Low-dose erythromycin reduces delayed gastric emptying and improves gastric motility after Billroth I pylorus-preserving pancreaticoduodenectomy

A reduction in delayed gastric emptying by classic pancreaticoduodenectomy with an antecolic gastrojejunal anastomosis and a retrogastric omental patch

BACKGROUND

Delayed gastric emptying (DGE) continues to be a major cause of morbidity following pancreaticoduodenectomy (PD). A change in the method of reconstruction following PD was instituted in an attempt to reduce the incidence DGE.

METHODS

Patients undergoing PD from January 2002 to December 2008 were reviewed and outcomes determined. Pylorus-preserving pancreaticoduodenectomy (PPPD) with a retrocolic duodenojejunal anastomosis (n = 79) or a classic PD with a retrocolic gastrojejunostomy (n = 36) was performed prior to January 2008. Thereafter, a classic PD with an antecolic gastrojejunal anastomosis and placement of a retrogastric vascular omental patch was undertaken (n = 36).

RESULTS

A statistically significant decrease in DGE was noted in the antecolic group compared to the entire retrocolic group (14% vs 40%; p = 0.004) and compared to patients treated by classic PD with a retrocolic anastomosis alone (14% vs 39%; p = 0.016). On multivariate analysis, the only modifiable factor associated with reduced DGE was the antecolic technique with an omental patch, odds ratio (OR) 0.3 (confidence interval (CI) 0.1-0.8) p = 0.022. Male gender was associated with an increased risk of DGE with OR 2.3 (CI 1.1-4.8) p = 0.026.

CONCLUSION

A classic PD combined with an antecolic anastomosis and retrogastric vascular omental patch results in a significant reduction in DGE.

Clinical validation and risk factors for delayed gastric emptying based on the International Study Group of Pancreatic Surgery (ISGPS) Classification

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy (PD). Because an objective, universally accepted definition of DGE does not yet exist, it is impossible to compare complication rates and outcomes of new operative approaches, operative techniques, and clinical trials. The International Study Group of Pancreatic Surgery (ISGPS) has proposed a universal classification for DGE based on clinical outcomes, but this classification has not been tested rigorously and applied to clinical data. Therefore, the aim of this study was to analyze our experience and to identify predictive factors for DGE by applying the ISGPS classification at a high-volume hospital.

METHODS

From October 2002 to December 2007, 129 consecutive patients underwent PD at the Department of Surgery, Yonsei University Medical Center. The severity of DGE was determined according to the ISGPS classification, and risk factors were evaluated retrospectively.

RESULTS

The overall incidence of DGE was 33.3%, with 16 (12.4%) patients having grade A, 14 (10.9%) grade B, and 13 (10.1%) grade C. Clinical outcomes worsened progressively as clinical relevant DGE increased. In multivariate analysis, clinically relevant pancreatic fistula (grade B/C) and patients with benign pathology were identified as independent factors for DGE.

CONCLUSION

Pancreatic leakage is a serious complication after PD and is also associated with DGE. The ISGPS classification is a clear and useful tool to assess clinical outcomes.

Erythromycin establishes early oral feeding in neonates operated for congenital intestinal atresias

PURPOSE

The recovery of gastrointestinal function following surgery for congenital intestinal atresias can be prolonged and may increase morbidity and hospital stay. This study was conducted to investigate the prokinetic effect of erythromycin in neonates undergoing surgery for small bowel atresias.

METHODS

A randomized-controlled trial was conducted at the Departments of Paediatrics and Paediatric Surgery, Military Hospital, Rawalpindi, Pakistan, from January to December 2007 to study the prokinetic effect of erythromycin (3 mg/kg per dose 4 times daily). Thirty consecutive neonates undergoing primary anastomosis for congenital small bowel atresias were randomly divided into two groups: group I (erythromycin) and group II (control). The groups were similar in terms of gestational age, sex, mode of delivery, birth weight and types of atresias. Postoperative recovery of intestinal functions was measured as time taken to achieve full enteral feed (150 ml/kg per 24 h), duration of total parenteral nutrition (TPN) and hospital stay.

RESULTS

Neonates receiving oral erythromycin achieved full enteral feeding early (13.07 vs. 16.13 days) required TPN for shorter duration (10.53 vs. 13.73 days) and their hospital stay was less (16.2 vs. 18.0 days) as compared to the neonates in the control group who did not receive any erythromycin. The differences were statistically significant.

CONCLUSION

The administration of oral erythromycin following primary anastomosis for small intestinal atresias results in early recovery of intestinal function, fewer days on TPN and a trend for shorter hospital stay.

Prospective nonrandomized comparison between pylorus-preserving and subtotal stomach-preserving pancreaticoduodenectomy from the perspectives of DGE occurrence and postoperative digestive functions

BACKGROUND

To determine the influence of pylorus preservation after pancreaticoduodenectomy, we compared the postoperative course of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) and pylorus-preserving pancreaticoduodenectomy (PPPD).

METHODS

A prospective, nonrandomized comparison of 77 consecutive patients undergoing PPPD (n = 37) or SSPPD (n = 40) between January 2003 and March 2007 was planned. The early postoperative course, dietary intake, and the incidence of delayed gastric emptying (DGE) were evaluated.

RESULTS

SSPPD included significantly more cases of regional lymph node dissection (D2, PPPD 53% vs. SSPPD 80%) and portal vein resection. The median duration of surgery (457 vs. 520 min) was significantly shorter, and blood loss (619 vs. 1,235 ml) was significantly less in PPPD. Regarding postoperative clinical factors, the duration of nasogastric tube intubation (1 vs.1 day), days until solid diet (7 vs. 7 days), and the incidence of DGE (9% vs.10%) were similar in PPPD and SSPPD. However, the postoperative/preoperative body weight ratio (95% vs. 93%) was significantly higher, and the postoperative hospital stay (31 vs. 38 days) was significantly shorter in PPPD (p < 0.05).

CONCLUSIONS

Despite the bias of the operative factors, the incidence of DGE and postoperative dietary intake after SSPPD was comparable with PPPD, and therefore, pylorus preservation seemed to have no impact on postoperative dietary intake or DGE.

Delayed gastric emptying: the state of the highest level of evidence

Delayed gastric emptying (DGE) has been regarded as the most common complication after pancreaticoduodenectomy (PD). Opinions about DGE and its incidence widely vary between studies and between institutions. To crystallize current concepts of DGE we resorted to a systematic literature search of level I evidence. We found 16 randomized controlled trials (RCTs) where DGE was measured but only 4 of these trials tested methods to influence DGE (erythromycin, enteral nutrition, or antecolic duodenojejunostomy). Constant heterogeneity for the definition of DGE was observed; 13 RCTs used 6 different clinical definitions based on some form of NG tube requirement after surgery, and the 3 remaining RCTs used non-clinical objective criteria. The most common element of the clinical definitions was the need for an NG tube >10 postoperative days. Ten RCTs used some form of this definition and the reported mean incidence of DGE was 17% however the range varied from 5% to 57%. The trials with the least number of cases appeared to have the widest variation in DGE incidence. We concluded after this systematic review that the disparate opinions about DGE could not be mediated with the highest level of evidence. The studies were underpowered or compromised by a lack of homogeneity in definition and design. The incidence of DGE cannot be succinctly measured; therefore the variables that influence DGE are not understood. We can begin to make progress by using the same definition such as the recently published definition provided by the International Study Group of Pancreatic Surgery.

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.

Hormones of the gut-brain axis as targets for the treatment of upper gastrointestinal disorders

The concept of the gut forming the centre of an integrated gut-brain-energy axis - modulating appetite, metabolism and digestion - opens up new paradigms for drugs that can tackle multiple symptoms in complex upper gastrointestinal disorders. These include eating disorders, nausea and vomiting, gastroesophageal reflux disease, gastroparesis, dyspepsia and irritable bowel syndrome. The hormones that modulate gastric motility represent targets for gastric prokinetic drugs, and peptides that modify eating behaviours may be targeted to develop drugs that reduce nausea, a currently poorly treated condition. The gut-brain axis may therefore provide a range of therapeutic opportunities that deliver a more holistic treatment of upper gastrointestinal disorders.

Prophylactic octreotide and delayed gastric emptying after pancreaticoduodenectomy: results of a prospective randomized double-blinded placebo-controlled trial

AIMS

To evaluate the impact of prophylactic octreotide on gastric emptying in patients undergoing pancreaticoduodenectomy. Postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE) are common complications after pancreaticoduodenectomy. Whereas several prospective randomized trials propose the prophylactic use of octreotide to prevent pancreatic fistula formation, somatostatin has, however, been associated with delayed gastric emptying after partial duodenopancreatectomy.

METHODS

In this prospective, randomized, double-blinded, placebo-controlled trial we analyzed the influence of prophylactic octreotide on delayed gastric empting after pancreaticoduodenectomy. Patients were randomized to the placebo group (n=32) and the octreotide group (n=35). Primary endpoint was the incidence of delayed gastric emptying, secondary endpoints included perioperative morbidity other than DGE. DGE was measured by clinical signs, gastric scintigraphy and the hydrogen breath test. Risk factors for DGE other than octreotide were analyzed by univariate and multivariate analyses.

RESULTS

DGE measured by clinical signs was similar between both groups studied ( approximately 20% of the patients). Gastric scintigraphy (T(1/2)) was 76.3+/-15.2 min in the octreotide group and 86.7+/-18.0 min in controls at day 7, respectively. The H(2) breath test was 65.0+/-6.5 min in octreotide treatment group and 67.0+/-5.7 min in controls at day 8. POPF grade C occurred in approximately 3% of the patients, although prophylactic treatment of octreotide did not reduce the incidence of POPF. Multivariate analysis showed that postoperative intraabdominal bleeding and infection were independent risk factors for DGE. Furthermore preoperative biliary stenting reduced postoperative DGE after partial duodenopancreatectomy.

CONCLUSION

Prophylactic octreotide has no influence on gastric emptying and does not decrease the incidence of postoperative pancreatic fistula after pancreaticoduodenectomy.

Effect of erythromycin and azithromycin on sensation afferent nerve functions of gastrointestinal tract in rats

AIM: To investigate the effect of erythromycin and azithromycin on sensation afferent nerve functions of gastrointestinal tract in rats and its corresponding mechanism.

METHODS: Sixty-four rats were randomly divided into erythromycin group, azithromycin group, control group, low dose group (0.1 mg/kg), medium dose group (0.5 mg/kg) and high dose group (1 mg/kg). Spontaneous afferent nerve discharge and gastric distention-induced afferent nerve discharge of subdiaphragmatic vagus nerve were recorded half an hour before and after intravenous injection of different doses of erythromycin and azithromycinin.

RESULTS: Intravenous low erythromycin and azithromycin dose had no obvious exciting effect on spontaneous afferent nerve discharge and gastric distention- induced afferent nerve discharge of subdiaphragmatic vagus nerve after 20 min. Intravenous medium and high erythromycin and azithromycin dose had obvious exciting effect on spontaneous afferent nerve discharge (erythromycin: 8.34 ± 0.37, 8.54 ± 0.26 vs 7.78 ± 0.23, 7.84 ± 8.27; azithromycin: 8.57 ± 0.43, 8.28 ± 0.38 vs 7.74 ± 0.21, 7.86 ± 0.30) and gastric distention-induced afferent nerve discharge of subdiaphragmatic vagus nerve (erythromycin: 8.54 ± 0.34, 8.61 ± 0.20 vs 8.13 ± 0.36, 8.19 ± 0.21; azithromycin: 8.54 ± 0.30, 8.42 ± 0.21 vs 8.24 ± 0.22, 8.22 ± 0.19), which was statistically significant compared with the control and low dose groups.

CONCLUSION: Erythromycin and azithromycin have significant effects on sensation afferent nerve functions of gastrointestinal tract in rats.

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.

Impaired Emptying of the Retained Distal Stomach Causes Delayed Gastric Emptying after Pylorus-preserving Pancreaticoduodenectomy

OBJECTIVE

Delayed gastric emptying (DGE) is the major morbidity after pylorus-preserving pancreaticoduodenectomy (PPPD). Gastroscintigraphy was used to characterize food distribution in the proximal and distal stomach during emptying.

PATIENTS AND METHODS

Between October 2000 and June 2003, 20 healthy volunteers and 23 PPPD patients underwent single-phase gastric emptying scintigraphy 14 days after surgery. Scintigraphic studies of the stomach were divided into proximal and distal regions, and the ratio of proximal to distal radiation counts (P/DR) was plotted. Momentary monitor-displayed images were compared to evaluate meal distribution during emptying.

RESULTS

There were 21 eligible patients, 12 without symptoms of DGE (sDGE-) and 9 with symptoms of DGE (sDGE+). In healthy volunteers the mean P/DR value was maintained at a level of > or = 2.5, and momentary images showed dilated proximal and constricted distal stomach throughout meal emptying. In both the solid and liquid phase tests, the average P/DR value for sDGE- patients was slightly lower than that for healthy volunteers, and momentary images showed early emptying of the solid meal. The mean P/DR value for sDGE+ patients was abnormally low and remained constant throughout the assessment. Momentary images showed significant dilatation of the distal stomach, with constant full size. The odds ratio for the change in P/DR per minute decreased after surgery, especially in sDGE+ patients, indicating a loss of contractility of the distal stomach. At the 6-month follow-up, the P/DR values exhibited a normal decreasing trend but were lower for sDGE+ patients than for healthy volunteers.

CONCLUSIONS

The P/DR curve provides new insight into normal and pathological gastric function. After surgery, temporary loss of contractility of the distal stomach causes symptoms of DGE.

Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy

BACKGROUND

Pancreatic fistula (PF) and delayed gastric emptying (DGE) are, respectively, the most frightening and most frequent complications after pancreaticoduodenectomy (PD). This study was undertaken to determine which independent factors influence the development of PF and DGE after PD.

STUDY DESIGN

Between January 1996 and December 2005, 131 consecutive patients underwent a PD with pancreaticogastrostomy. A total of 22 items, entered prospectively, were examined with univariate and multivariate analysis. PF was defined as amylase-rich fluid collected by needle aspiration from an intraabdominal collection or from the drainage placed intraoperatively from day 3. DGE was defined as the need for nasogastric decompression beyond the 10(th) postoperative day.

RESULTS

PF occurred in 14 patients (10.7%), with a mean length of hospital stay of 40.1+/-16.6 days. DGE occurred in 41 patients (31.3%), with a mean length of hospital stay of 35.5+/-13.6 days. PF and DGE increased postoperative length of stay. Multivariate analysis identified two independent factors for PF: heart disease as a risk factor and arterial hypertension as a protective factor. According to these two predictive factors, the observed rates of PF ranged from 4.1% to 66.6%. Age and early enteral feeding with nasojejunal tube were independent risk factors for DGE. DGE was statistically more frequent when surgical complications occurred or when an intraabdominal collection was present.

CONCLUSIONS

Heart disease was a risk factor and arterial hypertension was a protective factor of PF. Age and early enteral feeding were independent risk factors for DGE. DGE is linked to the occurrence of other postoperative intraabdominal complications.

Type of gastrointestinal reconstruction affects postoperative recovery after pancreatic head resection

BACKGROUND/PURPOSE

The postoperative recovery of gastric motility with various reconstructions after pancreatic head resection has been reported. However, little is known about this recovery after pancreatic head resection with segmental duodenectomy (PHRSD). Some have attributed gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD) to tube gastrostomy, but its effect on gastric motility has not been investigated. In this study, the postoperative recovery after PHRSD and PPPD, and gastric motility with and without gastrostomy after PPPD were investigated.

METHODS

We analyzed the first appearance of gastric phase III motility, postoperative systemic status, and body weight (BW; n = 32). The Imanaga PPPD and PHRSD were compared because the procedures differ only in the length of the remaining duodenum. Traverso and Roux-en-Y PPPDs were compared because the two procedures are similar except for the creation of gastrostomy.

RESULTS

(1) Times to first appearance of gastric phase III motility and BW recovery were significantly better after PHRSD than after the Imanaga PPPD (P < 0.05). (2) Times to first gastric phase III motility and resumption of a regular diet as well as periods of gastric sump tube use and postoperative hospital stay were significantly shorter after the Roux-en-Y than after the Traverso PPPD (P < 0.05).

CONCLUSIONS

Preservation of as long a portion of the duodenum as possible, the choice of a Roux-en-Y duodenojejunostomy, and the avoidance of peritoneal fixation of the gastric wall may be factors that improve the recovery of gastric motility and BW after pancreatic head resection.

Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy

The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreatoduodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.

Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: A review of the literature and critical reappraisal of the implicated pathomechanism

Pylorus-preserving pancreaticoduodenectomy (PPPD) is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying (DGE) comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/Medline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy (PD) vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported (but not yet tested in large-scale studies) modification, that is, PPPD with antecolic duodenojejunostomy.

Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection

BACKGROUND

Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality.

METHODS

We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were "delayed gastric emptying," "pancreaticoduodenectomy," "Whipple procedure," "pylorus-preserving pancreaticoduodenectomy," and "complications following pancreatic resection" in various combinations.

RESULTS

A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported.

CONCLUSIONS

The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as "centralizing" pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.

Recent randomized controlled trials in pancreaticoduodenectomy

OBJECTIVES

To analyze and summarize the recent randomized controlled trials (RCTs) investigating pancreaticoduodenectomy (PD).

METHODS

A MEDLINE search was performed to identify prospective RCTs on PD published during the last decade. Eligible RCTs were analyzed using the following items: publication year, geographical area, study theme, sample size, and multicenter study. Moreover, the quality of each RCT was evaluated.

RESULTS

Thirty-four articles were eligible for review. One to 6 RCTs have been carried out annually during the recent 10 years. Geographically, 15 trials were performed in Europe, 10 trials in North America, and 9 in Asia. Studies concerning postoperative complications in the early postoperative period such as pancreatic fistula and delayed gastric emptying have been most frequent. Randomized controlled trials comparing anastomotic procedures for the remnant pancreas, standard PD versus PD with extended lymphadenectomy, and PD versus pylorus-preserving PD follow in descending order. The average sample size has been 117, and 10 RCTs had sample size less than 50. The rate of multicenter studies among all RCTs is 21%, with the rate in the most recent 5 years having increased 2-fold compared with that in the earlier period. Concerning the quality of RCTs, calculation of sample size was described in only 14 RCTs and intention to treat analysis was performed in 26 RCTs.

CONCLUSIONS

This study reviewed 34 RCTs on PD performed all over the world. Although the quality of every RCT was not satisfactory, high-grade evidence obtained by these RCTs should be applied in clinical settings to improve surgical quality and quality of life for each patient.

Early and enduring nutritional and functional results of pylorus preservation vs classic Whipple procedure for pancreatic cancer

BACKGROUND AND AIMS

There have been many supportive data that the pylorus-preserving pancreatoduodenectomy (PPPD) might be equal to the classic Whipple pancreatoduodenectomy (PD) in terms of oncological radicality. However, few reports are available on the early postoperative and enduring functional changes, nutritional status, body composition, and quality of life years after surgery. The aim of this study was to compare nutritional and functional results of the different techniques in a retrospective evaluation and prospective cohort study.

PATIENTS AND METHODS

In May 1998, the standard surgical approach in the Department of Surgery, University-Hospital Mannheim, changed from PD to PPPD. The early postoperative and enduring functional changes, quality of life, oncological radicality, and nutritional status after years were compared between 128 patients after PD and 111 patients after PPPD. In a retrospective manner, the intra- and postoperative course was evaluated. In survivors, we prospectively analyzed the functional, nutritional, and oncological outcomes after 54 months (mean) in PD and after 24 months (mean) in PPPD patients.

RESULTS

The PPPD and PD groups did not differ according to age, gender, preoperative condition, or tumor localization. The PPPD group demonstrated favorable results (p<0.05) for operation time (PPPD 341+/-74 vs PD 386+/-89 min), blood loss (793+/-565 vs 1,000+/-590 ml), blood transfusions (416+/-691 vs 653+/-776 ml), delayed gastric emptying (6 vs 13%), and hospital stay (20 vs 24 days). However, a possible bias has to be mentioned since more T4 stages were diagnosed in the PD group (3 vs 11%), and even more extended (venous) resections were performed in the PD group (7 vs 24%). Morbidity (32 vs 30%) and mortality (5 vs 3%) did not differ between the two groups. After 24 months (PPPD, n=22) and 54 months (PD, n=16), there was no difference in global quality of life in recurrence-free patients. While the preoperative body weight was reached after 4 months (median) in the PPPD group, it was reached after 6 months (p<0.05) in the PD group. Bioelectrical impedance analysis (BIA) revealed a significantly (p<0.05) lower total body water (55 vs 60%) and significantly higher total body fat (26 vs 18%) in PPPD than in PD patients. Long-term follow-up showed no significant statistical differences in survival between both groups.

CONCLUSION

Besides favorable postoperative outcome in specific aspects and equal oncological outcome of PPPD, pylorus preservation seems to have advantages in enduring functional and nutritional status years after surgery for pancreatic cancer.

Effects of Somatostatin Prophylaxis after Pylorus-preserving Pancreaticoduodenectomy: Increased Delayed Gastric Emptying and Reduced Plasma Motilin

Somatostatin inhibits gastroenteropancreatic exocrine secretion and is often used after pancreaticoduodenectomy to reduce pancreatic secretion to minimize tissue damage and pancreatic stump complications. Because our earlier clinical work saw a major increase in delayed gastric emptying (DGE) with somatostatin prophylaxis after pylorus-preserving pancreaticoduodenectomy (PPPD), this small-group study was designed to confirm or disprove that observation. From August 1997 to December 2000, a total of 23 post-PPPD patients were randomized to receive somatostatin prophylaxis [somatostain (+)] (n = 11) or not [somatostatin] (-) (n = 12). The incidence of DGE, scintographic solid-phase emptying results on day 14 postoperatively, and sequential fasting plasma motilin levels were compared, as motilin levels are related to both gastric motility and somatostatin levels. The somatostatin(+) group exhibited greatly increased patient complaints of DGE: 9 of 11 (82%) versus 3 of 12 (25%) in the somatostatin(-) group. Radiologic scintography showed somatostatin prophylaxis prolonged the half-time (T(1/2)) of solid-phase emptying: 144.5 +/- 51.4 minutes for somatostatin(+) versus 89.0 +/- 59.9 minutes for somatostatin(-) (p < 0.001). Comparing pre-PPPD and post-PPPD plasma motilin levels prior to somatostatin infusion, motilin decreased 80% in reaction to the surgery. For somatostatin(-) patients, motilin levels oscillated, or "rang," postoperatively, reaching a higher level on day 3, declined to a new record minimum on day 7, and by day 21 were 50% of the original and the slope of the recovery curve was increasing well. In somatostatin(+) patients the same ringing pattern was observed but decreased with motilin levels 30% to 70% lower than in the somatostatin(-) patients. By day 21 somatostatin(+) motilin levels were recovering but still only 20% original levels, and the slope of the recovery curve was not optimistic. On postoperative day 14 the plasma motilin levels (below approximately 6 bg/ml) correlated strongly with DGE for both groups. Despite the small sample size, the results indicated that (1) somatostatin prophylaxis significantly decreases fasting plasma motilin; (2) somatostatin prophylaxis produces lingering suppression of plasma motilin; (3) PPPD surgery itself significantly reduces fasting motilin levels with recovery to 50% normal at day 21; (4) the mechanism of somatostatin-induced DGE seems related to reduced fasting plasma motilin levels.

Effects of erythromycin on plasma gastrin, somatostatin, and motilin levels in healthy volunteers and postoperative cancer patients

Erythromycin, an antibiotic agent, is known to be a motilin receptor agonist. Motilin is a peptide hormone that regulates gastric motility. One of the gastrointestinal motility regulatory factors has been assumed to be the induction of changes in the levels of peptides (gastrin, somatostatin and motilin) in plasma. We have elucidated the effects of erythromycin by examining changes in the plasma levels of gastroinitestinal peptides. In this study, we investigated the effects of erythromycin on the plasma levels of gastrointestinal peptides (somatostatin, motilin, and gastrin) in healthy volunteers and patients with delayed gastric emptying (DGE). After a single oral administration, erythromycin caused a significant increase in plasma gastrin-like immunoreactive substance (IS) levels at 60 min. But the agent did not alter the levels of somatostatin- and motilin-IS. DGE is the most frequent postoperative complication after pylorus-preserving pancreatoduodenectomy. Molitin is assumed to be one important factor that influences DGE. We also examined the effects of erythromycin on the plasma motilin-IS levels of postoperative patients. The plasma motilin-IS levels were increased after 1 week of oral administration of erythromycin compared with preadministration. These results suggest that the pharmacologic effects of erythromycin in promoting gastric emptying are closely related to changes in plasma motilin-IS levels.

Preservation of the left gastric vein in delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy

The definition of delayed gastric emptying (DGE) after pyloric-preserving pancreaticoduodenectomy (PPPD) varies among surgeons. We compared and evaluated three different definitions reported elsewhere. In addition, we investigated the correlation between multiple surgical factors and recovery of gastric motility. First, 55 consecutive patients were reviewed to assess the three different definitions. Second, surgical factors affecting gastric motility were investigated in 46 patients showing no major complications. All 55 patients underwent PPPD, which was reconstructed with antecolic duodenojejunostomy, with aggressive lymph node dissection and with no mortality. The duration of nasogastric intubation was 2 days, and a solid diet started on the 12th postoperative day (median). Re-nasogastric intubation or emesis was observed in 12.7% of patients. Overall, DGE occurrence rate was 5.5%-29.1%, with striking differences depending on the type of definition. Technically, division of the left gastric vein was accompanied with significantly delayed removal of the nasogastric tube (3 versus 2 days, P = 0.0002) and delayed start on a solid diet (14 versus 9 days, P < 0.0001) compared with its preservation. Antecolic duodenojejunostomy after PPPD improved DGE occurrence despite aggressive surgery, and preservation of LGV accelerated restoration of gastric motility in our experiments. However, an understanding of a common definition of DGE is needed when discussing the outcome of the various interventions.

[Pancreaticoduodenectomy in the era of evidence based medicine]

The aim of this comprehensive literature review was to analyse evidence based data in the field of pancreaticoduodenectomy. Pylorus preserving does reduce mortality or morbidity of the standard procedure and could increase the risk of delayed gastric emptying. Pancreaticogastrostomy does not decrease the rate of postoperative pancreatic fistula and is not superior to the pancreaticojejunal anastomosis which is more physiological. No other procedure (chemical occlusion, octreotide, stenting) has been demonstrated to prevent pancreatic fistula. Octreotide injection could be advocated in centres where there is a high rate of pancreatic fistula, when pancreatic parenchyma is soft and the main pancreatic duct thin. Intra-abdominal drainage is not beneficial and could be associated with some morbidity. Its use needs to be further evaluated. When a resection is done for pancreatic cancer, less than 5% of patients are a live five years after surgery with postoperative mortality rate of 5% in expert centres and a high morbidity rate (25-50%). Extended lymphadenectomy does not increase survival. The first trials showed that adjuvant therapies could be beneficial for pancreatic cancers, but further trials did not confirm these findings. Adjuvant therapy is not validated for pancreatic cancers and needs to be considered only in the settings of clinical trials.

Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications

Patients undergoing pylorus-preserving pancreatoduodenenectomy (PPPD) have a risk of up to 50% for developing delayed gastric emptying (DGE) in the early postoperative course. From 1994 to August 2002, a total of 204 patients underwent PPPD for pancreatic or periampullary cancer (50%), chronic pancreatitis (42%), and other indications (8%). Retrocolic end-to-side duodenojejunostomy was performed below the mesocolon. DGE was defined by the inability to tolerate a regular diet after day 10 (DGE10) or day 14 (DGE14) postoperatively, as well as the need for a nasogastric tube at or beyond day 10 (DGE10GT). Postoperative morbidity was 38%, 30-day mortality was 2.9%, and median postoperative length of stay was 15 days. DGE occurred in 14.7% (DGE10), 5.9% (DGE14), and 6.4% (DGE10GT), respectively. After further exclusion of 21 patients (10.3%) with major complications and no possible oral intake (because of death, reoperation, or mechanical ventilation), the frequencies of DGE10, DGE14, and DGE10GT in the remaining group of 183 patients were 9%, 2%, and 2%, respectively. Multivariate analysis revealed postoperative complications (P<0.001), the presence of portalvenous hypertension (P<0.01), and tumors as indications for surgery (P<0.01) as independent risk factors for DGE10. The overall incidence of DGE was low after PPPD. In those patients experiencing DGE, however, other postoperative complications were the most important factor associated with its occurrence.

Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications

Patients undergoing pylorus-preserving pancreatoduodenenectomy (PPPD) have a risk of up to 50% for developing delayed gastric emptying (DGE) in the early postoperative course. From 1994 to August 2002, a total of 204 patients underwent PPPD for pancreatic or periampullary cancer (50%), chronic pancreatitis (42%), and other indications (8%). Retrocolic end-to-side duodenojejunostomy was performed below the mesocolon. DGE was defined by the inability to tolerate a regular diet after day 10 (DGE10) or day 14 (DGE14) postoperatively, as well as the need for a nasogastric tube at or beyond day 10 (DGE10GT). Postoperative morbidity was 38%, 30-day mortality was 2.9%, and median postoperative length of stay was 15 days. DGE occurred in 14.7% (DGE10), 5.9% (DGE14), and 6.4% (DGE10GT), respectively. After further exclusion of 21 patients (10.3%) with major complications and no possible oral intake (because of death, reoperation, or mechanical ventilation), the frequencies of DGE10, DGE14, and DGE10GT in the remaining group of 183 patients were 9%, 2%, and 2%, respectively. Multivariate analysis revealed postoperative complications (P<0.001), the presence of portalvenous hypertension (P<0.01), and tumors as indications for surgery (P<0.01) as independent risk factors for DGE10. The overall incidence of DGE was low after PPPD. In those patients experiencing DGE, however, other postoperative complications were the most important factor associated with its occurrence.

Scientific Surgery

The BJS is committed to the practice of surgery based on scientific evidence. Each month we will publish a list of randomized trials and meta-analyses collated from English-language publications. A collection of all these papers will be available in the Scientific Surgery archive which will be held on the BJS website together with links to free Medline sites where the full papers can be accessed (see below for details). If you have recently published a randomized trial that has not been featured in Scientific Surgery, the Editors would be pleased to receive a reprint and consider its inclusion.