Enteral nutrition prolongs delayed gastric emptying in patients after Whipple resection

Knockout Genes in Bowel Anastomoses: A Systematic Review of Literature Outcomes

BACKGROUND

The intestinal wound healing process is a complex event of three overlapping phases: exudative, proliferative, and remodeling. Although some mechanisms have been extensively described, the intestinal healing process is still not fully understood. There are some similarities but also some differences compared to other tissues. The aim of this systematic review was to summarize all studies with knockout (KO) experimental models in bowel anastomoses, underline any recent knowledge, and clarify further the cellular and molecular mechanisms of the intestinal healing process. A systematic review protocol was performed.

MATERIALS AND METHODS

Medline, EMBASE, and Scopus were comprehensively searched.

RESULTS

a total of eight studies were included. The silenced genes included interleukin-10, the four-and-one-half LIM domain-containing protein 2 (FHL2), cyclooxygenase-2 (COX-2), annexin A1 (ANXA-1), thrombin-activatable fibrinolysis inhibitor (TAFI), and heparin-binding epidermal growth factor (HB-EGF) gene. Surgically, an end-to-end bowel anastomosis was performed in the majority of the studies. Increased inflammatory cell infiltration in the anastomotic site was found in IL-10-, annexin-A1-, and TAFI-deficient mice compared to controls. COX-1 deficiency showed decreased angiogenesis at the anastomotic site. Administration of prostaglandin E2 in COX-2-deficient mice partially improved anastomotic leak rates, while treatment of ANXA1 KO mice with Ac2-26 nanoparticles reduced colitis activity and increased weight recovery following surgery.

CONCLUSIONS

our findings provide new insights into improving intestinal wound healing by amplifying the aforementioned genes using appropriate gene therapies. Further research is required to clarify further the cellular and micromolecular mechanisms of intestinal healing.

Impact of Early Enteral Nutrition on Delayed Gastric Emptying and Nutritional Status After Pancreaticoduodenectomy

BACKGROUND

Although early enteral nutrition (EEN) is an accepted practice after pancreaticoduodenectomy (PD), the impact of EEN on postoperative complications or nutritional status remains unclear. We aimed to investigate the impact of EEN on delayed gastric emptying (DGE) and nutritional status after PD.

METHODS

A total of 143 patients underwent PD between January 2012 and September 2020. We excluded patients who underwent a two-stage pancreatojejunostomy, in whom the enteral tube was accidentally pulled out, or with insufficient information in their medical records. The incidence of postoperative complications was compared between patients who received EEN (EEN group, n = 21) and those who did not (control group, n = 21) after propensity score matching. Univariate and multivariate analyses were performed to identify the risk factors affecting the incidence of these complications. Nutritional status was assessed at postoperative months 1, 3, and 6.

RESULTS

The incidence of grade B/C DGE in the EEN group was significantly lower than that in the control group (4.8% vs. 28.6%, p = 0.03). There was no significant difference in overall morbidity, incidence of any other postoperative complications, or all-grade DGE. In multivariate analysis, EEN was associated with a reduction in the incidence of grade B/C DGE (p < 0.01). In the analysis of nutritional status, EEN was significantly associated with better nutritional status at postoperative month 1.

CONCLUSION

EEN can lead to a lower clinically relevant DGE rate and better nutritional status in the early postoperative period in patients undergoing PD.

Stereotactic Ablative Radiotherapy Using CALYPSO® Extracranial Tracking for Intrafractional Tumor Motion Management-A New Potential Local Treatment for Unresectable Locally Advanced Pancreatic Cancer? Results from a Retrospective Study

(1) Background: The aim of this study was to evaluate the efficacy and safety of SABR for LAPC using Calypso® Extracranial Tracking for intrafractional, fiducial-based motion management, to present this motion management technique, as there are yet no published data on usage of Calypso® during SABR for LAPC, and to report on our clinical outcomes. (2) Methods: Fifty-four patients were treated with SABR in one, three, or five fractions, receiving median BED10 = 112.5 Gy. Thirty-eight patients received systemic treatment. End points were OS, FFLP, PFS, and toxicity. Actuarial survival analysis and univariate analysis were investigated. (3) Results: Median follow-up was 20 months. Median OS was 24 months. One-year FFLP and one-year OS were 100% and 90.7%, respectively. Median PFS was 18 months, and one-year PFS was 72.2%. Twenty-five patients (46.3%) were alive at the time of analysis, and both median FU and OS for this subgroup were 26 months. No acute/late toxicity > G2 was reported. (4) Conclusions: SABR for LAPC using Calypso® presented as an effective and safe treatment and could be a promising local therapeutic option with very acceptable toxicity, either as a single treatment or in a multimodality regimen. Dose escalation to the tumor combined with systemic treatment could yield better clinical outcomes.

Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying

BACKGROUND

Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD) that impairs recovery and quality of life. The purpose of this study was to assess the impact risk-stratified pancreatectomy clinical pathways (RSPCPs) had on delayed gastric emptying (DGE) and identify factors associated with DGE in a contemporary period.

METHODS

A single-institution, prospective database was queried for consecutive PDs during July 2011-November 2019. Using international definitions, DGE rates were compared between periods before and after RSPCPs were implemented in 2016, classifying patients according to their postoperative pancreatic fistula (POPF) risk. Risk factors were analyzed to identify modifiable targets.

RESULTS

Among 724 elective PDs, 552 (76%) were for adenocarcinoma and 172 (24%) for other diagnoses. Of the 197 (27%) patients with DGE, 119 (16%) had type A, 41 (6%) type B, and 38 (5%) type C. In the overall cohort, DGE rates were higher with pylorus-preserving vs. classic hand-sewn reconstruction (odds ratio [OR] - 1.84; p < 0.001), postoperative abscess (OR - 2.54; p = 0.003), and non-white patients (p = 0.007), but lower after implementation of RSPCPs (OR - 0.34, p < 0.001). In the 374 patients treated with RSPCPs, only 17% (n = 65/374) developed DGE. Patients with protocol-compliant NGT removal ≤ 48 h were less likely to experience DGE (OR - 1.46, p = 0.042).

CONCLUSION

Our data suggest that implementation of preoperatively assigned RSPCPs as a care bundle was the most important factor in decreasing DGE. These gains were accentuated in patients who underwent early nasogastric tube removal and had a classic hand-sewn gastro-jejunostomy reconstruction. Application of these modifiable factors is generalizable with low implementation barriers.

ESPEN practical guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Friend or foe? Feeding tube placement at the time of pancreatoduodenectomy: propensity score case-matched analysis

BACKGROUND

The role of concomitant gastrostomy or jejunostomy feeding tube (FT) placement during pancreatoduodenectomy (PD) and its impact on patient outcomes remain controversial.

METHODS

NSQIP database was surveyed for patients undergoing PD between 2014 and 2017. FT placement was identified using CPT codes. Propensity scores were used to match the two groups (1:1) on baseline characteristics and intraoperative variables including pancreas specific ones (duct size, gland texture, underlying disease, wound class, use of wound protector, drain placement, type of pancreatic reconstruction and vascular reconstruction). Outcomes were compared. Finally, a subset analyses for patients with delayed gastric emptying (DGE) or postoperative pancreatic fistula (POPF) were performed.

RESULTS

Out of 15,224 PD, 1,104 (7.5%) had FT. POPF and DGE rates were 17% and 18%, respectively, for the entire cohort. Feeding jejunostomy was the most placed FT (88.2%). Patients with FT placement were more likely to be older (mean, 65.8 vs. 64.6 y), smokers (22.6% vs. 17.8%) who had preoperative weight loss (22.5% vs. 15.3%), ASA class ≥ 3 (80.8% vs. 77.5%), preoperative transfusion (1.5% vs. 0.84%), chemotherapy (22.8% vs. 17.5%), and radiation (14.5% vs. 6.8%, p < 0.05). The matched cohort included 880 patients in each group with completely balanced preoperative and intraoperative characteristics. In the matched cohort, patients with FT placement had higher overall morbidity (52.2% vs. 44.3%, p = 0.001), major morbidity (28.4% vs. 22.5%, p = 0.004), organ/space infection (14.4% vs. 10.9%, p = 0.026), re-operation (8.6% vs. 5.1%, p = 0.003), DGE (26.8% vs. 16.4%, p < 0.001), and longer mean hospital length of stay (12.9 vs. 11.2 days, p = 0.001) than those without FT. There was no difference in mortality (1.7% vs. 2.2%, p = 0.488) or readmission rate (20.2% vs. 17.2%, p = 0.099). In patients with DGE and POPF, FT placement was not associated with morbidity, mortality, length of stay, or readmission rate (p > 0.05).

CONCLUSION

Patients with FT placement during PD tend to have higher postoperative morbidity and delayed recovery.

Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials

Introduction

Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several RCTs have explored operative strategies to minimize DGE, however, the optimal combination of gastric resection approach, anastomotic route, configuration and the use of enteroenterostomy remains unclear.

Methods

MEDLINE, Embase and CENTRAL databases were systematically searched for RCTs comparing gastric resection (classic Whipple, pylorus-resecting, pylorus-preserving), anastomotic route (antecolic, retrocolic), configuration (loop gastroenterostomy/Billroth II, Roux-en-Y), and use of enteroenterostomy (Braun). A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimizing DGE.

Results

Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6 per cent (647 patients). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35 per cent of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32 per cent of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (odds ratio 2.10, 95 per cent credibility interval (cr.i.) 0.92 to 4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when this was used (odds ratio 1.90, 95 per cent cr.i. 0.92 to 3.90). Having a Braun enteroenterostomy ranked the best in 96 per cent of comparisons.

Conclusion

Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE.

Preregistration

PROSPERO submitted 23 December 2020. CRD42021227637

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Scoring System for Surgical Site Infection after Pancreaticoduodenectomy Using Clinical Data

Object: To analyze the factors influencing surgical site infection (SSI) after pancreaticoduodenectomy and to establish a scoring system for predicting such infections. Methods: Patients who underwent pancreaticoduodenectomy in the Department of Hepatobiliary Surgery of the Second Affiliated Hospital of Chongqing Medical University from January 2015 to March 2019 were divided randomly into a model group and a test group in a proportion of 3:1. According to whether an SSI occurred after operation, the model group was divided into an incision-infection group and a non-infection group. Univariable analysis and multivariable regression analysis were used to analyze factors related to post-operative incision infection and to establish a clinical predictive scoring system. The scoring system was evaluated for the test group. Results: A total of 236 patients, 177 in the model group and 59 in the test group, were included. In the model group, univariable and logistic regression analysis showed that tumor nature (benign versus malignant), post-operative albumin concentration, pancreatic fistula formation, post-operative cough, and peri-operative blood transfusion were the independent risk factors for incision infection. Then we established a clinical predictive scoring system. In the test group, the area under the receiver operator characteristic curve of the system was 0.768 (p < 0.001, with sensitivity = 59.1% and specificity = 94.6%). Conclusion: The scoring system had good clinical prediction ability and high specificity, so it was worth using in the clinic.

Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy

Importance

Technical proficiency at robotic pancreaticoduodenectomy (RPD) and video assessment are promising tools for understanding postoperative outcomes. Delayed gastric emptying (DGE) remains a major driver of cost and morbidity after pancreaticoduodenectomy.

Objective

To determine if technical variables during RPD are associated with postoperative DGE.

Design, Setting, and Participants

A retrospective study was conducted of technical assessment performed in all available videos (n = 192) of consecutive RPDs performed at a single academic institution from October 3, 2008, through September 27, 2016.

Exposures

Video review of gastrojejunal anastomosis during RPD.

Main Outcomes and Measures

Delayed gastric emptying was classified according to International Study Group of Pancreatic Surgery criteria. Video analysis reviewed technical variables specific in the construction of the gastrojejunal anastomosis. Using multivariate analysis, DGE was correlated with known patient variables and technical variables, individually and combined.

Results

Of 410 RPDs performed, video was available for 192 RPDs (80 women and 112 men; mean [SD] age, 65.7 [11.1] years). Delayed gastric emptying occurred in 41 patients (21.4%; grade A, 15; grade B, 14; and grade C, 12). Patient variables contributing to DGE on multivariate analysis were advanced age (odds ratio [OR] 1.11; 95% CI, 1.05-1.16; P < .001), small pancreatic duct size (OR, 0.84; 95% CI, 0.72-0.98; P = .03), and postoperative pseudoaneurysm (OR, 17.29; 95% CI, 2.34-127.78; P = .005). However, technical variables contributing to decreased DGE on multivariate analysis included the flow angle (within 30° of vertical) between the stomach and efferent jejunal limb (OR, 0.25; 95% CI, 0.08-0.79; P = .02), greater length of the gastrojejunal anastomosis (OR, 0.40; 95% CI, 0.20-0.77; P = .006), and a robotic-sewn anastomosis (robotic suture vs stapler: OR, 0.30; 95% CI, 0.09-0.95; P = .04).

Conclusions and Relevance

This study examines modifiable technical factors through the use of review of video obtained at the time of operation and suggests ways by which the surgical construction of the gastrojejunal anastomosis during RPD may reduce the incidence of DGE as a framework for prospective quality improvement.

Antecolic reconstruction is associated with a lower incidence of delayed gastric emptying compared to retrocolic technique after Whipple or pylorus-preserving pancreaticoduodenectomy

BACKGROUND

The aim of present study is to investigate the relationship between the antecolic (AC) route of gastrojejunostomy (GJ) after pancreaticoduodenectomy (PD) or duodenojejunostomy (DJ) reconstruction after pylorus-preserving pancreaticoduodenectomy (PPPD), and the incidence of delayed gastric emptying (DGE).

METHODS

An electronic search of 4 databases to identify all articles comparing AC and retrocolic (RC) reconstruction after PD or PPPD was performed.

RESULTS

Fifteen studies involving 2270 patients were included for final pooled analysis. The overall incidence of DGE was 27.2%. Meta-analysis results showed AC group had lower incidence of DGE (odds ratio, 0.29; 95% confidence interval [CI], 0.16-0.52, P < .0001) and shorter hospital length of stay (weight mean difference, -3.29; 95% CI, -5.2 to -1.39, P = .0007). Days until to liquid and solid diet in the AC group were also significantly earlier than that in the RC group (P = .0006 and P < .0001). There was no difference in operative time, incidence of pancreatic fistula and bile leakage, and mortality, respectively.

CONCLUSIONS

AC route of GJ after PD or DJ after PPPD is associated with a lower incidence of DGE. However, the preferred route for GJ or DJ reconstruction remains to be investigated in well-powered, randomized, controlled trial.

Application of an early oral feeding protocol after pylorus-preserving pancreaticoduodenectomy

PURPOSE

This study evaluates the effect of an enhanced recovery after surgery (ERAS)-based nutrition support protocol on oral intake and weight change in patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD).

METHODS

A 14-day postoperative nutrition support protocol was developed to initiate oral intake after 1 week of enteral tube feeding and parenteral nutrition (early oral feeding, EOF). Forty-eight patients who underwent PPPD participated in the study (non-EOF, n = 23; EOF, n = 25). General information, nutrition supply route and amount, blood chemistry, and weight changes were tracked.

RESULTS

The enteral tube feeding duration was 2.7 days shorter in the EOF group than in the non-EOF group. Furthermore, the EOF group started oral liquid and soft diets 1.1 and 2.5 days earlier than the non-EOF group, respectively. Compared with the non-EOF group, the EOF group reported a higher energy intake (22.1%; p = 0.001) and protein intake (17.4%; p = 0.000) via oral route. Although cumulative energy and protein intakes were similar in both groups, weight reduction in the EOF group (3.6 ± 0.1%, 2.2 ± 0.7 kg) was significantly less than the non-EOF group (8.2 ± 0.9%, 5.2 ± 0.5 kg). The blood levels of total protein and transferrin increased and prealbumin decreased, regardless of the EOF application. Serum albumin increased significantly only in the EOF group.

CONCLUSION

The EOF protocol developed for post-PPPD patients enables the early initiation and increase in the amount of oral intake while significantly alleviating weight loss.

The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy

BACKGROUND

A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence.

DATA SOURCE

We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles.

RESULTS

Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0-100%; median: 18.7%) and 14.3% (range: 1.8%-58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Braun's entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies.

CONCLUSIONS

ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.

Case-control study of the efficacy of retrogastric Roux-en-Y choledochojejunostomy

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.

Does the Ileal Brake Contribute to Delayed Gastric Emptying After Pancreatoduodenectomy?

Delayed gastric emptying (DGE) represents a significant cause for morbidity following pancreatoduodenectomy (PD). At a time when no specific and universally effective therapy exists to treat these patients, elucidating other potential (preventable or treatable) mechanisms for DGE is important. The aim of the manuscript was to test the hypothesis that ileal brake contributes to DGE in PD patients receiving jejunal tube feeding by systematically reviewing experimental and clinical literature. A series of clinically relevant questions were framed related to the potential role of the ileal brake in development of DGE post-PD and formed the basis of targeted literature searches. A comprehensive search of major reference databases from January 1980 to June 2015 was carried out which included human and animal studies. The ileal brake is a feedback loop neurally mediated by the vagus and sympatho-adrenergic pathways and hormonally by gut peptides including glucagon-like peptide-1, peptide YY (PYY), and neurotensin. The most potent stimulus for this inhibitory reflex is intra-ileal fat. There is evidence to indicate the role of an inhibitory reflex (on gastric emptying) mediated by PYY and CCK which, in turn, are stimulated by nutrient delivery into the distal small intestine providing indirect support to the role of ileal brake in post-PD DGE. The ileal brake is a likely factor contributing to DGE post-PD. While there has been no study to directly test this hypothesis, there is compelling indirect evidence to support it. Designing a trial that would answer such a question appears to be the most appropriate way forward.

Understanding Clinical Issues in Postoperative Nutrition After Pancreaticoduodenectomy

Postoperative nutrition support for patients undergoing pancreaticoduodenectomy (Whipple's procedure) may be complicated due to gastrointestinal tract dysfunction (gastroparesis, dumping, and malabsorption) subsequent to the procedure. Clinical management of these patients may be adversely affected by procedure-specific knowledge deficits (method of gastrointestinal [GI] reconstruction), common and expected surgical complications, and the available route for alimentation. It is the aim of this report to provide the reader with an overview of the procedure, common postoperative nutrition issues, and available interventions.

Early enteral nutrition vs parenteral nutrition following pancreaticoduodenectomy: Experience from a single center

AIM: To analyze and compare postoperative morbidity between patients receiving total parenteral nutrition (TPN) and early enteral nutrition supplemented with parenteral nutrition (EEN + PN).

METHODS: Three hundred and forty patients receiving pancreaticoduodenectomy (PD) from 2009 to 2013 at our center were enrolled retrospectively. Patients were divided into two groups depending on postoperative nutrition support scheme: an EEN + PN group (n = 87) and a TPN group (n = 253). Demographic characteristics, comorbidities, preoperative biochemical parameters, pathological diagnosis, intraoperative information, and postoperative complications of the two groups were analyzed.

RESULTS: The two groups did not differ in demographic characteristics, preoperative comorbidities, preoperative biochemical parameters or pathological findings (P > 0.05 for all). However, patients with EEN + PN following PD had a higher incidence of delayed gastric emptying (16.1% vs 6.7%, P = 0.016), pulmonary infection (10.3% vs 3.6%, P = 0.024), and probably intraperitoneal infection (18.4% vs 10.3%, P = 0.059), which might account for their longer nasogastric tube retention time (9 d vs 5 d, P = 0.006), postoperative hospital stay (25 d vs 20 d, P = 0.055) and higher hospitalization expenses (USD10397 vs USD8663.9, P = 0.008), compared to those with TPN.

CONCLUSION: Our study suggests that TPN might be safe and sufficient for patient recovery after PD. Postoperative EEN should only be performed scrupulously and selectively.

[Treatment of postoperative impairment of gastrointestinal motility, cholangitis and pancreatitis]

Although the mortality associated with major hepatopancreaticobiliary surgery has continuously decreased during the last decades, the morbidity of these procedures remains high. Functional disturbances of normal gastrointestinal motility as well as inflammation and infections of surgically treated organs are frequent complications resulting in considerably prolonged lengths of stay in hospital and increased healthcare costs. This review article highlights the therapeutic approaches and recent developments in the treatment of delayed gastric emptying, prolonged postoperative ileus, postoperative cholangitis and pancreatitis after hepatopancreaticobiliary surgery. Current practice is discussed on the basis of recent results in basic and clinical research, review articles, meta-analyses and guidelines.

Delayed Gastric Emptying After Stapled Versus Hand-Sewn Anastomosis of Duodenojejunostomy in Pylorus-Preserving Pancreaticoduodenectomy: a Randomized Controlled trial

BACKGROUND

A retrospective analysis indicated that the incidence of delayed gastric emptying (DGE) was less after using a circular stapler (CS) for duodenojejunostomy than that after hand-sewn (HS) anastomosis in pylorus-preserving pancreaticoduodenectomy (PpPD). This randomized clinical trial compared the incidence of DGE postoperative after CS duodenojejunostomy with that of conventional HS anastomosis in PpPD.

METHODS

We randomly assigned 101 patients (age 20-80) undergoing PpPD to receive CS duodenojejunostomy (group CS, n = 50) or HS duodenojejunostomy (group HS, n = 51) in two Japanese cancer center hospitals between 2011 and 2013. The patients were stratified by institution and size of the main pancreatic duct (<3 or ≥3 mm). The primary endpoint was the incidence of grade B or C DGE according to the international definition with a non-inferiority margin of 5 %. This trial is registered with University hospital Medical Information Network (UMIN) Center: UMIN000005463.

RESULTS

Per-protocol analysis of data on 95 patients showed that grade B or C DGE was found in 4 (8.9 %) of 45 patients who underwent CS anastomosis and in 8 (16 %) of 50 patients who underwent HS anastomosis (P = 0.015). There were no differences in the overall incidence of DGE (P = 0.98), passage of the contrast medium through the anastomosis (P = 0.55), or hospital stays (P = 0.22).

CONCLUSIONS

CS duodenojejunostomy is not inferior to HS anastomosis with respect to the incidence of clinically significant DGE, justifying its use as treatment option.

Double loop reconstruction following pancreaticoduodenectomy for malignant tumor: Short-term outcome

BACKGROUND

To evaluate the use of a double loop reconstruction following pylorus preserving proximal pancreaticoduodenectomy (PPPPD).

METHODS

Morbidity and mortality were evaluated in 55 patients undergoing PPPPD for malignant tumors, followed by a double loop reconstruction.

RESULTS

The mean intra-operative blood loss was 908mL±531. In-hospital mortality was 5.4% (3/55 pts). The mean length of hospital stay was 17±5 days (range 12-45 days). Postoperative complications occurred in 25 patients (46.2%). Five patients developed an anastomotic leak, one biliary and four pancreatic (4/55; 7%). Delayed gastric emptying occurred in 8 patients (14.5%). Reoperation was required in two patients for hemorrhage.

CONCLUSIONS

A double loop alimentary reconstruction following PPPPD led to a low incidence of DGE and pancreatic fistula. Although mortality rate was higher than that reported by referral centres, this technique has been performed in a not specialized unit attaining acceptable results.

Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand?

Pancreatic resection has become a feasible treatment of pancreatic neoplasms, and with improvements in surgical techniques and perioperative management, mortality associated with pancreatic surgery has decreased considerably. Despite this improvement, a high rate of complications is still associated with these procedures. Among these complications, delayed gastric emptying (DGE) and postoperative pancreatic fistula (POPF) have a substantial impact on patient outcomes and burden our healthcare system. Technical modifications and postoperative approaches have been proposed to reduce rates of both POPF and DGE in patients undergoing pancreatectomy; however, to date, their rates have remained unchanged. In the present study, we summarize the findings of the most significant studies that have investigated these complications. In particular, several studies focused on technical modifications including extent of dissection, stent placement, nature of anastomosis, type of reconstruction, and application of biological or non-biological agents to site of anastomosis. Moreover, postoperatively, drain placement, duration of drain usage, postoperative feeding, and use of pharmacological agents were studied to reduce rates of POPF and DGE. In this review, we summarize the most relevant literature on this fundamental aspect of pancreatic surgery. Despite studies identifying the potential benefit of technical modifications and postoperative approaches, these findings remain controversial and suggest need for further extensive investigation. Most importantly, we recommend that all surgeons performing these procedures base their practice on the most updated and highest available level of evidence.

Delayed Gastric Emptying After Pancreaticoduodenectomy: an Analysis of Risk Factors and Cost

INTRODUCTION

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD), yet it remains incompletely understood. The International Study Group of Pancreatic Surgery (ISGPS) in 2007 defined a three-tiered grading system to standardize studies of DGE.

METHODS

In this study, 721 patients undergoing PD between 2006 and 2012 were retrospectively categorized by the ISGPS DGE criteria, as well as a modified grading system (termed primary DGE) if, on retrospective review, DGE was not believed to be a sequela of a separate complication. Predictive factors and associated outcomes were determined.

RESULTS

ISGPS-defined DGE occurred in 140 (19.4%) patients. In a multivariate analysis, predictors of ISGPS-defined DGE included abdominal infection (odds ratio (OR) 5.5, p < 0.001), male gender (OR 1.92, p = 0.007), smoking history (OR 1.75 p = 0.033), and periampullary adenocarcinoma (OR 1.66, p = 0.041). Primary DGE occurred in 12.2% of patients. Predictors included abdominal infection (OR 3.15, p < 0.001) and smoking history (OR 2.04, p = 0.008). Median hospital charges increased over $10,000 with each severity grade of DGE (p < 0.001).

CONCLUSION

DGE is common after PD and contributes substantially to cost. DGE is frequently a secondary complication of abdominal infection, and interventions that limit such complications may be the most effective strategy toward preventing DGE.

Enteral nutrition in pancreaticoduodenectomy: a literature review

Pancreaticoduodenectomy (PD) is considered the gold standard treatment for periampullory carcinomas. This procedure presents 30%–40% of morbidity. Patients who have undergone pancreaticoduodenectomy often present perioperative malnutrition that is worse in the early postoperative days, affects the process of healing, the intestinal barrier function and the number of postoperative complications. Few studies focus on the relation between enteral nutrition (EN) and postoperative complications. Our aim was to perform a review, including only randomized controlled trial meta-analyses or well-designed studies, of evidence regarding the correlation between EN and main complications and outcomes after pancreaticoduodenectomy, as delayed gastric emptying (DGE), postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), length of stay and infectious complications. Several studies, especially randomized controlled trial have shown that EN does not increase the rate of DGE. EN appeared safe and tolerated for patients after PD, even if it did not reveal any advantages in terms of POPF, PPH, length of stay and infectious complications.

Pancreatic cancer surgery and nutrition management: a review of the current literature

Surgery remains the only curative treatment for pancreaticobiliary tumors. These patients typically present in a malnourished state. Various screening tools have been employed to help with preoperative risk stratification. Examples include the subjective global assessment (SGA), malnutrition universal screening tool (MUST), and nutritional risk index (NRI). Adequate studies have not been performed to determine if perioperative interventions, based on nutrition risk assessment, result in less morbidity and mortality. The routine use of gastric decompression with nasogastric sump tubes may be unnecessary following elective pancreatic resections. Instead, placement should be selective and employed on a case-by-case basis. A wide variety of feeding modalities are available, oral nutrition being the most effective. Artificial nutrition may be provided by temporary nasal tube (nasogastric, nasojejunal, or combined nasogastrojejunal tube) or surgically placed tube [gastrostomy (GT), jejunostomy (JT), gastrojejunostomy tubes (GJT)], and intravenously (parenteral nutrition, PN). The optimal tube for enteral feeding cannot be determined based on current data. Each is associated with a specific set of complications. Dual lumen tubes may be useful in the presence of delayed gastric emptying (DGE) as the stomach may be decompressed while feeds are delivered to the jejunum. However, all feeding tubes placed in the small intestine, except direct jejunostomies, commonly dislodge and retroflex into the stomach. Jejunostomies are associated with less frequent, but more serious complications. These include intestinal torsion and bowel necrosis. PN is associated with septic, metabolic, and access-related complications and should be the feeding strategy of last-resort. Enteral feeds are clearly preferred over parental nutrition. A sound understanding of perioperative nutrition may improve patient outcomes. Patients undergoing pancreatic cancer surgery should undergo multidisciplinary nutrition screening and intervention, and the surgical/oncological team should include nutrition professionals in managing these patients in the perioperative period.

Factors influencing clinically significant delayed gastric emptying after subtotal stomach-preserving pancreatoduodenectomy

BACKGROUND

Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pylorus ring is resected and most of the stomach is preserved, has been performed recently in Japan. This study was undertaken to clarify the incidence of delayed gastric emptying (DGE) after SSPPD at a high-volume hospital and to determine the independent factors that influence the development of DGE after SSPPD.

METHODS

Between 2002 and 2011, 201 consecutive patients underwent standardized SSPPD. After SSPPD, DGE (defined according to the International Study Group of Pancreatic Surgery) was analyzed, and associated variables were assessed by univariate and multivariate analyses, retrospectively.

RESULTS

Clinically significant DGE (grades B and C) occurred in 35 (17 %) of the 201 patients; 26 patients had other accompanying abdominal complications (secondary DGE), and pancreatic leakage was the sole risk factor for DGE (odds ratio 6.63, 95 % CI 2.86-15.74; p < 0.001). Only nine (4 % of all patients) of the 35 patients with clinically significant DGE were classified as having DGE that had arisen without any obvious etiology (primary DGE).

CONCLUSIONS

DGE after SSPPD is strongly linked to the occurrence of other postoperative intra-abdominal complications such as pancreatic fistula. The incidence rate of primary DGE after SSPPD was 4 %. Although the ISGPS classification of DGE is clearly applicable, the grades do not explain why DGE occurs. Primary and secondary DGE should therefore be defined separately.

Does Braun enteroenterostomy reduce delayed gastric emptying after pancreaticoduodenectomy?

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.

Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature

Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.

Comparison of intraoperative versus delayed enteral feeding tube placement in patients undergoing a Whipple procedure

BACKGROUND

The intraoperative placement of an enteral feeding tube (FT) during pancreaticoduodenectomy (PD) is based on the surgeon's perception of need for postoperative nutrition. Published preoperative risk factors predicting postoperative morbidity may be used to predict FT need and associated intraoperative placement.

METHODS

A retrospective review of patients who underwent PD during 2005-2011 was performed by querying the National Surgical Quality Improvement Program (NSQIP) database with specific procedure codes. Patients were categorized based on how many of 10 possible preoperative risk factors they demonstrated. Groups of patients with scores of ≤ 1 (low) and ≥ 2 (high), respectively, were compared for FT need, length of stay (LoS) and organ space surgical site infections (SSIs).

RESULTS

Of 138 PD patients, 82 did not have an FT placed intraoperatively, and, of those, 16 (19.5%) required delayed FT placement. High-risk patients were more likely to require a delayed FT (29.3%) compared with low-risk patients (9.8%) (P = 0.026). The 16 patients who required a delayed FT had a median LoS of 15.5 days, whereas the 66 patients who did not require an FT had a median LoS of 8 days (P < 0.001).

CONCLUSIONS

In this analysis, subjects considered as high-risk patients were more likely to require an FT than low-risk patients. Assessment of preoperative risk factors may improve decision making for selective intraoperative FT placement.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Complications after pancreatic resection: diagnosis, prevention and management

BACKGROUND

Although mortality after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has decreased, morbidity still remains high. The aim of this review article is to present, define, predict, prevent, and manage the main complications after pancreatic resection (PR).

METHODS

A non-systematic literature search on morbidity and mortality after PR was undertaken using the PubMed/MEDLINE and Embase databases.

RESULTS

The main complications after PR are delayed gastric emptying (DGE), pancreatic fistula (PF), and bleeding, as defined by the International Study Group on Pancreatic Surgery. PF occurs in 10% to 15% of patients after PD and in 10% to 30% of patients after DP. The different techniques of pancreatic anastomosis and pancreatic remnant closure do not show significant advantages in the prevention of PF, nor does the perioperative use of somatostatin and its analogues. The trend is for conservative or interventional radiology therapy for PF (with enteral nutrition), which achieves a success rate of approximately 80%. DGE after PD occurs in 20% to 50% of patients. Prophylactic erythromycin may reduce the incidence of DGE. Gastric aspiration with erythromycin is usually effective in one to three weeks. Bleeding (gastrointestinal and intraabdominal) occurs in 4% to 16% of patients after PD and in 2% to 3% of patients after DP. Endovascular treatment can only be used for a haemodynamically stable patient. In cases of haemodynamic instability or associated septic complications, surgical treatment is necessary. In expert centres, the mortality rates can be less than 1% after DP and less than 3% after PD.

CONCLUSION

There is a need for improved strategies to prevent and treat complications after PR.

Pancreatic surgery: indications, complications, and implications for nutrition intervention

Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.

[Gastroenteric reconstruction route after pancreaticoduodenectomy: antecolic versus retrocolic]

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.

Systematic review of five feeding routes after pancreatoduodenectomy

BACKGROUND

Current European guidelines recommend routine enteral feeding after pancreato-duodenectomy (PD), whereas American guidelines do not. The aim of this study was to determine the optimal feeding route after PD.

METHODS

A systematic search was performed in PubMed, Embase and the Cochrane Library. Included were studies on feeding routes after PD that reported length of hospital stay (primary outcome).

RESULTS

Of 442 articles screened, 15 studies with 3474 patients were included. Data on five feeding routes were extracted: oral diet (2210 patients), enteral nutrition via either a nasojejunal tube (NJT, 165), gastrojejunostomy tube (GJT, 52) or jejunostomy tube (JT, 623), and total parenteral nutrition (TPN, 424). Mean(s.d.) length of hospital stay was shortest in the oral diet and GJT groups (15(14) and 15(11) days respectively), followed by 19(12) days in the JT, 20(15) days in the TPN and 25(11) days in the NJT group. Normal oral intake was established most quickly in the oral diet group (mean 6(5) days), followed by 8(9) days in the NJT group. The incidence of delayed gastric emptying varied from 6 per cent (3 of 52 patients) in the GJT group to 23.2 per cent (43 of 185) in the JT group, but definitions varied widely. The overall morbidity rate ranged from 43.8 per cent (81 of 185) in the JT group to 75 per cent (24 of 32) in the GJT group. The overall mortality rate ranged from 1.8 per cent (3 of 165) in the NJT group to 5.4 per cent (23 of 424) in the TPN group.

CONCLUSION

There is no evidence to support routine enteral or parenteral feeding after PD. An oral diet may be considered as the preferred routine feeding strategy after PD.

Clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a systematic review and meta-analysis

BACKGROUND

The clinical risk factors of delayed gastric emptying (DGE) in patients after pancreaticoduodenectomy (PD) remains controversial. Herein, we conducted a systematic review to quantify the associations between clinical risk factors and DGE in patients after conventional PD or pylorus preserving pancreaticoduodenectomy (PPPD).

METHODS

A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1970 to 2012 was performed. Cohort, case-control studies, and randomized controlled trials that examined clinical risk factors of DGE were included.

RESULTS

Eighteen studies met final inclusion criteria (total n = 3579). From the pooled analyses, preoperative diabetes (OR 1.49, 95% CI, 1.03-2.17), pancreatic fistulas (OR 2.66, 95% CI, 1.65-4.28), and postoperative complications (OR 4.71, 95% CI, 2.61-8.50) were significantly associated with increased risk of DGE; while patients with preoperative biliary drainage (OR 0.68, 95% CI, 0.48-0.97) and antecolic reconstruction (OR 0.17, 95% CI, 0.07-0.41) had decreased risk of DGE development. Gender, malignant pathology, preoperative jaundice, intra-operative transfusion, PD vs. PPPD and early enteral feeding were not significantly associated with DGE development (all P > 0.05).

CONCLUSIONS

Our findings demonstrate that preoperative diabetes, pancreatic fistulas, and postoperative complications were clinical risk factors predictive for DGE. Antecolic reconstruction and preoperative biliary drainage result in a reduction in DGE. Knowledge of these risk factors may assist in identification and appropriate referral of patients at risk of DGE.

Nutritional status and nutritional support before and after pancreatectomy for pancreatic cancer and chronic pancreatitis

Cachexia, malnutrition, significant weight loss, and reduction in food intake due to anorexia represent the most important pathophysiological consequences of pancreatic cancer. Pathophysiological consequences result also from pancreatectomy, the type and severity of which differ significantly and depend on the type of the operation performed. Nutritional intervention, either parenteral or enteral, needs to be seen as a method of support in pancreatic cancer patients aiming at the maintenance of the nutritional and functional status and the prevention or attenuation of cachexia. Oral nutrition could reduce complications while restoring quality of life. Enteral nutrition in the post-operative period could also reduce infective complications. The evidence for immune-enhanced feed in patients undergoing pancreaticoduodenectomy for pancreatic cancer is supported by the available clinical data. Nutritional support during the post-operative period on a cyclical basis is preferred because it is associated with low incidence of gastric stasis. Postoperative total parenteral nutrition is indicated only to those patients who are unable to be fed orally or enterally. Thus nutritional deficiency is a relatively widesoread and constant finding suggesting that we must optimise the nutritional status both before and after surgery.

Feeding jejunostomy during Whipple is associated with increased morbidity

BACKGROUND

Placement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD.

MATERIALS AND METHODS

This is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients.

RESULTS

Thirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001) were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis.

CONCLUSION

Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity.

Pneumatosis in Post-Whipple Patients

Pneumatosis intestinalis (PI) is the finding of air in the wall of the intestine. Clinical significance ranges from an incidental radiologic finding to an indicator of life-threatening disease requiring surgical intervention. We report the incidence and consequence of PI in a 7-year, single-surgeon, retrospective review. Data from demographics, imaging, and outcomes were analyzed. Two-tailed Fisher's exact test was performed to analyze the difference between groups. A total of 214 patients underwent a Whipple procedure with a routinely placed feeding tube during this period. Most had a gastrojejunal feeding tube, 80.4 per cent. Thirteen patients developed PI. Overall reoperation rate was nine of 201 versus four of 13 in the PI group ( P < 0.02). Three patients taken back to the operating room with peritonitis and PI had a necrotic bowel. A fourth patient was taken to surgery for unrelenting upper gastrointestinal bleeding. The remaining nine were managed nonoperatively with resolution of PI. The 90-day death rate in those without PI was 2.9 per cent versus 23.3 per cent with PI ( P < 0.02). Isolated PI can be managed nonoperatively; however, in the presence of peritonitis, it is a strong predictor of lethal complications.