneumonia and the length of postoperative hospital stay.

CONCLUSIONS

B-II reconstruction after PD has a lower incidence of grade B and C DGE and shorter operation time compared with R-Y reconstruction.

Intraoperative endoluminal pyloromyotomy as a novel approach to reduce delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy-a retrospective study

Background

Delayed gastric emptying (DGE) is one of the most common complications after pylorus-preserving partial pancreaticoduodenectomy (ppPD). The aim of this retrospective study was to assess whether an intraoperative pyloromyotomy during ppPD prior to the creation of duodenojejunostomy reduces DGE.

Methods

Patients who underwent pylorus-preserving pancreaticoduodenectomy between January 2015 and December 2017 were divided into two groups on the basis of whether an intraoperative pyloromyotomy was performed (pyloromyotomy (PM) group) or not (no pyloromyotomy (NP) group). The primary endpoint was DGE according to the ISGPS definition. The confirmatory analysis of the primary endpoint was performed with multivariate analysis.

Results

One hundred and ten patients were included in the statistical analysis. Pyloromyotomy was performed in 44 of 110 (40%) cases. DGE of any grade was present in 62 patients (56.4%). The DGE rate was lower in the PM group (40.9%) compared with the NP group (66.7%), and pyloromyotomy was associated with a reduced risk for DGE in univariate (OR 0.35, 95% CI 0.16–0.76; P = 0.008) and multivariate analyses (OR 0.32, 95% CI 0.13–0.77; P = 0.011). The presence of an intra-abdominal complication was an independent risk factor for DGE in the multivariate analysis (OR 5.54, 95% CI 2.00–15.36; P = 0.001).

Conclusion

Intraoperative endoluminal pyloromyotomy during ppPD was associated with a reduced risk for DGE in this retrospective study. Pyloromyotomy should be considered a simple technique that can potentially reduce DGE rates after ppPD.

Is delayed gastric emptying associated with pylorus ring preservation in patients undergoing pancreaticoduodenectomy?

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.

Delayed gastric emptying after Pancreaticoduodenectomy: a propensity score-matched analysis and clinical Nomogram study

Background

Delayed gastric emptying (DGE) is a common and frustrating complication of pancreaticoduodenectomy (PD). Studies suggest that surgical methods and other clinical characteristics may affect the occurrence of DGE. Nevertheless, the results of such studies are conflicting. The objective of this work was to perform a propensity score matching analysis to compare the differences between pylorus-preserving pancreaticoduodenectomy (PPPD) and pylorus-removing pancreaticoduodenectomy (PrPD) and to develop and validate a nomogram to predict the probability of severe DGE (SDGE).

Methods

This retrospective study enrolled patients who underwent PD at our institution from December 2009 to December 2018. Propensity score matching was applied at a ratio of 1:1 to compare PPPD and PrPD groups. We compared incidence of complications, DGE, lengths of hospital stay, hospitalization costs, and mortality. Univariate and multivariate logistic regression analysis were performed to identify potential risk factors of severe DGE. Finally, a nomogram was developed and validated to predict severe DGE.

Results

The PPPD group had a significantly higher rate of postoperative pancreatic fistula (29.9% versus 17.4%, P < 0.05) and less blood loss (463.7 ml versus 694.9 ml, P < 0.05). After propensity score matching, the PPPD group had a significantly higher rate of postoperative DGE (19.2% versus 3.8%, P < 0.05), especially severe DGE (17.3% versus 0%) than the PrPD group. There were no significant differences in terms of lengths of hospital stay, hospitalization costs or mortality between the groups. Surgical method, biliary leakage, abdominal infection, and diabetes were independent risk factors for SDGE. The nomogram predicted SDGE with a training C - index of 0.798 and a validation C - index of 0.721.

Conclusion

PPPD increases the risk of DGE than PrPD, especially SDGE. Our prediction nomogram gives good prediction of SDGE after pancreaticoduodenectomy.

Long-Term Surgical Complications After Pancreatoduodenectomy: Incidence, Outcomes, and Risk Factors

BACKGROUND

Long-term complications following pancreatoduodenectomy (PD) can significantly impact quality of life and healthcare utilization. Most reports focus on short-term (within 90 days) PD outcomes; however, the incidence and risk factors for long-term complications (> 90 days) remain to be evaluated. We sought to identify the incidence, outcomes, and risk factors for long-term complications post-PD.

METHODS

All PD survivors between 2010 and 2017 were identified from a single-institutional database. Long-term complications (> 90 days post-PD and not resulting from cancer recurrence), including biliary stricture, cholangitis, pancreatitis, peptic ulcer, small bowel obstruction, and incisional hernia, were identified. Logistic regression was used to identify perioperative predictors of long-term complications.

RESULTS

Of 906 PDs, 628 long-term survivors met criteria for analysis (mean age of 65.3 years, 47% female). Median follow-up and overall survival were 51.1 months (95% CI 47.6, 55.7) and 68.5 months (95% CI 57.9, 81.4), respectively. A total of 198 (31.5%) experienced at least one long-term complication. Complications included incisional hernia (17.7%), biliary stricture or cholangitis (8.0%), pancreatitis (5.7%), small bowel obstruction (4.3%), and peptic ulcer (3.2%). In total, 108 (17.2%) of the complications required an intervention, nearly half of which were surgical. On multivariable analysis, several predictors of long-term complications were identified: obesity (BMI ≥ 30 kg/m²), postoperative wound infection, prolonged index length of stay, readmission (< 90 days), operative approach (open vs. robotic), and pylorus-preservation.

CONCLUSION

Long-term complications occur in nearly a third of PDs and nearly one-fifth of all PDs require re-intervention. Several modifiable predictors of long-term complications were identified.

Randomized Trial of Pylorus-Preserving vs. Pylorus-Resecting Pancreatoduodenectomy: Long-Term Morbidity and Quality of Life

BACKGROUND

The randomized controlled PROPP trial (DKRS00004191) showed that pylorus-resecting pancreatoduodenectomy (PR) is not superior to the pylorus-preserving procedure (PP) in terms of perioperative outcome, specifically in reduction of delayed gastric emptying. Non-superiority of PR was also confirmed in a recent meta-analysis of randomized controlled trials. However, long-term data on morbidity and quality of life after PP compared to PR are sparse. The aim of this study was to investigate long-term outcomes of patients included in the PROPP trial.

METHODS

Between February 2013 and June 2016, a total of 188 patients underwent PD and were intraoperatively randomized to either preservation or resection of the pylorus (95 vs. 93 patients). For long-term follow-up, morbidity and quality of life (EORTC QLQ-C30/PAN26) were monitored until January 1, 2018. Statistical analysis was performed on an intention-to-treat basis.

RESULTS

The mean duration of follow-up was 34.3 (± 11.3) months. Sixty-three of the 188 patients had died (PP n = 33, PR n = 30), 29 patients were lost to follow-up (PP n = 17, PR n = 12), and the remaining 96 patients were included in long-term follow-up (PP n = 45, PR n = 51). There was no difference between PP and PR patients regarding endocrine and exocrine pancreatic function, receipt of adjuvant/palliative chemotherapy, cancer recurrence, and other relevant characteristics. Late cholangitis occurred significantly more often in patients following pylorus resection (P = 0.042). Reoperations, readmissions to hospital, and quality of life scores except pain were comparable between the two study groups.

CONCLUSIONS

Similar to short-term results, long-term follow-up showed no significant differences between pylorus resection compared to pylorus preservation.

Gastroduodenal artery: single key for many locks

Gastroduodenal artery (GDA) commonly arises from common hepatic artery, a branch of celiac axis. It holds a unique anatomical position that connects the foregut and midgut due to its intimate communications with foregut and midgut arterial supply. Its numerous anatomical variations have a significant impact on planning and performance of hepatopancreaticobiliary (HPB) surgery. Its close relation to the first part of duodenum, common bile duct and head of pancreas makes it susceptible for inadvertent bleeding during or after surgery, or due to various HPB pathologies. Also, a large number of vascular interventions rely on GDA and its branches. Careful preoperative planning is the key and a detailed knowledge and awareness of its variant anatomy is of paramount importance, be it liver resections, liver transplant, biliary and pancreatic resections and pancreatic transplant or transarterial procedures involving these arteries. GDA can also be a cause of gastrointestinal hemorrhage due to true or pseudoaneurysms and anatomy has significant implications on its management. The article provides a succinct review on relevance of GDA anatomy and variations and highlights that preoperative planning and intraoperative awareness of variations is the key to performance of safe HPB surgery and interventions.

Pancreaticoduodenectomy with right gastric vessels preservation: impact on intraoperative and postoperative outcomes

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.

Pylorus preservation pancreatectomy or not

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.

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

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.

Impact of Braun anastomosis on reducing delayed gastric emptying following pancreaticoduodenectomy: a prospective, randomized controlled trial

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.

Delayed Gastric Emptying After Pancreaticoduodenectomy: Is Subtotal Stomach Preserving Better or Pylorus Preserving?

BACKGROUND

Delayed gastric emptying (DGE) is one of the main complications after pancreaticoduodenectomy (PD). Literature review and meta-analysis were used to evaluate whether subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) may have less incidence than pylorus-preserving pancreaticoduodenectomy (PPPD).

METHODS

Online search for studies comparing PPPD to SSPPD was done. Primary outcome was DGE. Quality of included studies was evaluated and heterogeneity was assessed. Relative risk (RR) and 95% confidence intervals (CI) were calculated from pooled data in RCTs and retrospective studies.

RESULTS

Eight studies met our selection criteria, with a total of 663 patients undergoing pancreaticoduodenectomy; 309 underwent PPPD and 354 underwent SSPPD. Median age was 66 years. Average male/female ratio was 57 vs. 43%, respectively. There was lower incidence of DGE with SSPPD (RR 0.527; 95% CI 0.363-0.763; p < 0.001) and less nasogastric tube days with SSPPD (RR -0.544; 95% CI -876 to -0.008; p = 0.047). Operative blood loss was more in SSPPD (RR 0.285; 95% CI 0.071-0.499; p = 0.009). There was no statistical difference between the two groups regarding length of hospital stay, incidence of pancreatic fistula, abscesses, overall morbidity, or postoperative mortality.

CONCLUSION

SSPPD was associated with less DGE than PPPD. Larger prospective randomized studies are needed to investigate the association of this result with other complications in more depth.

The effect of pylorus removal on delayed gastric emptying after pancreaticoduodenectomy: a meta-analysis of 2,599 patients

BACKGROUND

Delayed gastric emptying is a serious complication of pancreaticoduodenectomy. The effect of pylorus removal on delayed gastric emptying has not been well evaluated.

STUDY DESIGN

We searched five databases (PubMed, EMBASE and the Cochrane Central Register of Controlled Trials, Scopus and Web of Science) up to July 2014. The meta-regression analysis was performed to evaluate any factors accountable for the heterogeneity. Publication bias was assessed by Egger's test, and corrected by Duval's trim and fill method. Subgroup analyses were conducted for different surgical techniques of pyloric removal. Other intraoperative and postoperative parameters were compared between two groups.

RESULTS

We included 27 studies involving 2,599 patients, with a moderate-high heterogeneity for primary outcome (I(2) = 63%). Meta-regression analysis showed that four variables primarily contributed to the heterogeneity, namely nasogastric tube intubation time, solid food start time, preoperative diabetes percentage and the number of patients in pylorus-preserving group. After excluding four studies, the remaining twenty-three studies showed reduced heterogeneity (I(2) = 51%). Then we used Duval's trim and fill method to correct publication bias. The corrected MH odds ratio was 0.78 (95% CI: 0.52-1.17). A subgroup analysis showed that pylorus removal tends to reduce delayed gastric emptying incidence for subtotal stomach-preserving pancreaticoduodenectomy or pylorus-resecting pancreaticoduodenectomy, compared with pylorus-preserving group. However, standard Whipple procedure failed to show any significant reduction of DGE compared with pylorus-removal group. No significant differences were observed in terms of length of hospital stay, infection and pancreatic fistula; however, pylorus removal resulted in longer operation time, more blood loss and higher mortality.

CONCLUSION

The pylorus removal does not significantly reduce the overall incidence of delayed gastric emptying. Subtotal stomach-preserving pancreaticoduodenectomy or pylorus-resecting pancreaticoduodenectomy tends to reduce delayed gastric emptying incidence, but needs further validation.

Pancreaticoduodenectomy with preservation of gastric tube blood flow after esophagectomy: Report of a case

•

We performed a pancreaticoduodenectomy in which the gastroduodenal artery was preserved.

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The patient who had previously undergone esophagectomy, was diagnosed as middle bile duct cancer.

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In order to prevent gastric tube ischemia, the gastroduodenal artery and gastroepiploic artery had to be preserved.

INTRODUCTION

During pancreaticoduodenectomy (PD), the gastroduodenal artery (GDA) is commonly divided. In this study, we described the clinical features of PD in which the GDA was preserved in order to avoid gastric tube ischemia in a patient who had previously undergone esophagectomy.

PRESENTATION OF CASE

A 70-year-old man had previously undergone esophagectomy. Esophagectomy and gastric tube reconstruction were performed 10 years earlier due to superior thoracic esophageal cancer. The patient was referred to our hospital for the treatment of obstructive jaundice and was diagnosed with middle bile duct cancer. We performed PD and preserved the GDA. The postoperative course was uneventful, and the gastric tube continued functioning well.

DISCUSSION

In a patient with a prior esophagectomy and gastric tube reconstruction, the blood flow to the gastric tube is supplied only by the GDA via the right gastroepiploic artery (RGEA). Therefore, we carefully chose a technique that would preserve the GDA and avoid gastric tube ischemia. Oncologically, this procedure may be debatable because the efficiency of lymph node dissection along the GDA and RGEA may be compromised. PD involving GDA preservation in common bile duct (CBD) cancer may be acceptable because the CBD is behind the pancreatic head, and the CBD lymph flows into the para-aorta lymph nodes behind the pancreas.

CONCLUSION

This procedure is suitable for patients who have previously undergone esophagectomy and this procedure prevents digestive function disorders. Using this method, preoperative angiographic assessment and meticulous surgical technique may lead to successful outcomes.

Prevention of delayed gastric emptying after pylorus-preserving pancreatoduodenectomy with antecolic reconstruction, a long jejunal loop, and a jejuno-jejunostomy

BACKGROUND

Delayed gastric emptying (DGE) is one of the major complications following pylorus-preserving pancreatoduodenectomy (PPPD). It leads to significant patient distress and prolonged hospitalization and therefore increased treatment costs. DGE etiology remains unclear but seems to be multifactorial. In order to decrease DGE rates, reconstruction methods have been modified. The presented retrospective study was to evaluate outcomes of different surgical techniques at our institution with special emphasis on retrocolic and antecolic reconstruction types.

MATERIAL AND METHODS

One hundred thirteen consecutive patients underwent PPPD between September 2004 and December 2011 for periampullary and bile duct lesions of the pancreatic head and the papilla of Vater. These patients were reviewed for DGE occurrence and other factors. Four different types of reconstruction were applied: the classic retrocolic reconstruction using a short jejunal loop (short loop, n = 40) and three types of reconstructions using a long loop: one with a long loop and retrocolic duodenojejunostomy (n = 22), another with a long loop and an additional latero-lateral enterostomy (Braun's anastomosis, n = 23), and finally, an antecolic group with Braun's anastomosis (n = 28). Patients were reviewed for DGE incidence and severity following the International Study Group of Pancreatic Surgery definition of DGE.

RESULTS

The highest DGE occurrence was noted in the retrocolic group using a short jejunal loop (15 of 32 patients, 46.9%), whereas the reconstruction types using long loops showed a notable decrease: DGE occurred in 4 of 16 patients (25%) in the retrocolic group, in 6 of 21 patients (28.6%) in the retrocolic group with an additional latero-lateral enterostomy (Braun's anastomosis), and finally, only 1 of 22 patients (4.5%, p = 0.009) in the antecolic group with Braun's anastomosis presenting with DGE, grade A. However, neither hospitalization time nor days in the intensive care unit were significantly different. There was no difference in DGE rates between the retrocolic long-loop groups with and without Braun's anastomosis.

CONCLUSION

The results of this retrospective study suggest that the antecolic route with a long jejunal loop and Braun's anastomosis minimizes DGE rates.

Association of preoperative symptoms of gastric outlet obstruction with delayed gastric emptying after pancreatoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) is among the most common complications after pancreatoduodenectomy (PD) and might demand postoperative nutritional support. The aim of this study was to investigate the association between preoperative symptoms of gastric outlet obstruction and DGE after PD in an attempt to identify patients in whom placement of a feeding tube at time of operation might be beneficial.

METHODS

We analyzed a consecutive series of 401 patients undergoing PD from a prospective database. Preoperative symptoms of nausea, vomiting, loss of appetite, weight loss, postprandial complaints, and dysphagia were retrospectively determined. Primary outcome was clinically relevant DGE according to the International Study Group of Pancreatic Surgery classification and the necessity of postoperative insertion of a nasojejunal feeding tube.

RESULTS

The incidence of clinically relevant DGE was 33.2% (133/401 patients). A nasojejunal feeding tube was inserted in 119 patients (29.7%). Patients having ≥2 symptoms of gastric outlet obstruction except weight loss (50 patients; 12.5%), were at a greater risk of developing both DGE (21.1% vs 8.2%; P < .001) and the need for insertion of a feeding tube (21.8% vs 8.5%; P < .001). In multivariable logistic regression analysis, the presence of ≥2 symptoms of gastric outlet obstruction other than weight loss remained a significant predictor of DGE (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.7-5.8) and the need for insertion of a nasojejunal feeding tube (OR, 3.1; 95% CI, 1.7-5.7).

CONCLUSION

The preoperative presence of ≥2 symptoms of gastric outlet obstruction is a significant predictor of postoperative DGE after PD. By applying this risk factor, patients in whom placement of a feeding tube during surgery should be considered can be identified.

Does antecolic reconstruction decrease delayed gastric emptying after pancreatoduodenectomy?

Delayed gastric emptying (DGE) is a frequent complication after pylorus-preserving pancreatoduodenectomy (PpPD). Kawai and colleagues proposed pylorus-resecting pancreatoduodenectomy (PrPD) with antecolic gastrojejunal anastomosis to obviate DGE occurring after PpPD. Here we debate the reported differences in the prevalence of DGE in antecolic and retrocolic gastro/duodeno-jejunostomies after PrPD and PpPD, respectively. We concluded that the route of the gastro/duodeno-jejunal anastomosis with respect to the transverse colon; i.e., antecolic route or retrocolic route, is not responsible for the differences in prevalence of DGE after pancreatoduodenectomy (PD) and that the impact of the reconstructive method on DGE is related mostly to the angulation or torsion of the gastro/duodeno-jejunostomy. We report a prevalence of 8.9% grade A DGE and 1.1% grade C DGE in a series of 89 subtotal stomach-preserving PDs with Roux-en Y retrocolic reconstruction with anastomosis of the isolated Roux limb to the stomach and single Roux limb to both the pancreatic stump and hepatic duct. Retrocolic anastomosis of the isolated first jejunal loop to the gastric remnant allows outflow of the gastric contents by gravity through a “straight route”.

Delayed gastric emptying improved by straight stomach reconstruction with twisted anastomosis to the jejunum after pylorus-preserving pancreaticoduodenectomy (PPPD) in 118 consecutive patients at a single institution

PURPOSE

Delayed gastric emptying (DGE) is a leading cause of complication after pylorus-preserving pancreaticoduodenectomy (PPPD). Its incidence has been reported to range from 5 to 57%. We describe a modified reconstruction method, which resulted in a low rate of DGE.

METHODS

Between April 2003 and March 2008, we performed PPPD and reconstruction using an antecolic method in 118 consecutive patients. After PPPD, reconstruction was done using conventional Child procedure in 12 patients (PPPD group) and with the following modifications in the remaining 106 patients (PPPDR group): duodenojejunostomy was performed using the straight method and the jejunum was anastomosed with a 30° counterclockwise twist. We evaluated the incidence of DGE based on the grading system defined by the International Study Group of Pancreatic Surgery (ISGPS).

RESULTS

The PPPDR group had a lower incidence of DGE than the PPPD group (PPPD), occurring in 7 patients (7%) versus 4 patients (33%), respectively. However, the overall morbidity rates and postoperative hospital stays of the two groups did not differ significantly.

CONCLUSIONS

Straight stomach reconstruction with a twisted anastomosis could reduce the incidence of DGE after PPPD reconstruction.

Comparison of different pancreatic anastomosis techniques using the definitions of the International Study Group of Pancreatic Surgery: a single surgeon's experience

OBJECTIVES

We aimed to compare different techniques using the definitions of the International Study Group of Pancreatic Surgery for postoperative complications after pancreaticoduodenectomy.

METHODS

The perioperative data of 119 patients that underwent pancreaticoduodenectomy by a single surgeon were retrospectively analyzed. Pancreaticojejunal anastomosis was performed using the dunking method (n = 39), the duct-to-mucosa anastomosis method (n = 40), and the duct-to-mucosa adaptation (n = 40).

RESULTS

The most frequent complication was postoperative pancreatic fistula (POPF; grades A, 21%; B, 8%; and C, 3%), postpancreatectomy hemorrhage (PPH; grades B, 7% and C, 1%), and delayed gastric emptying (DGE; grades A, 1% and B, 6%). No significant differences in POPF were found between patients who underwent different types of pancreatic anastomoses. Only pancreatic ductal adenocarcinoma (P = 0.001) and pancreatic texture (P = 0.012) were potentially related to POPF. Patients with or without POPF grade A had shorter postoperative stays than patients with grade B or C POPF (P < 0.001), and similar findings were obtained for DGE and PPH.

CONCLUSIONS

The successful management of pancreatic anastomoses depends more on a meticulous surgical technique and appropriate experience rather than on the type of technique. Furthermore, the International Study Group of Pancreatic Surgery definitions of POPF, DGE, and PPH seem objective and universally acceptable.

An antecolic Roux-en Y type reconstruction decreased delayed gastric emptying after pylorus-preserving pancreatoduodenectomy

The aim of this study was to identify a preferable procedure reducing the incidence of delayed gastric emptying (DGE) after pylorus-preserving pancreatoduodenectomy (PPPD). Data on 132 consecutive patients with pancreatobiliary disease, who underwent PPPD, were collected retrospectively. A retrocolic Billroth I type reconstruction (B-I group) and an antecolic Roux-en Y type reconstruction (R-Y group) were performed for 54 and 78 patients after PPPD, respectively. Clinical measures of DGE were compared between the two groups. The incidence of DGE was 81% in B-I group and 10% in R-Y group (P < 0.001). The type of reconstruction (P < 0.001), operative time (P = 0.016), and postoperative complications (P = 0.001) were significantly associated with DGE by univariate analysis. Only the type of reconstruction (P < 0.001) was identified as an independent factor, which was associated with DGE by multivariate analysis. An antecolic Roux-en Y type duodenojejunostomy could be a useful reconstruction method after PPPD to prevent the occurrence of DGE.

Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after pancreatic resection. In the literature, the reported incidence of DGE after pancreatic surgery varies considerably between different surgical centers, primarily because an internationally accepted consensus definition of DGE is not available. Several surgical centers use a different definition of DGE. Hence, a valid comparison of different study reports and operative techniques is not possible.

METHODS

After a literature review on DGE after pancreatic resection, the International Study Group of Pancreatic Surgery (ISGPS) developed an objective and generally applicable definition with grades of DGE based primarily on severity and clinical impact.

RESULTS

DGE represents the inability to return to a standard diet by the end of the first postoperative week and includes prolonged nasogastric intubation of the patient. Three different grades (A, B, and C) were defined based on the impact on the clinical course and on postoperative management.

CONCLUSION

The proposed definition, which includes a clinical grading of DGE, should allow objective and accurate comparison of the results of future clinical trials and will facilitate the objective evaluation of novel interventions and surgical modalities in the field of pancreatic surgery.

Surgical anatomy of the innervation of pylorus in human and Suncus murinus, in relation to surgical technique for pylorus-preserving pancreaticoduodenectomy

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.