Impact of routine nasogastric decompression versus no nasogastric decompression after pancreaticoduodenectomy on perioperative outcomes: meta-analysis

Differential Gains in Surgical Outcomes for High-Risk vs Low-Risk Pancreaticoduodenectomy with Successive Refinements of Risk-Stratified Care Pathways

BACKGROUND

The use of risk-stratified pancreatectomy care pathways (RSPCPs) is associated with reduced length of stay (LOS). This study sought to evaluate the impact of successive pathway revisions with the hypothesis that high-risk patients require iterative pathway revisions to optimize outcomes.

STUDY DESIGN

A prospectively maintained database (October 2016 to December 2021) was evaluated for pancreaticoduodenectomy patients managed with RSPCPs preoperatively assigned based on postoperative pancreatic fistula (POPF) risk. Launched in October 2016 (version [V] 1), RSPCPs were optimized in February 2019 (V2) and November 2020 (V3). Targeted pathway components included earlier nasogastric tube removal, diet advancement, reduced intravenous fluids and opioids, institution-specific drain fluid amylase cutoffs for early day 3 removal, and patient education. Primary outcome was LOS. Secondary outcomes included major complication (Accordion grade 3+), POPF (International Study Group for Pancreatic Surgery Grade B/C), and delayed gastric emptying (DGE).

RESULTS

Of 481 patients, 234 were managed by V1 (83 high-risk), 141 by V2 (43 high-risk), and 106 by V3 (43 high-risk). Median LOS reduction was greatest in high-risk patients with a 7-day reduction (pre-RSPCP, 12 days; V1, 9 days; V2, 7 days; V3, 5 days), compared with low-risk patients (pre-pathway, 10 days; V1, 6 days; V2, 5 days; V3, 4 days). Complications decreased significantly among high-risk patients (V1, 45%; V2, 33%; V3, 19%; p < 0.001), approaching rates in low-risk patients (V1, 21%; V2, 20%; V3, 14%). POPF (V1, 33%; V2, 23%; V3, 16%; p < 0.001) and DGE (V1, 23%; V2, 22%; V3, 14%; p < 0.001) improved among high-risk patients.

CONCLUSIONS

Risk-stratified pancreatectomy care pathways are associated with reduced LOS, major complication, Grade B/C fistula, and DGE. The easiest gains in surgical outcomes are generated from the immediate improvement in the patients most likely to be fast-tracked, but high-risk patients benefit from successive application of the learning health system model.

Recent Advances in Pancreatic Ductal Adenocarcinoma: Strategies to Optimise the Perioperative Nutritional Status in Pancreatoduodenectomy Patients

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy for which the mainstay of treatment is surgical resection, followed by adjuvant chemotherapy. Patients with PDAC are disproportionately affected by malnutrition, which increases the rate of perioperative morbidity and mortality, as well as reducing the chance of completing adjuvant chemotherapy. This review presents the current evidence for pre-, intra-, and post-operative strategies to improve the nutritional status of PDAC patients. Such preoperative strategies include accurate assessment of nutritional status, diagnosis and appropriate treatment of pancreatic exocrine insufficiency, and prehabilitation. Postoperative interventions include accurate monitoring of nutritional intake and proactive use of supplementary feeding methods, as required. There is early evidence to suggest that perioperative supplementation with immunonutrition and probiotics may be beneficial, but further study and understanding of the underlying mechanism of action are required.

Lengthened Efferent Limb in Braun Enteroenterostomy Reduces Delayed Gastric Emptying After Pancreaticoduodenectomy

BACKGROUND

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD), but a method to prevent DGE has not been established. This study aims to demonstrate a novel technique utilizing a lengthened efferent limb in Billroth-II (B-II) reconstruction during PD and to evaluate the impact of the longer efferent limb on DGE occurrence.

METHODS

Patients who underwent PD with B-II reconstruction were divided into two groups: PDs with lengthened (50-60 cm) efferent limb (L group) and standard length (0-30 cm) efferent limb (S group). Postoperative outcomes were compared. DGE was defined and graded according to the International Study Group of Pancreatic Surgery criteria.

RESULTS

Among 283 consecutive patients who underwent PD from 2002 to 2021, 206 patients were included in this study. Patients who underwent Roux-en-Y reconstruction (n = 77) were excluded. Compared with the S group, the L group included older patients and those who underwent PD after 2016 (p = 0.025, < 0.001, respectively). D2 lymphadenectomy, antecolic route reconstruction, and Braun enteroenterostomy were performed more frequently in the L group (p = 0.040, < 0.001, < 0.001, respectively). The rate of DGE was significantly decreased to 6% in the L group, compared with 16% in the S group (p = 0.027), which might lead to a shorter hospital stay in the L group (p < 0.001). Multivariable analysis identified two factors as independent predictors for DGE: intraabdominal abscess [odds ratio (OR) 5.530, p = 0.008] and standard efferent limb length (OR 2.969, p = 0.047).

CONCLUSION

A lengthened efferent limb in Braun enteroenterostomy could reduce DGE after PD.

The tube, the pancreatoduodenectomy-and the dogma

Routine use of NG-tubes following pancreatoduodenectomies is not indicated