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Werba G, Sparks AD, Lin PP, Johnson LB, Vaziri K. The PrEDICT-DGE score as a simple preoperative screening tool identifies patients at increased risk for delayed gastric emptying after pancreaticoduodenectomy. HPB (Oxford) 2022; 24:30-39. [PMID: 34274231 DOI: 10.1016/j.hpb.2021.06.417] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/17/2021] [Accepted: 06/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Morbidity after Pancreaticoduodenectomy (PD) has remained unchanged over the past decade. Delayed Gastric Emptying (DGE) is a major contributor with significant impact on healthcare-costs, quality of life and, for malignancies, even survival. We sought to develop a scoring system to aid in easy preoperative identification of patients at risk for DGE. METHODS The ACS-NSQIP dataset from 2014 to 2018 was queried for patients undergoing PD with Whipple or pylorus preserving reconstruction. 15,154 patients were analyzed using multivariable logistic regression to identify risk factors for DGE, which were incorporated into a prediction model. Subgroup analysis of patients without SSI or fistula (primary DGE) was performed. RESULTS We identified 9 factors independently associated with DGE to compile the PrEDICT-DGE score: Procedures (Concurrent adhesiolysis, feeding jejunostomy, vascular reconstruction with vein graft), Elderly (Age>70), Ductal stent (Lack of biliary stent), Invagination (Pancreatic reconstruction technique), COPD, Tobacco use, Disease, systemic (ASA>2), Gender (Male) and Erythrocytes (preoperative RBC-transfusion). PrEDICT-DGE scoring strongly correlated with actual DGE rates (R2 = 0.95) and predicted patients at low, intermediate, and high risk. Subgroup analysis of patients with primary DGE, retained all predictive factors, except for age>70 (p = 0.07) and ASA(p = 0.30). CONCLUSION PrEDICT-DGE scoring accurately identifies patients at high risk for DGE and can help guide perioperative management.
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Affiliation(s)
- Gregor Werba
- Department of Surgery, George Washington University, Washington, DC, USA.
| | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Paul P Lin
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Lynt B Johnson
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University, Washington, DC, USA
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2
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de Ponthaud C, Menegaux F, Gaujoux S. Updated Principles of Surgical Management of Pancreatic Neuroendocrine Tumours (pNETs): What Every Surgeon Needs to Know. Cancers (Basel) 2021; 13:5969. [PMID: 34885079 PMCID: PMC8656761 DOI: 10.3390/cancers13235969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/25/2021] [Accepted: 11/25/2021] [Indexed: 02/07/2023] Open
Abstract
Pancreatic neuroendocrine tumours (pNETs) represent 1 to 2% of all pancreatic neoplasm with an increasing incidence. They have a varied clinical, biological and radiological presentation, depending on whether they are sporadic or genetic in origin, whether they are functional or non-functional, and whether there is a single or multiple lesions. These pNETs are often diagnosed at an advanced stage with locoregional lymph nodes invasion or distant metastases. In most cases, the gold standard curative treatment is surgical resection of the pancreatic tumour, but the postoperative complications and functional consequences are not negligible. Thus, these patients should be managed in specialised high-volume centres with multidisciplinary discussion involving surgeons, oncologists, radiologists and pathologists. Innovative managements such as "watch and wait" strategies, parenchymal sparing surgery and minimally invasive approach are emerging. The correct use of all these therapeutic options requires a good selection of patients but also a constant update of knowledge. The aim of this work is to update the surgical management of pNETs and to highlight key elements in view of the recent literature.
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Affiliation(s)
- Charles de Ponthaud
- Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France; (C.d.P.); (F.M.)
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France
- Paris-Sorbonne University, 21 rue de l’Ecole de Médecine, 75006 Paris, France
| | - Fabrice Menegaux
- Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France; (C.d.P.); (F.M.)
- Paris-Sorbonne University, 21 rue de l’Ecole de Médecine, 75006 Paris, France
| | - Sébastien Gaujoux
- Department of General, Visceral, and Endocrine Surgery, Pitié-Salpêtrière Hospital, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France; (C.d.P.); (F.M.)
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP, Bat. Husson Mourier, 47-83 Boulevard de l’Hôpital, 75013 Paris, France
- Paris-Sorbonne University, 21 rue de l’Ecole de Médecine, 75006 Paris, France
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3
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Kaczmarek DJ, Heling DJ, Gonzalez-Carmona MA, Strassburg CP, Branchi V, Matthaei H, Kalff J, Manekeller S, Glowka TR, Weismüller TJ. Management of post-operative pancreatic fistulas following Longmire-Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy. BMC Gastroenterol 2021; 21:425. [PMID: 34772366 PMCID: PMC8588716 DOI: 10.1186/s12876-021-02000-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/28/2021] [Indexed: 01/08/2023] Open
Abstract
Background Pylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT. Methods We included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between − 100 and − 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed. Results PGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8–38) and 3 EVT film/sponge exchanges (range 1–9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT. Conclusions EVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.
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Affiliation(s)
| | - Dominik J Heling
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | | | | | - Vittorio Branchi
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Jörg Kalff
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Steffen Manekeller
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Tim R Glowka
- Department for General, Visceral, Thoracic and Vascular Surgery, University of Bonn, Bonn, Germany
| | - Tobias J Weismüller
- Department of Internal Medicine I, University of Bonn, Bonn, Germany. .,Department of Internal Medicine - Gastroenterology and Oncology, Vivantes Humboldt Hospital, Am Nordgraben 2, 13509, Berlin, Germany.
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4
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Miyazawa M, Kawai M, Hirono S, Okada KI, Kitahata Y, Kobayashi R, Ueno M, Hayami S, Miyamoto A, Yamaue H. Previous upper abdominal surgery is a risk factor for nasogastric tube reinsertion after pancreaticoduodenectomy. Surgery 2021; 170:1223-1230. [PMID: 33958204 DOI: 10.1016/j.surg.2021.03.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/28/2021] [Accepted: 03/30/2021] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Motoki Miyazawa
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuji Kitahata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ryohei Kobayashi
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masaki Ueno
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shinya Hayami
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Atsushi Miyamoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
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5
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Lee SH, Lee YH, Hur YH, Kim HJ, Choi BG. A comparative study of postoperative outcomes after stapled versus handsewn gastrojejunal anastomosis for pylorus-resecting pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2021; 25:84-89. [PMID: 33649259 PMCID: PMC7952675 DOI: 10.14701/ahbps.2021.25.1.84] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/24/2022] Open
Abstract
Backgrounds/Aims A stapler is widely used in various surgeries, and there have been recent attempts to use it for performing duodenojejunostomy and gastrojejunostomy during pancreaticoduodenectomy. This study aimed to compare the postoperative results of handsewn gastrojejunostomy (HGJ) and stapled gastrojejunstomy (SGJ) limited to pylorus-resecting pancreaticoduodenectomy (PrPD) performed by a single surgeon. Methods This retrospective study was conducted between January 2014 and March 2020, and included 131 patients who underwent PrPD performed by a single surgeon. Of the total subjects, 90 were in the HGJ group and 41 in the SGJ group. Results The mean time of surgery was significantly shorter in the stapled group than in the handsewn group (450.4±75.4 min vs. 397.1±66.5 min, p<0.001). However, there were no significant differences between the groups in the rates of postoperative pancreatic fistula, bile leak, chyle leak, intra-abdominal fluid collection, postoperative bleeding, ileus, Clavien-Dindo, rate of reoperation, and 30-day mortality, including delayed gastric emptying (DGE) (n=11 vs. n=6, p=0.92). Conclusions Gastrojejunostomy using a stapler in PrPD reduces the reconstruction time without any increase in the rate of complications, including DGE. Therefore, using a stapler for gastrojejunostomy in pancreaticoduodenectomy is feasible and safe.
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Affiliation(s)
- Sook Hyun Lee
- Department of Surgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Yun Ho Lee
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Korea
| | - Young Hoe Hur
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Korea
| | - Hee Joon Kim
- Department of Surgery, Chonnam National University Hospital and Medical School, Gwangju, Korea
| | - Byung Gwan Choi
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Korea
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Kingham TP, Aveson VG, Wei AC, Castellanos JA, Allen PJ, Nussbaum DP, Hu Y, D'Angelica MI. Surgical management of biliary malignancy. Curr Probl Surg 2021; 58:100854. [PMID: 33531120 PMCID: PMC8022290 DOI: 10.1016/j.cpsurg.2020.100854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/12/2020] [Indexed: 02/07/2023]
Affiliation(s)
| | - Victoria G Aveson
- New York Presbyterian Hospital-Weill Cornel Medical Center, New York, NY
| | - Alice C Wei
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Peter J Allen
- Duke Cancer Center, Chief, Division of Surgical Oncology, Duke University School of Medicine, Durham, NC
| | | | - Yinin Hu
- Division of Surgical Oncology, University of Maryland, Baltimore, MD
| | - Michael I D'Angelica
- Memorial Sloan Kettering Cancer Center, Professor of Surgery, Weill Medical College of Cornell University, New York, NY..
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7
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Acher AW, Barrett JR, Schwartz PB, Stahl C, Aiken T, Ronnekleiv-Kelly S, Minter RM, Leverson G, Weber S, Abbott DE. Early vs Late Readmissions in Pancreaticoduodenectomy Patients: Recognizing Comprehensive Episodic Cost to Help Guide Bundled Payment Plans and Hospital Resource Allocation. J Gastrointest Surg 2021; 25:178-185. [PMID: 32671797 PMCID: PMC7363013 DOI: 10.1007/s11605-020-04714-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/22/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Previous studies on readmission cost in pancreaticoduodenectomy patients use estimated cost data and do not delineate etiology or cost differences between early and late readmissions. We sought to identify relationships between postoperative complication type and readmission timing and cost in pancreaticoduodenectomy patients. METHODS Hospital cost data from date of discharge to postoperative day 90 were merged with 2008-2018 NSQIP data. Early readmission was within 30 days of surgery, and late readmission was 30 to 90 days from surgery. Regression analyses for readmission controlled for patient comorbidities, complications, and surgeon. RESULTS Of 230 patients included, 58 (25%) were readmitted. The mean early and late readmission costs were $18,365 ± $20,262 and $24,965 ± $34,435, respectively. Early readmission was associated with index stay deep vein thrombosis (p < 0.01), delayed gastric emptying (p < 0.01), and grade B pancreatic fistula (p < 0.01). High-cost early readmission had long hospital stays or invasive procedures. Common late readmission diagnoses were grade B pancreatic fistula requiring drainage (n = 5, 14%), failure to thrive (n = 4, 14%), and bowel obstruction requiring operation (n = 3, 11%). High-cost late readmissions were associated with chronic complications requiring reoperation. CONCLUSION Early and late readmissions following pancreaticoduodenectomy differ in both etiology and cost. Early readmission and cost are driven by common complications requiring percutaneous intervention while late readmission and cost are driven by chronic complications and reoperation. Late readmissions are frequent and a significant source of resource utilization. Negotiations of bundled care payment plans should account for significant late readmission resource utilization.
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Affiliation(s)
- Alexandra W. Acher
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - James R. Barrett
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Patrick B. Schwartz
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Chris Stahl
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Taylor Aiken
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Sean Ronnekleiv-Kelly
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Rebecca M. Minter
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Glen Leverson
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Sharon Weber
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
| | - Daniel E. Abbott
- grid.471391.9Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792 USA
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8
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Patel BY, White L, Gavriilidis P, Satyadas T, Frampton AE, Pai M. A systematic review into patient reported outcomes following pancreaticoduodenectomy for malignancy. Eur J Surg Oncol 2020; 47:970-978. [PMID: 33339639 DOI: 10.1016/j.ejso.2020.11.146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy is associated with high rates of morbidity. This combined with the psychological burden of cancer, may impact on a patient's quality of life (QoL), which can be measured by using patient-reported outcomes (PRO). OBJECTIVE To perform a systematic review to evaluate the measurement of PRO after pancreaticoduodenectomy for cancer. METHODS 7 different databases were searched using 2 groups of search terms, one relating to pancreaticoduodenectomy, and one to PRO. Three authors screened the search results independently in a systematic manner based on predefined inclusion and exclusion criteria. RESULTS 27 studies, with 2173 eligible patients were included in the final analysis. Most of the included studies used validated instruments. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire was most popular and used in 12 studies. The methodology of all included studies was also scrutinised. 12 studies were deemed to have high quality methodology according to pre-defined criteria. CONCLUSION The instruments and methods used to measure PRO are variable. The quality of PRO within the available literature has improved over time, as has the number of studies measuring PRO. PRO should be measured with uniformity in future trials so that patients can be provided with more comprehensive information regarding post-operative recovery and QoL during the shared decision-making process preoperatively.
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Affiliation(s)
- Bhavik Y Patel
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Laura White
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Paschalis Gavriilidis
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Thomas Satyadas
- Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, UK
| | - Adam E Frampton
- HPB Surgical Unit, Royal Surrey County Hospital Foundation NHS Trust, Guildford, Surrey, GU2 7XX, UK; Dept. of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, The Leggett Building, Daphne Jackson Road, Guildford, University of Surrey, Surrey, GU2 7WG, UK; Division of Cancer, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0NN, UK
| | - Madhava Pai
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK.
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Is delayed gastric emptying associated with pylorus ring preservation in patients undergoing pancreaticoduodenectomy? Asian J Surg 2020; 44:137-142. [PMID: 32951961 DOI: 10.1016/j.asjsur.2020.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/OBJECTIVE A high incidence of delayed gastric emptying (DGE) is observed in patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). However, DGE incidence after pancreaticoduodenectomy varied because of heterogeneity in surgical techniques, number of surgeons, and DGE definition. This study aimed to evaluate the difference in the incidence of DGE following PpPD and pylorus-resecting pancreaticoduodenectomy (PrPD) and to analyze the risk factor of DGE by a single surgeon to determine whether pylorus preservation was the main factor of DGE. METHODS This retrospective study included 115 patients who underwent PpPD (with pylorus ring preservation) and PrPD (without pylorus ring preservation) with laparotomy by a single surgeon at a tertiary center. RESULTS The overall incidence of DGE was 23.1%. For comparison, 20 patients (39.2%) in the PpPD group and 5 patients (8.8%) in the PrPD group had DGE, showing a significant difference (p < 0.001). On univariate analysis, hypertension, PpPD, operation time, intraoperative bleeding, packed red blood cell transfusion ≥500 mL, and clinically relevant postoperative pancreatic fistula were associated with DGE. Multivariate analysis identified pylorus preservation and clinically relevant postoperative pancreatic fistula as risk factors for DGE. CONCLUSION Compared with PpPD, PrPD significantly reduced the incidence of DGE.
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10
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A rare cause of anastomotic stricture after distal gastrectomy: management with an endoscopic scissor. VideoGIE 2020; 5:342-343. [PMID: 32817924 PMCID: PMC7426617 DOI: 10.1016/j.vgie.2020.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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Hu Y, Johnston LE, Shami VM, Bauer TW, Adams RB, Stukenborg GJ, Zaydfudim VM. Comparative Effectiveness of Resection vs Surveillance for Pancreatic Branch Duct Intraductal Papillary Mucinous Neoplasms With Worrisome Features. JAMA Surg 2019; 153:225-232. [PMID: 29167899 DOI: 10.1001/jamasurg.2017.4587] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Yinin Hu
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Lily E. Johnston
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Vanessa M. Shami
- Department of Gastroenterology, University of Virginia School of Medicine, Charlottesville
| | - Todd W. Bauer
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Reid B. Adams
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - George J. Stukenborg
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville,Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia School of Medicine, Charlottesville,Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville
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12
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Yu YD, Han JH, Jung SW, Kim DS. Safety and efficacy of peripheral nutrition fluid (MG-TNA®) in patients undergoing surgery for hepatobiliary and pancreatic disease: Results of a phase 4 trial. Ann Hepatobiliary Pancreat Surg 2019; 23:133-137. [PMID: 31225414 PMCID: PMC6558125 DOI: 10.14701/ahbps.2019.23.2.133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/28/2019] [Accepted: 03/29/2019] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Essential nutritional support and nutrition therapy for patients with hepatobiliary and pancreatic diseases undergoing surgery is critical, as it may improve clinical outcome. How to implement rational fluid therapy and nutritional support after surgery and effectively protect organ function is crucial for postoperative recovery. The aim this study was to examine the safety and efficacy of peripheral nutrition fluid (MG-TNA®) in patients undergoing surgery for hepatobiliary and pancreatic disease. Methods All adult patients undergoing surgery for hepatobiliary and pancreatic disease received peripheral nutrition fluid (MG-TNA®) on the second postoperative day for 3 days. During administration of parenteral nutrition, patients were closely monitored for adverse effects (primary endpoint). Secondary endpoints included nutritional parameters such as serum prealbumin, transferrin, and creatine kinase (CK) levels. Results Thirty patients completed the study and were included in the full analysis set. There was no evidence of metabolic complications such as hyperglycemia, azotemia, hypertriglyceridemia, metabolic acidosis and hypokalemia. In addition, there were no adverse effects. There was a significant decrease in serum prealbumin and CK on the third postoperative day (p<0.0001). Although not statistically significant, serum transferrin levels tended to decrease (p=0.0519). Conclusions Administration of peripheral nutrition fluid (MG-TNA®) during postoperative period in patients undergoing surgery for hepatobiliary and pancreatic disease proved to be safe with improvement of the nutritional state of the patient.
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Affiliation(s)
- Young-Dong Yu
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jae-Hyun Han
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, St. Vincent's Hospital, Suwon, Korea
| | - Sung-Won Jung
- Department of Surgery, Inje University Paik Hospital, Ilsan, Korea
| | - Dong-Sik Kim
- Division of HBP Surgery & Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Ellis RJ, Gupta AR, Hewitt DB, Merkow RP, Cohen ME, Ko CY, Bilimoria KY, Bentrem DJ, Yang AD. Risk factors for post-pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra-abdominal infection. J Surg Oncol 2019; 119:925-931. [PMID: 30737792 PMCID: PMC7747058 DOI: 10.1002/jso.25398] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/08/2019] [Accepted: 01/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), but the rate of DGE in the absence of other intra-abdominal complications is poorly understood. The objectives of this study were to define the incidence of DGE and identify risk factors for DGE in patients without pancreatic fistula or other intra-abdominal infections. METHODS Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy variables to identify patients with DGE following PD without evidence of fistula or intra-abdominal infection. Multivariable models were developed to assess preoperative, intraoperative, and technical factors associated with DGE. RESULTS The rate of DGE was 11.7% in 10502 cases without pancreatic fistula or intra-abdominal infection. Patients were more likely to develop DGE if age ≥75 (odds ratio [OR], 1.22; P = 0.003), male (OR, 1.29; P < 0.001), underwent pylorus-sparing PD (OR, 1.27; P = 0.004), or had a prolonged operative time (OR, 1.38 if greater than seven vs less than 5 hours; P = 0.005). Factors not associated with DGE included BMI, pathologic indication, and surgical approach. CONCLUSION The incidence of DGE after PD is notable even in patients without other abdominal complications. Identification of patients at increased risk for DGE may aid patient counseling as well as decisions regarding surgical technique, enteral feeding access, and enhanced-recovery pathways.
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Affiliation(s)
- Ryan J. Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Aakash R. Gupta
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - D. Brock Hewitt
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan P. Merkow
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Mark E. Cohen
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Clifford Y. Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Karl Y. Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - David J. Bentrem
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Anthony D. Yang
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
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Klaiber U, Probst P, Büchler MW, Hackert T. Pylorus preservation pancreatectomy or not. Transl Gastroenterol Hepatol 2017; 2:100. [PMID: 29264438 DOI: 10.21037/tgh.2017.11.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is the treatment of choice for various benign and malignant tumors of the pancreatic head or the periampullary region, and the only hope for cure in patients with cancer at this side. While it has been associated with high morbidity and mortality rates in the last century, its centralization in specialized institutions together with refinements in the operative technique and better management of postoperative complications have made PD a standardized, safe procedure. Besides the classic Whipple procedure including distal gastrectomy, two variations of PD with or without pylorus resection, but preservation of the entire stomach in either procedure exist today. Pylorus-preserving PD has gained wide acceptance as standard procedure and is being performed by an increasing number of pancreatic surgeons. After its oncological adequacy was questioned initially, pylorus-preserving PD was shown to be equivalent to the classic Whipple procedure regarding tumor recurrence and long-term survival. Moreover, operation time and blood loss were shown to be reduced in the pylorus-preserving procedure and benefits in nutritional status and quality of life were observed. However, preservation of the pylorus has been suggested to result in an increased incidence of postoperative delayed gastric emptying (DGE). In this context, pylorus-resecting PD has become popular especially in Japan with the aim to prevent DGE by removal of the pylorus but preservation of the stomach. In contrast to positive results from early studies, latest high-quality randomized controlled trial (RCT) data show that pylorus resection does not reduce DGE compared to the pylorus-preserving operation. Non-superiority of pylorus resection was also confirmed in current meta-analysis on this topic. This article summarizes the existing evidence on PD with or without pylorus preservation and derives recommendations for daily practice.
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Affiliation(s)
- Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Does Pancreaticogastrostomy Decrease the Occurrence of Delayed Gastric Emptying After Pancreatoduodenectomy? Pancreas 2017; 46:1064-1068. [PMID: 28787334 DOI: 10.1097/mpa.0000000000000892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES This study investigates the factors that could influence the development of delayed gastric emptying (DGE) after pancreatoduodenectomy (PD). Delayed gastric emptying is a common complication after PD. The postoperative course is affected by a lengthened hospital stay, a decrease of the patients' quality of life, and a delayed adjuvant treatment. METHODS From January 2000 to December 2012, 257 patients underwent PD in the same center. Forty-six variables were retrospectively extracted from medical records. Delayed gastric emptying (grades A, B, and C) was defined by the International Study Group of Pancreatic Surgery classification. Univariate and multivariate analyses were performed to identify factors associated with DGE. RESULTS Delayed gastric emptying occurred in 133 patients (51.8%), 89 grade A (66.9%), 27 grade B (20.3%), and 17 grade C (12.8%). Biliary fistula (odds ratio [OR], 8.87; 95% confidence interval [CI], 2.07-37.99, P = 0.003), sepsis (OR, 8.02; 95% CI, 3.22-19.99; P < 0.0001), and intra-abdominal collection (OR, 3.43; 95% CI, 1.06-11.06; P = 0.039) were identified as independent risk factors for DGE, whereas pancreaticogastrostomy (OR, 0.32; 95% CI, 0.16-0.64; P < 0.001) decreased the occurrence of DGE. CONCLUSIONS Delayed gastric emptying was linked to the occurrence of postoperative intra-abdominal complications, and reconstruction by pancreaticogastrostomy was beneficial by decreasing its incidence.
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Neoadjuvant Therapy for Pancreatic Cancer: Systematic Review of Postoperative Morbidity, Mortality, and Complications. Am J Clin Oncol 2017; 39:302-13. [PMID: 26950464 DOI: 10.1097/coc.0000000000000278] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this review was to assess whether neoadjuvant chemotherapy and chemoradiotherapy (CRT) result in differential postoperative morbidity and mortality as compared with pancreatic tumor resection surgery alone. Using PRISMA guidelines and the PubMed search engine, we reviewed all prospective phase II trials of neoadjuvant chemotherapy and CRT for pancreatic cancer that examined postoperative morbidities and mortalities. A total of 30 articles were identified, collated, and analyzed. Risks of postoperative complications vary based on trial. With surgery alone, the most common postoperative complications included delayed gastric emptying (DGE) (17% to 24%), pancreatic fistula (10% to 20%), anastomotic leaks (0% to 15%), postoperative bleeding (2% to 13%), and infections/sepsis (17% to 20%). With surgery alone, the mortality was <5%. Neoadjuvant chemotherapy showed comparable fistula rates (3% to 4%), leaks (3% to 11%), infection (3% to 7%), with mortality 0% to 4% in all but 1 study. CRT for resectable/borderline resectable patients also showed comparable complication rates: DGE (6% to 15%), fistulas (2% to 3%), leaks (3% to 7%), bleeding/hemorrhage (2% to 13%), infections/sepsis (3% to 19%), with 9/13 studies showing a mortality of ≤4%. As compared with initially borderline/resectable tumors, CRT for initially unresectable tumors (despite less data) showed higher complication rates: DGE (13% to 33%), fistulas (3% to 25%), infections/sepsis (3% to 16%). However, the confounding factor of the potentially higher tumor burden as an associative agent remains. The only parameters slightly higher than historical surgery-only complication rates were leaks and bleeding/hemorrhage (13% to 20%). Mortality rates in these patients were consistently 0%, with 2 outliers. Hence, neoadjuvant chemotherapy/CRT is safe from a postoperative complication standpoint, without significant increases in complication rates compared with surgery alone. Resectable and borderline resectable patients have fewer complications as compared with unresectable patients, although data for the latter are lacking.
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Yang XW, Chen JY, Yan WL, Du J, Wen ZJ, Yan XZ, Yang PH, Yang J, Zhang BH. Case-control study of the efficacy of retrogastric Roux-en-Y choledochojejunostomy. Oncotarget 2017; 8:81226-81234. [PMID: 29113382 PMCID: PMC5655277 DOI: 10.18632/oncotarget.16006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 02/28/2017] [Indexed: 01/04/2023] Open
Abstract
The traditional, retrocolic/antegastric Roux-en-Y choledochojejunostomy is technically complicated, and the incidence of postoperative complications remains high. Here we report the outcome of 59 consecutively treated patients (study group, SG) that underwent a new choledochojejunostomy method in which the jejunal loop is passed behind the antrum pyloricum (retrogastric route). A retrospective comparison was made between this group of patients and 187 patients (control group, CG) that underwent conventional Roux-en-Y choledochojejunostomy (antegastric route). Baseline clinicopathological characteristics were similar in both groups, except for the BMI, which was significantly higher in the SG. The time spent on constructing the anastomosis, as well as overall postoperative complications, did not differ between groups. Compared with the CG, the incidence of postoperative delayed gastric emptying was decreased in the SG, and the time elapsed before the patients' first postoperative liquid food consumption was shorter. We ascribe these beneficial effects to the superiority of the modified, retropyloric choledochojejunostomy approach, and propose that this surgical technique is particularly suitable for obese patients, especially those with a short ascending bowel loop.
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Affiliation(s)
- Xin-Wei Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jun-Yi Chen
- Department of General Surgery, the Fourth People's Hospital of Shanghai, Shanghai, China
| | - Wen-Liang Yan
- Department of Dermatology, Jinling Hospital, Nanjing, China
| | - Jing Du
- Second Military Medical University, Shanghai, China
| | - Zhi-Jian Wen
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Xing-Zhou Yan
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Ping-Hua Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jue Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Bao-Hua Zhang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
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Liu Y, Xue X. Systematic review of peri-operative nutritional support for patients undergoing hepatobiliary surgery. Hepatobiliary Surg Nutr 2015; 4:304-12. [PMID: 26605277 DOI: 10.3978/j.issn.2304-3881.2014.12.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Malnutrition is prevalent among peri-operative patients undergoing hepatobiliary surgery and is an important prognostic factor. Both hepatobiliary disease and surgical trauma significantly affects body's metabolism and environment. Therefore, it is very important for patients with liver diseases undergoing hepatobiliary surgery to receive essential nutritional support during peri-operative period. METHODS We summarized our clinical experience and reviewed of related literature to find the way for implementing the appropriate nutritional strategy. RESULTS We found after comprehensively evaluating nutrition status, function of liver and gastrointestinal tract, nutritional strategy would be selected correctly. In severe malnutrition, initiation of enteral nutrition (EN) and/or parenteral nutrition (PN) with essential or special formulae is often recommended. Especially nasojejunal feeding is indicated that early application can improve nutritional status and liver function, reduce complications and prolong survival. CONCLUSIONS The reasonable peri-operative nutritional support therapy can improve the effect of surgical treatment and promote the patients' recovery.
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Affiliation(s)
- Yin Liu
- Intensive Care Unit, Aerospace Central Hospital, Aerospace Clinical Medical College Affiliated to Peking University, Beijing 100049, China
| | - Xiaoyan Xue
- Intensive Care Unit, Aerospace Central Hospital, Aerospace Clinical Medical College Affiliated to Peking University, Beijing 100049, China
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Haltmeier T, Kaderli RM, Kurmann A, Beldi G, Angst E, Candinas D, Gloor B. Delayed Gastric Emptying after Pancreaticoduodenectomy: Analysis of Associated Risk Factors. Am Surg 2015. [DOI: 10.1177/000313481508101119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tobias Haltmeier
- University Clinic for Visceral Surgery and Medicine Inselspital Bern University Hospital Bern, Switzerland
- Department of Surgery Division of Acute Care Surgery and Surgical Critical Care Los Angeles County and University of Southern California Medical Center Los Angeles, California
| | - Reto M. Kaderli
- University Clinic for Visceral Surgery and Medicine Inselspital Bern University Hospital Bern, Switzerland
| | - Anita Kurmann
- University Clinic for Visceral Surgery and Medicine Inselspital Bern University Hospital Bern, Switzerland
- Department of Medicine Division of Endocrinology, Diabetes and Metabolism Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts
| | - Guido Beldi
- University Clinic for Visceral Surgery and Medicine Inselspital Bern University Hospital Bern, Switzerland
| | - Eliane Angst
- University Clinic for Visceral Surgery and Medicine Inselspital Bern University Hospital Bern, Switzerland
- Clinic for Surgery and Orthopedics Cantonal Hospital of Schaffhausen Schaffhausen, Switzerland
| | - Daniel Candinas
- University Clinic for Visceral Surgery and Medicine Inselspital Bern University Hospital Bern, Switzerland
| | - Beat Gloor
- University Clinic for Visceral Surgery and Medicine Inselspital Bern University Hospital Bern, Switzerland
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Nakamura T, Ambo Y, Noji T, Okada N, Takada M, Shimizu T, Suzuki O, Nakamura F, Kashimura N, Kishida A, Hirano S. Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy. J Gastrointest Surg 2015; 19:1425-32. [PMID: 26063079 DOI: 10.1007/s11605-015-2870-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/30/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND One of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5-20%. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal end-to-side anastomosis in SSPPD. METHODS Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007-March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010-September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively. RESULTS The incidence of DGE was 21.3% in the SSPPD-ETS group and 2.5% in the SSPPD-STS group (P = 0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different. CONCLUSIONS The greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD.
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Affiliation(s)
- Toru Nakamura
- Department of Surgery, Teine-Keijinkai Hospital, Teine-ku, Sapporo, Japan,
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John GK, Singh VK, Pasricha PJ, Sinha A, Afghani E, Warren D, Sun Z, Desai N, Walsh C, Kalyani RR, Hall E, Hirose K, Makary MA, Stein EM. Delayed Gastric Emptying (DGE) Following Total Pancreatectomy with Islet Auto Transplantation in Patients with Chronic Pancreatitis. J Gastrointest Surg 2015; 19:1256-61. [PMID: 25986058 DOI: 10.1007/s11605-015-2848-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence and factors associated with delayed gastric emptying (DGE) in patients undergoing total pancreatectomy with islet auto transplantation (TP-IAT) for chronic pancreatitis are unknown. METHODS A retrospective study of all patients who underwent TP-IAT at Johns Hopkins Hospital (JHH) from August 2011 to November 2014 was performed. The International Study Group of Pancreatic Surgery (ISGPS) clinical grading of DGE was used in this study. KEY RESULTS A total of 39 patients with chronic pancreatitis underwent TP-IAT during the study period. The prevalence of DGE following TP-IAT was 35.9%. Twenty-five patients (64.1%) had no DGE, 10 (25.6%) had grade A, 2 (5.1%) had grade B, and 2 patients (5.1%) had grade C DGE. Patients with DGE had 5.7-fold higher odds of having a hospital length of stay (LOS) greater than 14 days (OR 5.70, 95% CI 1.37-23.76, p = 0.02). Patients undergoing laparoscopic TP-IAT had significantly shorter LOS (10.5 vs. 14 days, p = 0.02) and lower need for prokinetics (0.01) during the postoperative course. CONCLUSIONS AND INFERENCES DGE is common after TP-IAT and can prolong LOS. Laparoscopic TP-IAT lowers LOS and need for prokinetics postoperatively. Further studies are needed to determine if laparoscopic approaches will improve long-term dysmotility.
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Affiliation(s)
- George K John
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1830 East Monument St, Suite 429, Baltimore, MD, 21287, USA
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Beisani M, Dopazo C, Blanco L, Caralt M, Sapisochín G, Olsina JJ, Balsells J. Antecolic anastomosis and delayed gastric emptying: still a benefit in patients without intra-abdominal complications? Eur Surg 2015. [DOI: 10.1007/s10353-015-0311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Pancreaticoduodenectomy, the Whipple resection, is a complex operation that is commonly performed for patients with pancreatic ductal adenocarcinoma and other malignant or benign lesions in the head of the pancreas. It can be done with low morbidity and mortality rates, particularly when performed at high-volume hospitals and by high-volume surgeons. While it has been conventionally reserved for patients with early-stage malignant disease, it is being used increasingly for patients with locally extensive tumors who have undergone neoadjuvant therapy and downstaging. This article summarizes the role of pancreaticoduodenectomy for the treatment of patients with pancreatic cancer. It highlights the surgical staging of disease, the technical aspects of the operation and perioperative care, and the oncologic outcome.
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Affiliation(s)
- Timothy R Donahue
- Departments of Surgery, Division of General Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA; Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA.
| | - Howard A Reber
- Molecular and Medical Pharmacology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
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Zhang XF, Yin GZ, Liu QG, Liu XM, Wang B, Yu L, Liu SN, Cui HY, Lv Y. Does Braun enteroenterostomy reduce delayed gastric emptying after pancreaticoduodenectomy? Medicine (Baltimore) 2014; 93:e48. [PMID: 25101987 PMCID: PMC4602449 DOI: 10.1097/md.0000000000000048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Whether an additional Braun enteroenterostomy is necessary in reducing delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) has not yet been well investigated. Herein, in this retrospective study, 395 consecutive cases of patients undergoing classic PD from 2009 to 2013 were reviewed. Patients with and without Braun enteroenterostomy were compared in preoperative baseline characteristics, surgical procedure, postoperative diagnosis, and morbidity including DGE. The DGE was defined and classified by the International Study Group of Pancreatic Surgery recommendation. The incidence of DGE was similar in patients with or without Braun enteroenterostomy following PD (37/347, 10.7% vs 8/48, 16.7%, P = 0.220). The patients in the 2 groups were not different in patient characteristics, lesions, surgical procedure, or postoperative complications, although patients without Braun enteroenterostomy more frequently presented postoperative vomiting than those with Braun enteroenterostomy (33.3% vs 15.3%, P = 0.002). Bile leakage, pancreatic fistula, and intraperitoneal abscess were risk factors for postoperative DGE (all P < 0.05). Prokinetic agents and acupuncture were effective in symptom relief of DGE in 24 out of 45 patients and 12 out of 14 patients, respectively.The additional Braun enteroenterostomy following classic PD was not associated with a decreased rate of DGE. Postoperative abdominal complications were strongly correlated with the onset of DGE. Prokinetic agents and acupuncture could be utilized in some patients with DGE.
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Affiliation(s)
- Xu-Feng Zhang
- Department of Hepatobiliary Surgery (X-FZ, G-ZY, Q-GL, X-ML, BW, LY, S-NL, YL); Institute of Advanced Surgical Technology and Engineering (X-FZ, X-ML, YL); Department of Chinese Acupuncture and Moxibustion, First Affiliated Hospital of Medical College, Xi'an Jiaotong University (H-YC), Xi'an, China
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Cao SS, Lin QY, He MX, Zhang GQ. Effect of antecolic versus retrocolic reconstruction for gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A meta-analysis. SURGICAL PRACTICE 2014. [DOI: 10.1111/1744-1633.12055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Shuang-Shuang Cao
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Qi-Yuan Lin
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Man-Xi He
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
| | - Guang-Quan Zhang
- Department of Hepatobiliary Surgery; Sixth People's Hospital of Chengdu; Chengdu China
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Imamura N, Chijiiwa K, Ohuchida J, Hiyoshi M, Nagano M, Otani K, Kondo K. Prospective randomized clinical trial of a change in gastric emptying and nutritional status after a pylorus-preserving pancreaticoduodenectomy: comparison between an antecolic and a vertical retrocolic duodenojejunostomy. HPB (Oxford) 2014; 16:384-94. [PMID: 23991719 PMCID: PMC3967891 DOI: 10.1111/hpb.12153] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 05/29/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although an antecolic duodenojejunostomy was reported to reduce post-operative delayed gastric emptying (DGE) compared with a retrocolic duodenojejunostomy after a pylorus-preserving pancreaticoduodenectomy (PPPD), the long-term effects of these procedures have rarely been studied. The aim of this prospective, randomized, clinical trial was to investigate the influence of the reconstruction route on post-operative gastric emptying and nutrition. METHODS Reconstruction was performed in 116 patients with an antecolic duodenojejunostomy (A group, n = 58) or a vertical retrocolic duodenojejunostomy (VR group, n = 58). Post-operative complications, including DGE, gastric emptying variables assessed by (13) C-acetate breath test and nutrition, were compared between the two groups for 1 year post-operatively. RESULTS The incidence of DGE was not significantly different between the procedures (A group: 12.1%; VR group: 20.7%, P = 0.316). At post-operative month 1, gastric emptying was prolonged in the VR versus the A group but not significantly so. At post-operative month 6, gastric emptying was accelerated significantly in the A versus the VR group. Post-operative weight recovery was significantly better in the VR versus the A group at post-operative month 12 (percentage of pre-operative weight, A group: 93.8 ± 1.2%; VR group: 98.5 ± 1.3%, P = 0.015). CONCLUSIONS A vertical retrocolic duodenojejunostomy was an acceptable procedure for the lower incidence of DGE and may contribute to better weight gain affected by moderate gastric emptying.
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Affiliation(s)
| | - Kazuo Chijiiwa
- Correspondence Kazuo Chijiiwa, Department of Surgical Oncology and Regulation of Organ Function, Miyazaki University School of Medicine, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan. Tel: +81 985 85 2905. Fax: +81 985 85 2808. E-mail:
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Antecolic versus retrocolic route of the gastroenteric anastomosis after pancreatoduodenectomy: a randomized controlled trial. Ann Surg 2014; 259:45-51. [PMID: 24096769 DOI: 10.1097/sla.0b013e3182a6f529] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate the relationship between the route of gastroenteric (GE) reconstruction after pancreatoduodenectomy (PD) and the postoperative incidence of delayed gastric emptying (DGE). BACKGROUND DGE is one of the most common complications after PD. Recent studies suggest that an antecolic route of the GE reconstruction leads to a lower incidence of DGE, compared to a retrocolic route. In a nonrandomized comparison within our trial center, we found no difference in DGE after antecolic or retrocolic GE reconstruction. METHODS Ten middle- to high-volume centers participated in the patient inclusion. Patients scheduled for PD who gave written informed consent were included and randomized during surgery after resection. Standard operation was a pylorus-preserving PD. Primary endpoint was DGE. Secondary endpoints included other complications and length of hospital stay. RESULTS There were 125 patients in the retrocolic group, and 121 patients in the antecolic group. Baseline and treatment characteristics did not differ between the study groups. In the retrocolic group, 45 patients (36%) developed clinically relevant DGE compared with 41 (34%) in the antecolic group (absolute risk difference: 2.1%; 95% confidence interval: -9.8% to 14.0%). There were no differences in need for postoperative (par)enteral nutritional support, other complications, hospital mortality, and median length of hospital stay. CONCLUSIONS The route of GE reconstruction after PD does not influence the postoperative incidence of DGE or other complications. The etiology and treatment of DGE, which occurs frequently after both procedures, need further investigation. The GE reconstruction after PD should be routed according to the surgeon's preference.
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Zhu XH, Wu YF, Qiu YD, Jiang CP, Ding YT. Effect of early enteral combined with parenteral nutrition in patients undergoing pancreaticoduodenectomy. World J Gastroenterol 2013; 19:5889-5896. [PMID: 24124335 PMCID: PMC3792338 DOI: 10.3748/wjg.v19.i35.5889] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 06/17/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of early enteral nutrition (EEN) combined with parenteral nutritional support in patients undergoing pancreaticoduodenectomy (PD).
METHODS: From January 2006, all patients were given EEN combined with parenteral nutrition (PN) (EEN/PN group, n = 107), while patients prior to this date were given total parenteral nutrition (TPN) (TPN group, n = 67). Venous blood samples were obtained for a nutrition-associated assessment and liver function tests on the day before surgery and 6 d after surgery. The assessment of clinical outcome was based on postoperative complications. Follow-up for infectious and noninfectious complications was carried out for 30 d after hospital discharge. Readmission within 30 d after discharge was also recorded.
RESULTS: Compared with the TPN group, a significant decrease in prealbumin (PAB) (P = 0.023) was seen in the EEN/PN group. Total bilirubin (TB), direct bilirubin (DB) and lactate dehydrogenase (LDH) were significantly decreased on day 6 in the EEN/PN group (P = 0.006, 0.004 and 0.032, respectively). The rate of grade I complications, grade II complications and the length of postoperative hospital stay in the EEN/PN group were significantly decreased (P = 0.036, 0.028 and 0.021, respectively), and no hospital mortality was observed in our study. Compared with the TPN group (58.2%), the rate of infectious complications in the EEN/PN group (39.3%) was significantly decreased (P = 0.042). Eleven cases of delayed gastric emptying were noted in the TPN group, and 6 cases in the EEN/PN group. The rate of delayed gastric emptying and hyperglycemia was significantly reduced in the EEN/PN group (P = 0.031 and P = 0.040, respectively).
CONCLUSION: Early enteral combined with PN can greatly improve liver function, reduce infectious complications and delayed gastric emptying, and shorten postoperative hospital stay in patients undergoing PD.
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Zhu X, Wu Y, Qiu Y, Jiang C, Ding Y. Comparative analysis of the efficacy and complications of nasojejunal and jejunostomy on patients undergoing pancreaticoduodenectomy. JPEN J Parenter Enteral Nutr 2013; 38:996-1002. [PMID: 23963691 DOI: 10.1177/0148607113500694] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The efficacy and feeding-related complications of a nasojejunal feeding tube and jejunostomy after pancreaticoduodenectomy (PD) was investigated with a randomized, controlled clinical trial at the Affiliated Drum Tower Hospital. METHODS Sixty-eight patients who underwent PD in the Department of Hepatobiliary Surgery were randomly divided into 2 groups: 34 patients received enteral feeding via a nasojejunal tube (NJT group) and 34 patients received enteral feeding via a jejunostomy tube (JT group). The assessment of clinical outcome was based on postoperative investigation of complications. The second part of the assessment included tube related complications and an index on catheter efficiency. RESULTS There were 15 cases with infectious complications in the JT group and 13 cases in the NJT group, and there was no significant difference in the rate of infectious complications between the 2 groups. The rate of intestinal obstruction and delayed gastric emptying was significantly decreased in the NJT group (P < .05). Catheter-related complications were more common in the JT group as compared with the NJT group (35.3% vs 20.6%, P < .05). The time for removal of the feeding tube and nasogastric tube was significantly decreased in the NJT group. The postoperative hospital stay in the NJT group was significantly decreased (P < .05), and there was no hospital mortality in this study. CONCLUSION Nasojejunal feeding is safer than jejunostomy, and it is associated with only minor complications. Nasojejunal feeding can significantly decrease the incidence of delayed gastric emptying and shorten the postoperative hospital stay.
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Affiliation(s)
- Xinhua Zhu
- Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yafu Wu
- Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yudong Qiu
- Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chunping Jiang
- Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yitao Ding
- Department of Hepatobiliary Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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Ramia JM, de la Plaza R, Quiñones JE, Veguillas P, Adel F, García-Parreño J. [Gastroenteric reconstruction route after pancreaticoduodenectomy: antecolic versus retrocolic]. Cir Esp 2013; 91:211-6. [PMID: 23452819 DOI: 10.1016/j.ciresp.2013.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 12/20/2012] [Accepted: 01/11/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) is a relatively common complication after cephalic pancreaticoduodenectomy (CPD). Its origin is not very clear, and it is believed that its appearance is due to multiple factors (hormones, appearance of other complications, particularly pancreatic fistulas, and the surgical technique). Among the technical aspects associated with DGE, it has been proposed that the route of gastroenteric reconstruction (antecolic or retrocolic) could have an effect on its incidence. MATERIAL AND METHODS A systemic review was made of the literature, searching for articles that compared both reconstruction routes after CPD, finding only 11 articles: 4 randomised clinical trials, one prospective study, and 6 retrospective studies. A meta-analysis could not be performed on them, due to the large methodological differences between them. RESULTS In the 4 randomised studies, 2 were in favour of the antecolic route, and 2 did not observe any differences between either of them. The antecolic route obtained a much lower DGE rate than the retrocolic one in the only prospective study. In 4 of the retrospective studies the antecolic route obtained a very low rate. The results of both routes were similar in another 2 retrospective studies, with the retrocolic route slightly better in one of them. CONCLUSIONS Using the published literature, the gastric reconstruction route associated with less DGE after CPD cannot currently be determined.
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Affiliation(s)
- José M Ramia
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Spain.
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Gawlas I, Sethi M, Winner M, Epelboym I, Lee JL, Schrope BA, Chabot JA, Allendorf JD. Readmission after pancreatic resection is not an appropriate measure of quality. Ann Surg Oncol 2012; 20:1781-7. [PMID: 23224136 DOI: 10.1245/s10434-012-2763-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND Hospital readmission has been proposed as a metric for quality of medical and surgical care. We examined our institutional experience with readmission after pancreatic resection, and assessed factors predictive of readmission. METHODS We reviewed 787 pancreatic resections performed at a single institution between 2006 and 2010. Univariate and multivariate logistic regression models were used to assess the relationships between preoperative and postoperative characteristics and readmission. Reasons for hospital readmission were examined in detail. RESULTS We found the 30-day readmission rate after pancreatic resection to be 11.6 %. In univariate analysis, young age, pancreaticoduodenectomy versus other operations, open versus laparoscopic technique, fistula formation, the need for reoperation, and any complication during the index hospitalization were predictive of readmission. In multivariate analysis, only young age and postoperative complication were predictive of readmission. Vascular resection, postoperative ICU care, length of stay, and discharge disposition were not associated with readmission. The most common reasons for readmission were leaks, fistulas, abscesses, and wound infections (45.1 %), delayed gastric emptying (12.1 %), venous thrombosis (7.7 %), and GI bleeding (7.7 %). CONCLUSIONS We found the vast majority of readmissions after pancreatic resection were to manage complications related to the operation and were not due to poor coordination of care or poor discharge planning. Because evidence-based measures to prevent these surgical complications do not exist, we cannot support the use of readmission rates themselves as a quality indicator after pancreatic surgery.
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Affiliation(s)
- Irmina Gawlas
- Department of Surgery, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA
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The use of the continuous suture technique in dunking pancreatojejunostomy without stenting. Surg Today 2012; 43:1008-12. [DOI: 10.1007/s00595-012-0363-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Accepted: 07/05/2012] [Indexed: 12/17/2022]
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Kunstman JW, Fonseca AL, Ciarleglio MM, Cong X, Hochberg A, Salem RR. Comprehensive analysis of variables affecting delayed gastric emptying following pancreaticoduodenectomy. J Gastrointest Surg 2012; 16:1354-61. [PMID: 22450953 DOI: 10.1007/s11605-012-1873-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 03/07/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), and criteria for its clinical diagnosis have recently been standardized by an international consensus group. We evaluated 24 operative and peri-operative variables to assess which were independent risk factors for DGE development. Secondarily, we also examined DGE incidence over time and evaluated the consensus guidelines' ability to diagnose DGE in patients with complicated post-operative courses. METHODS A prospective, single-surgeon database of 235 patients undergoing PD at an academic tertiary center was retrospectively reviewed and DGE was assessed per published guidelines. RESULTS DGE occurred in 42 patients overall (17.9 %), with incidence falling from 30.0 to 9.1% during the study period. Post-operative abscess, pancreatic fistula formation, pulmonary comorbidity, and increased intraoperative blood loss were found to be independent risk factors (p<0.05) for DGE on multivariate analysis. Changes in operative technique, such as pylorus preservation, did not associate with DGE. In a separate analysis, when patients with confounding post-operative events such as re-intubation or re-laparotomy were excluded, DGE incidence was 11.9 %. CONCLUSIONS Perturbation of the operative bed by a secondary complication seems to be the dominant risk for DGE development. The consensus guidelines for DGE diagnosis, while indispensable, may overestimate DGE incidence.
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Affiliation(s)
- John W Kunstman
- Section of Surgical Oncology, Department of Surgery, Yale University School of Medicine, P.O. Box 208062, New Haven, CT 06520-8062, USA
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Mezhir JJ. Management of complications following pancreatic resection: An evidence-based approach. J Surg Oncol 2012; 107:58-66. [DOI: 10.1002/jso.23139] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 04/09/2012] [Indexed: 12/19/2022]
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Rosso E, Lopez P, Roedlisch MN, Narita M, Oussoultzoglou E, Bachellier P. Double Omental Flap Reduced Perianastomotic Collections and Relaparotomy Rates after Pancreaticoduodenectomy with Pancreaticogastrostomy. World J Surg 2012; 36:1672-8. [DOI: 10.1007/s00268-012-1546-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Eshuis WJ, van Dalen JW, Busch ORC, van Gulik TM, Gouma DJ. Route of gastroenteric reconstruction in pancreatoduodenectomy and delayed gastric emptying. HPB (Oxford) 2012. [PMID: 22151452 DOI: 10.1111/j.1477-2574.2011.00403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy. Some previous studies suggest that antecolic (compared with retrocolic) gastroenteric reconstruction lowers the incidence of DGE. The present study was performed to investigate the relation between the route of gastroenteric reconstruction and DGE after pancreatoduodenectomy. METHODS In a consecutive series of pancreatoduodenectomies, the route of gastroenteric reconstruction was retrospectively determined. Hospital course was prospectively recorded. Patients with antecolic and retrocolic reconstruction were compared. Primary outcome was DGE (ISGPS definition). Secondary outcomes were other complications and hospital stay. RESULTS Of 154 included patients, 50% had retrocolic reconstruction. DGE occurred in 58% of retrocolic patients, vs 52% of antecolic patients (NS). 'Primary' DGE (without other intra-abdominal complications) occurred in 36% (retrocolic) and 20% (antecolic) (P= 0.02) of the patients. In multivariable analysis, the route of reconstruction was not associated with primary DGE. Clinically relevant primary DGE (grade B/C) did not differ, nor did the secondary outcomes. DISCUSSION The incidence of DGE did not differ between the study groups. 'Primary' DGE was more frequent in the retrocolic group, but in multivariable analysis, no association between the route of reconstruction and primary DGE was found. The preferred route for gastroenteric reconstruction after pancreatoduodenectomy remains to be investigated in a well-powered, randomized, controlled trial.
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Affiliation(s)
- Wietse J Eshuis
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Eshuis WJ, van Dalen JW, Busch ORC, van Gulik TM, Gouma DJ. Route of gastroenteric reconstruction in pancreatoduodenectomy and delayed gastric emptying. HPB (Oxford) 2012; 14:54-9. [PMID: 22151452 PMCID: PMC3252992 DOI: 10.1111/j.1477-2574.2011.00403.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy. Some previous studies suggest that antecolic (compared with retrocolic) gastroenteric reconstruction lowers the incidence of DGE. The present study was performed to investigate the relation between the route of gastroenteric reconstruction and DGE after pancreatoduodenectomy. METHODS In a consecutive series of pancreatoduodenectomies, the route of gastroenteric reconstruction was retrospectively determined. Hospital course was prospectively recorded. Patients with antecolic and retrocolic reconstruction were compared. Primary outcome was DGE (ISGPS definition). Secondary outcomes were other complications and hospital stay. RESULTS Of 154 included patients, 50% had retrocolic reconstruction. DGE occurred in 58% of retrocolic patients, vs 52% of antecolic patients (NS). 'Primary' DGE (without other intra-abdominal complications) occurred in 36% (retrocolic) and 20% (antecolic) (P= 0.02) of the patients. In multivariable analysis, the route of reconstruction was not associated with primary DGE. Clinically relevant primary DGE (grade B/C) did not differ, nor did the secondary outcomes. DISCUSSION The incidence of DGE did not differ between the study groups. 'Primary' DGE was more frequent in the retrocolic group, but in multivariable analysis, no association between the route of reconstruction and primary DGE was found. The preferred route for gastroenteric reconstruction after pancreatoduodenectomy remains to be investigated in a well-powered, randomized, controlled trial.
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Affiliation(s)
- Wietse J Eshuis
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
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Postoperative complications and survival rates for pancreatic cancer patients. Wien Klin Wochenschr 2011; 123:94-9. [PMID: 21253778 DOI: 10.1007/s00508-010-1513-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 11/01/2010] [Indexed: 01/04/2023]
Abstract
BACKGROUND/AIMS Surgical resection offers the only potential cure for pancreatic tumor. The goal of the present study is to determine complications associated with pancreatic resection and to describe their influence on the survival rate for pancreatic cancer patients. MATERIALS AND METHODS Between 1996 and 2009, the findings of 125 pancreatic cancer patients were analyzed in a prospective trial at the First Department of Surgery, University Hospital in Košice, Slovakia. RESULTS The overall mortality rate and morbidity rate were 3.2% (4 patients) and 27% (34 patients), respectively. In patients with postoperative complications, the median survival time was 12 months (range, 8-14 months), in patients without complications - 18 months (range, 15-20 months). CONCLUSION The presence of postoperative complications after pancreatic resections has negative influence on the survival rate for pancreatic cancer patients. Patients with a small pancreatic duct size (<3 mm) or a soft pancreatic remnant were at high risk of pancreatic leakage and postoperative complications.
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Malleo G, Crippa S, Butturini G, Salvia R, Partelli S, Rossini R, Bacchion M, Pederzoli P, Bassi C. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB (Oxford) 2010; 12:610-8. [PMID: 20961369 PMCID: PMC2999788 DOI: 10.1111/j.1477-2574.2010.00203.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study evaluates the incidence and clinical features and associated risk factors of delayed gastric emptying (DGE) after pancreaticoduodenectomy, employing the International Study Group of Pancreatic Surgery (ISGPS) consensus definition. METHODS Demographic, pathological and surgical details for 260 consecutive patients who underwent pylorus-preserving pancreaticoduodenectomy at a single institution were analysed using univariate and multivariate models. RESULTS Postoperative complications occurred in 108 (41.5%) and DGE was diagnosed in 36 (13.8%) of 260 patients. Among the 36 DGE patients, 16 had grade A, 18 grade B and two grade C DGE. Resumption of a solid diet (P < 0.001), time to passage of stool (P= 0.002) and hospital discharge (P < 0.001) occurred later in DGE patients. The need for total parenteral nutrition was significantly higher in DGE grade B/C patients (P < 0.001). In the univariate analysis, abdominal collections (P≤ 0.001), pancreatic fistula (PF) grades B and C (P < 0.001), biliary fistula (P= 0.002), pulmonary complications (P < 0.001) and sepsis (P= 0.002) were associated with DGE. Only abdominal collections (P= 0.009), PF grade B/C (P < 0.001) and sepsis (P= 0.024) were associated with clinically relevant DGE. In the multivariate analysis, PF grade B/C (P= 0.004) and biliary fistula (P= 0.039) were independent risk factors for DGE. CONCLUSIONS The ISGPS classification and grading systems correlate well with the clinical course of DGE and are feasible for patient management. The principal risk factors for DGE seem to be pancreatic and biliary fistulas.
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Affiliation(s)
- Giuseppe Malleo
- Department of Surgery, General Surgery B Unit, G. B. Rossi Hospital, University of Verona, Verona, Italy
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Affiliation(s)
- Sam Pappas
- Medical College of Wisconsin, Department of Surgery and Froedtert Memorial Lutheran Hospital, Nutrition Services Department, Milwaukee, Wisconsin
| | - Elizabeth Krzywda
- Medical College of Wisconsin, Department of Surgery and Froedtert Memorial Lutheran Hospital, Nutrition Services Department, Milwaukee, Wisconsin
| | - Nadine Mcdowell
- Medical College of Wisconsin, Department of Surgery and Froedtert Memorial Lutheran Hospital, Nutrition Services Department, Milwaukee, Wisconsin
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Hashimoto Y, Traverso LW. Incidence of pancreatic anastomotic failure and delayed gastric emptying after pancreatoduodenectomy in 507 consecutive patients: Use of a web-based calculator to improve homogeneity of definition. Surgery 2010; 147:503-15. [DOI: 10.1016/j.surg.2009.10.034] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Accepted: 10/06/2009] [Indexed: 12/20/2022]
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Abstract
Pancreaticoduodenectomy (PD) is the standard surgical treatment for resectable peri-ampullary tumors. It can be performed with or without pylorus preservation. Many surgeons have a negative opinion of pylorus preserving PD (PPPD) and consider it an inferior operation, especially from an oncological point of view. This article reviews the various aspects of PD in the context of operative factors like blood loss and operation time, complications such as delayed gastric emptying and anastomotic leaks, and the impact on quality of life and survival. We aim to show that PPPD is at least as good as classic PD, if not better in some aspects.
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Affiliation(s)
- Faisal Alsaif
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Shukla PJ, Barreto SG, Bedi MMS, Bheerappa N, Chaudhary A, Gandhi MD, Jacob M, Jesvanth S, Kannan DG, Kapoor VK, Kumar A, Maudar KK, Ramesh H, Sastry RA, Saxena R, Sewkani A, Sharma S, Shrikhande SV, Singh A, Singh RK, Surendran R, Varshney S, Verma V, Vimalraj V. Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study. HPB (Oxford) 2009; 11:638-44. [PMID: 20495631 PMCID: PMC2799616 DOI: 10.1111/j.1477-2574.2009.00105.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 06/16/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres. MATERIALS AND METHODS Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India. RESULTS Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9-54). The median number of PDs per surgeon per year was 16 (range 7-38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2-5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3-32.2%), and the median post-operative duration of hospital stay was 16 days (range 4-100 days). CONCLUSIONS This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.
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Affiliation(s)
- Parul J Shukla
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryTata Memorial Hospital, Mumbai
| | - Savio G Barreto
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryTata Memorial Hospital, Mumbai
| | - MMS Bedi
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryLakeshore Hospital, Cochin
| | - N Bheerappa
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryNizam's Institute, Hyderabad
| | - Adarsh Chaudhary
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySir Ganga Ram Hospital, New Delhi
| | - MD Gandhi
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryLakeshore Hospital, Cochin
| | - M Jacob
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryLakeshore Hospital, Cochin
| | - S Jesvanth
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryStanley Medical College, Chennai
| | - DG Kannan
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryStanley Medical College, Chennai
| | - Vinay K Kapoor
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - A Kumar
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - KK Maudar
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryBhopal Memorial Hospital and Research Center, Bhopal, India
| | - Hariharan Ramesh
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryLakeshore Hospital, Cochin
| | - RA Sastry
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryNizam's Institute, Hyderabad
| | - Rajan Saxena
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - Ajit Sewkani
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryBhopal Memorial Hospital and Research Center, Bhopal, India
| | - S Sharma
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryBhopal Memorial Hospital and Research Center, Bhopal, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryTata Memorial Hospital, Mumbai
| | - A Singh
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySir Ganga Ram Hospital, New Delhi
| | - Rajneesh K Singh
- Department of Gastrointestinal and Hepatopancreatobiliary SurgerySanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow
| | - R Surendran
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryStanley Medical College, Chennai
| | - Subodh Varshney
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryBhopal Memorial Hospital and Research Center, Bhopal, India
| | - V Verma
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryNizam's Institute, Hyderabad
| | - V Vimalraj
- Department of Gastrointestinal and Hepatopancreatobiliary SurgeryStanley Medical College, Chennai
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Nikfarjam M, Kimchi ET, Gusani NJ, Shah SM, Sehmbey M, Shereef S, Staveley-O'Carroll KF. A reduction in delayed gastric emptying by classic pancreaticoduodenectomy with an antecolic gastrojejunal anastomosis and a retrogastric omental patch. J Gastrointest Surg 2009; 13:1674-82. [PMID: 19548039 DOI: 10.1007/s11605-009-0944-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 06/03/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) continues to be a major cause of morbidity following pancreaticoduodenectomy (PD). A change in the method of reconstruction following PD was instituted in an attempt to reduce the incidence DGE. METHODS Patients undergoing PD from January 2002 to December 2008 were reviewed and outcomes determined. Pylorus-preserving pancreaticoduodenectomy (PPPD) with a retrocolic duodenojejunal anastomosis (n = 79) or a classic PD with a retrocolic gastrojejunostomy (n = 36) was performed prior to January 2008. Thereafter, a classic PD with an antecolic gastrojejunal anastomosis and placement of a retrogastric vascular omental patch was undertaken (n = 36). RESULTS A statistically significant decrease in DGE was noted in the antecolic group compared to the entire retrocolic group (14% vs 40%; p = 0.004) and compared to patients treated by classic PD with a retrocolic anastomosis alone (14% vs 39%; p = 0.016). On multivariate analysis, the only modifiable factor associated with reduced DGE was the antecolic technique with an omental patch, odds ratio (OR) 0.3 (confidence interval (CI) 0.1-0.8) p = 0.022. Male gender was associated with an increased risk of DGE with OR 2.3 (CI 1.1-4.8) p = 0.026. CONCLUSION A classic PD combined with an antecolic anastomosis and retrogastric vascular omental patch results in a significant reduction in DGE.
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Affiliation(s)
- Mehrdad Nikfarjam
- Liver, Pancreas and Foregut Unit, Department of Surgery, Penn State College of Medicine, Hershey, PA 17033-0850, USA.
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Reply to Comments on “An Antecolic Roux-en-Y Reconstruction Decreased Delayed Gastric Emptying After Pylorus-Preserving Pancreatoduodenectomy”. J Gastrointest Surg 2008. [DOI: 10.1007/s11605-008-0626-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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