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Perioperative Drug Treatment in Pancreatic Surgery-A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12051750. [PMID: 36902534 PMCID: PMC10003556 DOI: 10.3390/jcm12051750] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Pancreatic resections for malignant or benign diseases are associated with major morbidity and changes in physiology. To reduce perioperative complications and enhance recovery, many types of perioperative medical management have been introduced. The aim of this study was to provide an evidence-based overview on the best perioperative drug treatment. METHODS The electronic bibliographic databases Medline, Embase, CENTRAL, and Web of Science were systematically searched for randomized controlled trials (RCT) evaluating perioperative drug treatments in pancreatic surgery. The investigated drugs were somatostatin analogues, steroids, pancreatic enzyme replacement therapy (PERT), prokinetic therapy, antidiabetic drugs, and proton pump inhibitors (PPI). Targeted outcomes in each drug category were meta-analyzed. RESULTS A total of 49 RCT were included. The analysis of somatostatin analogues showed a significantly lower incidence of postoperative pancreatic fistula (POPF) in the somatostatin group compared to the control group (OR 0.58, 95% CI: 0.45 to 0.74). The comparison of glucocorticoids versus placebo showed significantly less POPF in the glucocorticoid group (OR 0.22, 95% CI: 0.07 to 0.77). There was no significant difference in DGE when erythromycin was compared to placebo (OR 0.33, 95% CI: 0.08 to 1.30). The other investigated drug regimens could only be analyzed qualitatively. CONCLUSION This systematic review provides a comprehensive overview on perioperative drug treatment in pancreatic surgery. Some often-prescribed perioperative drug treatments lack high quality evidence and further research is needed.
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Lengthened Efferent Limb in Braun Enteroenterostomy Reduces Delayed Gastric Emptying After Pancreaticoduodenectomy. World J Surg 2023; 47:1263-1270. [PMID: 36719447 DOI: 10.1007/s00268-023-06925-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 02/01/2023]
Abstract
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.
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Teres ligamentum wrap covering the pancreaticojejunostomy following pancreatoduodenectomy is associated with a lower rate of postoperative pancreas fistula: a prospective cohort study. HPB (Oxford) 2023; 25:116-123. [PMID: 36280427 DOI: 10.1016/j.hpb.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/26/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative pancreas fistula (POPF) is a common complication after pancreatoduodenectomy (PD). A Teres Ligamentum (TL)-wrap covering the pancreaticojejunostomy (PJ) is suggested as a potential solution to reduce POPF. The aim of this study was to compare POPF incidence (grade B/C) in patients with or without a TL-wrap. METHODS A prospective cohort study was performed between January 2019-December 2021. All consecutive patients were included. Patient, tumor and surgical characteristics and postoperative complications were compared in both open and robot-assisted surgery. RESULTS A total of 118 consecutive patients were included. The first 57 patients were treated without and the following 61 patients with a TL-wrap. There were no statistically significant differences between both groups regarding patient, pre-operative treatment and surgical characteristics. The occurrence of POPF was strongly reduced in the TL-wrap group compared to patients without a TL-wrap (3.3% vs 28.1%, P < 0.001). Also mean length of hospital stay was reduced (11.5 vs 18.8 days, P = 0.030). CONCLUSION The use of a TL-wrap covering the PJ as addition to the modified Blumgart anastomosis technique is associated with a significantly reduced POPF rate and a reduced length of hospital stay. A TL-wrap is a simple addition to a PJ that may be considered to improve postoperative outcome. This association must be studied more definitively in a randomized controlled trial.
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Degisors S, Caiazzo R, Dokmak S, Truant S, Aussilhou B, Eveno C, Pattou F, El Amrani M, Piessen G, Sauvanet A. Delayed gastric emptying following distal pancreatectomy: incidence and predisposing factors. HPB (Oxford) 2022; 24:772-781. [PMID: 34753675 DOI: 10.1016/j.hpb.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/06/2021] [Accepted: 09/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) following elective distal pancreatectomy (DP) is poorly known. This study aimed to report incidence of DGE following DP, to identify its predisposing factors, and to assess its impact on hospital stay. METHODS Patients who had elective DP without additional organ or vascular resection (2012-2017) in two academic hospitals were included. Factors predisposing to DGE, defined according to the International Study Group of Pancreatic Surgery, were identified by multivariate analysis. A systematic review was performed to evaluate DGE incidence following elective DP. RESULTS 311 elective DPs were performed. Three perioperative mortalities (1.0%) were unrelated to DGE. DGE occurred in 31 (10.0%) patients (grade A = 21, grade B = 7, grade C = 3) with a median hospital stay of 16 (13-22) days versus 10 (7-14) without DGE (p < 0.001). In multivariate analysis, predisposing factors of DGE were age>75 years (OR = 4.32 [1.53-12.19]; p = 0.006), open approach (OR = 2.97 [1.1-8]; p = 0.031) and POPF grade B-C (OR = 2.54 [1.05-6.1]; p = 0.038). The systematic review identified 7 series including 876 patients with an overall 8.1% DGE incidence. CONCLUSION DGE complicates around 10% of elective DP. Laparoscopic approach and prevention of POPF should be encouraged to reduce DGE incidence.
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Affiliation(s)
- Sébastien Degisors
- CHU Lille, Department of Digestive and Oncological Surgery, University of Lille, F-59000, Lille, France
| | - Robert Caiazzo
- CHU Lille, General and Endocrine Surgery, University of Lille, F-59000, Lille, France
| | - Safi Dokmak
- AP-HP, Department of HBP Surgery, Hôpital Beaujon, University of Paris, F-92110, Clichy, France
| | - Stéphanie Truant
- CHU Lille, Department of Digestive Surgery and Transplantation, University of Lille, F-59000, Lille, France
| | - Béatrice Aussilhou
- AP-HP, Department of HBP Surgery, Hôpital Beaujon, University of Paris, F-92110, Clichy, France
| | - Clarisse Eveno
- CHU Lille, Department of Digestive and Oncological Surgery, University of Lille, F-59000, Lille, France
| | - François Pattou
- CHU Lille, General and Endocrine Surgery, University of Lille, F-59000, Lille, France
| | - Mehdi El Amrani
- CHU Lille, Department of Digestive Surgery and Transplantation, University of Lille, F-59000, Lille, France
| | - Guillaume Piessen
- CHU Lille, Department of Digestive and Oncological Surgery, University of Lille, F-59000, Lille, France
| | - Alain Sauvanet
- AP-HP, Department of HBP Surgery, Hôpital Beaujon, University of Paris, F-92110, Clichy, France.
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Double tract-like gastric tube reconstruction decreases the incidences of delayed gastric emptying and bile reflux after esophagectomy: results of a pilot study of an experimental technique. Langenbecks Arch Surg 2022; 407:1431-1439. [DOI: 10.1007/s00423-022-02461-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
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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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Arango NP, Prakash LR, Chiang YJ, Dewhurst WL, Bruno ML, Ikoma N, Kim MP, Lee JE, Katz MHG, Tzeng CWD. Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying. J Gastrointest Surg 2021; 25:2221-2230. [PMID: 33236322 DOI: 10.1007/s11605-020-04877-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Natalia Paez Arango
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA.
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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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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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Yamaguchi H, Kimura Y, Imamura M, Nagayama M, Ito T, Kyuno D, Kono T, Kimura A, Akizuki E, Nishidate T, Okita K, Nobuoka T, Mizuguchi T, Hirata K, Takemasa I. Effect of Rikkunshito, a Traditional Japanese Herbal Medicine, on Delayed Gastric Emptying and Oral Dietary Intake After Pancreaticoduodenectomy: A Prospective, Randomized, Single-Center, Open-Labeled Study. Clin Exp Gastroenterol 2020; 13:577-587. [PMID: 33328753 PMCID: PMC7734068 DOI: 10.2147/ceg.s252913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 11/12/2020] [Indexed: 01/04/2023] Open
Abstract
Introduction Delayed gastric emptying (DGE) remains an important problem after pancreaticoduodenectomy (PD). There is a lack of effective treatments for early recovery of oral dietary intake. Rikkunshito (RKT), a Japanese herbal medicine, has been gaining attention as a facilitator of gastric emptying. We evaluated the effects of RKT on DGE after PD. Methods In this prospective, randomized, open-labeled study, patients were randomly allocated before PD in a 1:1 ratio to the RKT group or the control group that received no additional treatment. The RKT group received 2.5 g of RKT three times daily (7.5 g/day) from postoperative day (POD) 1 to POD 21. The primary endpoint was the incidence of DGE. Secondary endpoints were short-term postoperative outcomes including oral dietary intake volume and perioperative changes in levels of the hormones ghrelin and leptin. Patients were observed until hospital discharge. Results Twenty-six patients in each group (n = 52) completed the protocol treatment and were included in the analysis set. There were no statistically significant differences in basic characteristics and operative factors. The overall incidence of DGE was not statistically different between the RKT and control groups (30.8% vs 30.8%, p>0.9999). There were no statistically significant differences in the amount of postoperative oral dietary intake represented by total dietary intake (TDI) up to POD 14 and POD 21, complications, and length of hospital stay. No adverse events related to this study were observed. In the RKT group, total ghrelin and acyl-ghrelin were significantly upregulated and leptin was significantly downregulated earlier than in the control group. Conclusion RKT treatment from POD 1 to 21 did not reduce the incidence of DGE and had no clinically beneficial effect on short-term postoperative outcomes irrespective of changes in hormone levels.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Masafumi Imamura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Minoru Nagayama
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Tatsuya Ito
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Daisuke Kyuno
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Tsuyoshi Kono
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Akina Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Emi Akizuki
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Toshihiko Nishidate
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Kenji Okita
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Takayuki Nobuoka
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Toru Mizuguchi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan.,Department of Nursing and Surgical Science, Sapporo Medical University School of Health Science, Sapporo, Japan
| | - Koichi Hirata
- Department of Surgery, JR Sapporo Hospital, Sapporo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, School of Medicine, Sapporo, Japan
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11
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Watanabe N, Yokoyama Y, Ebata T, Igami T, Mizuno T, Yamaguchi J, Onoe S, Nagino M. The influence of the preoperative thickness of the abdominal cavity on the gastrojejunal anatomic position and delayed gastric emptying after pancreatoduodenectomy. HPB (Oxford) 2020; 22:1695-1702. [PMID: 32284279 DOI: 10.1016/j.hpb.2020.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 03/06/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to investigate the hypothesis that preoperative thickness of the abdominal cavity influenced on the gastrojejunostomy position and the incidence of delayed gastric emptying (DGE) after pancreatoduodenectomy. METHODS Between January 2009 and December 2018, consecutive patients who underwent subtotal stomach-preserving pancreatoduodenectomy were retrospectively reviewed. Thickness of the abdominal cavity at the level of the celiac axis (TACC) and umbilicus (TACU) were measured using computed tomography before surgery. The ventral deviation of the gastrojejunostomy was evaluated as the sagittal fundus anastomotic angle (SFAA) using sagittal computed tomography images taken after surgery. RESULTS A total of 281 patients were included. Of these, clinically relevant DGE (CR-DGE) was observed in 47 patients. TACC was significantly correlated with SFAA (R = 0.53, P < 0.001). Both TACC and SFAA were significantly greater in patients with CR-DGE compared to those without CR-DGE. In contrast, TACU was not associated with SFAA and the incidence of CR-DGE. Multivariate analysis revealed that TACC >110 mm (odds ratio, 3.07; p = 0.002) and pancreatic fistula (odds ratio, 2.71; p = 0.013) were identified as independent risk factors for CR-DGE. CONCLUSION Thickness of the upper abdominal cavity had a significant influence on gastrojejunal anatomic position and the development of CR-DGE after pancreatoduodenectomy.
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Affiliation(s)
- Nobuyuki Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunsuke Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Xiao Y, Hao X, Yang Q, Li M, Wen J, Jiang C. Effect of Billroth-II versus Roux-en-Y reconstruction for gastrojejunostomy after pancreaticoduodenectomy on delayed gastric emptying: A meta-analysis of randomized controlled trials. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:397-408. [PMID: 32897643 DOI: 10.1002/jhbp.828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/PURPOSE Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). The aim of the present meta-analysis was to evaluate the effect of Billroth-II(B-II) versus Roux-en-Y (R-Y) reconstruction for gastrojejunostomy on DGE after PD. METHODS A systematic literature search was performed using the electronic database MEDLINE (via PubMed and OVID), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) of the Cochrane Library to select pertinent randomized controlled trials (RCTs) on this topic from January 1990 to January 2020. The primary outcome was identified as postoperative DGE. Subgroup analysis was established to compare the incidence of grade B and C DGE. Software Revman 5.3 was used for the statistical analysis, summary statistics were calculated using fixed effect model or random effect model. RESULTS Five RCTs including a total of 612 patients were eligible for this meta-analysis. The incidence of grade B and C DGE was significantly lower with the B-II reconstruction than with the R-Y reconstruction (8.0% vs. 14.8%, OR = 0.49, 95% CI: 0.26-0.95, P = 0.03) and the B-II reconstruction took a shorter operation time (WMD=-7.18, 95% CI: [-13.09, -1.27], P = 0,02). No statistically significant difference was found between the two reconstruction methods in terms of the incidence of postoperative pancreatic fistula (POPF), bile leak, intra-abdominal abscess, postoperative pneumonia and the length of postoperative hospital stay. CONCLUSIONS B-II reconstruction after PD has a lower incidence of grade B and C DGE and shorter operation time compared with R-Y reconstruction.
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Affiliation(s)
- Yuqing Xiao
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Xiaofei Hao
- Department of General Medicine, Chengdu Fifth People's Hospital, Chengdu, China
| | - Qin Yang
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Ming Li
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Jun Wen
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Cuina Jiang
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
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13
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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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Cai X, Zhang M, Liang C, Xu Y, Yu W. Delayed gastric emptying after Pancreaticoduodenectomy: a propensity score-matched analysis and clinical Nomogram study. BMC Surg 2020; 20:149. [PMID: 32646466 PMCID: PMC7346444 DOI: 10.1186/s12893-020-00809-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/29/2020] [Indexed: 01/08/2023] Open
Abstract
Background Delayed gastric emptying (DGE) is a common and frustrating complication of pancreaticoduodenectomy (PD). Studies suggest that surgical methods and other clinical characteristics may affect the occurrence of DGE. Nevertheless, the results of such studies are conflicting. The objective of this work was to perform a propensity score matching analysis to compare the differences between pylorus-preserving pancreaticoduodenectomy (PPPD) and pylorus-removing pancreaticoduodenectomy (PrPD) and to develop and validate a nomogram to predict the probability of severe DGE (SDGE). Methods This retrospective study enrolled patients who underwent PD at our institution from December 2009 to December 2018. Propensity score matching was applied at a ratio of 1:1 to compare PPPD and PrPD groups. We compared incidence of complications, DGE, lengths of hospital stay, hospitalization costs, and mortality. Univariate and multivariate logistic regression analysis were performed to identify potential risk factors of severe DGE. Finally, a nomogram was developed and validated to predict severe DGE. Results The PPPD group had a significantly higher rate of postoperative pancreatic fistula (29.9% versus 17.4%, P < 0.05) and less blood loss (463.7 ml versus 694.9 ml, P < 0.05). After propensity score matching, the PPPD group had a significantly higher rate of postoperative DGE (19.2% versus 3.8%, P < 0.05), especially severe DGE (17.3% versus 0%) than the PrPD group. There were no significant differences in terms of lengths of hospital stay, hospitalization costs or mortality between the groups. Surgical method, biliary leakage, abdominal infection, and diabetes were independent risk factors for SDGE. The nomogram predicted SDGE with a training C - index of 0.798 and a validation C - index of 0.721. Conclusion PPPD increases the risk of DGE than PrPD, especially SDGE. Our prediction nomogram gives good prediction of SDGE after pancreaticoduodenectomy.
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Affiliation(s)
- Xianlei Cai
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China
| | - Miaozun Zhang
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China
| | - Chao Liang
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China
| | - Yuan Xu
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China
| | - Weiming Yu
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China.
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Baker JR, Sakoff JA, McCluskey A. The aryl hydrocarbon receptor (AhR) as a breast cancer drug target. Med Res Rev 2019; 40:972-1001. [PMID: 31721255 DOI: 10.1002/med.21645] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/04/2019] [Accepted: 10/29/2019] [Indexed: 12/25/2022]
Abstract
Breast cancer is the most common cancer in women, with more than 1.7 million diagnoses worldwide per annum. Metastatic breast cancer remains incurable, and the presence of triple-negative phenotypes makes targeted treatment impossible. The aryl hydrocarbon receptor (AhR), most commonly associated with the metabolism of xenobiotic ligands, has emerged as a promising biological target for the treatment of this deadly disease. Ligands for the AhR can be classed as exogenous or endogenous and may have agonistic or antagonistic activity. It has been well reported that agonistic ligands may have potent and selective growth inhibition activity in a number of oncogenic cell lines, and one (aminoflavone) has progressed to phase I clinical trials for breast cancer sufferers. In this study, we examine the current state of the literature in this area and elucidate the promising advances that are being made in hijacking the cytosolic-to-nuclear pathway of the AhR for the possible future treatment of breast cancer.
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Affiliation(s)
- Jennifer R Baker
- Chemistry, School of Environmental & Life Sciences, the University of Newcastle, Callaghan, NSW, Australia
| | - Jennette A Sakoff
- Department of Medical Oncology, Calvary Mater Newcastle Hospital, Waratah, NSW, Australia
| | - Adam McCluskey
- Chemistry, School of Environmental & Life Sciences, the University of Newcastle, Callaghan, NSW, Australia
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Jung JP, Zenati MS, Dhir M, Zureikat AH, Zeh HJ, Simmons RL, Hogg ME. Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy. JAMA Surg 2019; 153:918-927. [PMID: 29998288 DOI: 10.1001/jamasurg.2018.2089] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Jae Pil Jung
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mazen S Zenati
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mashaal Dhir
- Department of Surgery, State University of New York Upstate Medical University, Syracuse
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard L Simmons
- Division of Surgical Research, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Kim DH, Hong SC, Jang JY, Cho JK, Ju YT, Lee YJ, Jung EJ, Jeong SH, Park TJ, Kim JY, Kwag SJ, Park JH, Jeong CY. Comparing the surgical outcomes of stapled anastomosis versus hand-sewn anastomosis of duodenojejunostomy in pylorus-preserving pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:245-251. [PMID: 31501813 PMCID: PMC6728254 DOI: 10.14701/ahbps.2019.23.3.245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/21/2019] [Accepted: 04/30/2019] [Indexed: 12/28/2022] Open
Abstract
Backgrounds/Aims This study is to evaluate the perioperative outcomes of the duodenojejunostomy (DJ) procedure in pylorus preserving pancreaticoduodenectomy (PPPD). Methods In this study, as noted between 2010 and 2018, there were 77 PPPDs which were performed at our hospital by one surgeon. We began the circular stapled method from 2014, and continue with this procedure for the aforementioned surgeries including and up to today. The clinical data for the study were collected retrospectively to compare clinical outcomes of the two methods, the circular stapled anastomosis and the hand - sewn anastomosis. Results There were 34 patients in a circular stapled group, and 43 in a hand-sewn group as identified for this study. The delayed gastric emptying (DGE) occurred in 6 (17.64%) patients in the circular stapled group, and 10 (23.3%) in the hand-sewn group (p=0.547). It is noted that there was a serum albumin level measured on the 14th day after the operation, which was significantly high in the circular stapled group (3.41±0.47 (g/dl) vs 2.92±0.39 (g/dl), p<0.001). There were no significant differences in terms of the incidence of postoperative complications (58.8% vs 58.1%, p=0.952) and mortality rates (5.9% vs 0, p=0.192) among the patient participants in this study. Conclusions We conclude that using a circular stapler for the DJ procedure in PPPDs do not increase the development of a DGE, and is also helpful for the benefit of the patient's nutritional status going forward during recovery from the operation.
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Affiliation(s)
- Dong-Hwan Kim
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Soon-Chan Hong
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jae-Yool Jang
- Department of General Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Jin-Kyu Cho
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young-Tae Ju
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young-Joon Lee
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Eun-Jung Jung
- Department of General Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Sang-Ho Jeong
- Department of General Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Tae-Jin Park
- Department of General Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Ju-Yeon Kim
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Seung-Jin Kwag
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Ji-Ho Park
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chi-Young Jeong
- Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
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Limongelli P, Docimo L, Malleo G, Salvia R. Delayed Gastric Emptying after Pancreaticoduodenectomy: The Hunt Continues. J Am Coll Surg 2019; 226:333-334. [PMID: 29478471 DOI: 10.1016/j.jamcollsurg.2017.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 12/04/2017] [Indexed: 12/18/2022]
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Kobayashi S, Koizumi S, Hatori T, Segami K, Hoshino H, Otsubo T. The Vertical Array Reconstruction Technique in Pylorus-Preserving Pancreatoduodenectomy. Dig Surg 2018; 35:469-473. [PMID: 29316561 DOI: 10.1159/000485847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/27/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND/AIMS We describe a new reconstruction method of duodenojejunal anastomosis, the "vertical array reconstruction" (VAR) technique, following pylorus-preserving pancreatoduodenectomy (PPPD). METHODS The VAR technique aligns the stomach, duodenum, and jejunal loop vertically along the body's longitudinal axis. It was performed in 120 consecutive patients (between June 2008 and October 2015) who underwent PPPD. We evaluated the incidence of delayed gastric emptying (DGE). RESULTS The incidence of DGE was 1.7% (n = 2). The proposed clinical grading classified these 2 cases of DGE as grade B. There was no DGE related to pancreatic fistula. The median duration to starting a solid diet was 3 days (range 3-5 days). The median operative time was 450 min (range 391-550 min). CONCLUSION The VAR technique allows the upper digestive tract to be aligned linearly and can minimize the risk of DGE after PPPD.
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Affiliation(s)
- Shinjiro Kobayashi
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Satoshi Koizumi
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takashi Hatori
- International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Kouhei Segami
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hiroyuki Hoshino
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Takehito Otsubo
- Department of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
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Hajibandeh S, Hajibandeh S, Khan RMA, Malik S, Mansour M, Kausar A, Subar D. Stapled anastomosis versus hand-sewn anastomosis of gastro/duodenojejunostomy in pancreaticoduodenectomy: A systematic review and meta-analysis. Int J Surg 2017; 48:1-8. [PMID: 28987557 DOI: 10.1016/j.ijsu.2017.09.071] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/13/2017] [Accepted: 09/27/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Controversy exists regarding the best anastomotic method for pancreaticoduodenectomy (PD). We aimed to evaluate the perioperative outcomes of PD with stapled anastomosis (SA) versus hand-sewn anastomosis (HA) of gastrojejunostomy or duodenojejunostomy. METHODS We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Delayed gastric emptying (DGE), postoperative pancreatic fistula (POPF), anastomotic bleeding, anastomotic leak, intra-abdominal abscess and mortality were defined as the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models. RESULTS We identified 1 randomised controlled trial (RCT) and 5 observational studies reporting a total of 890 patients who underwent PD with SA (n = 300) or conventional HA (n = 590). Our analysis demonstrated that SA significantly reduced postoperative DGE (OR: 0.37, 95% CI 0.25-0.54, P < 0.00001) but significantly increased anastomotic bleeding (OR: 13.4, 95% CI 2.96-57.41, P = 0.0007) compared to HA. No significant difference was found in POPF (OR: 0.83, 95% CI 0.56-1.21, P = 0.33); anastomotic leak (OR: 0.50, 95% CI 0.09-3.79, P = 0.58); intra-abdominal abscess (OR: 1.39, 95% CI 0.71-2.70, P = 0.34); or mortality (RD: -0.01, 95% CI 0.03-0.02, P = 0.65) between two groups. CONCLUSIONS Our analysis demonstrated that compared to conventional HA, SA may be associated with lower incidence of DGE after PD without increasing the risk of clinically significant POPF, anastomotic leak or mortality. However, it is associated with higher rate of anastomotic bleeding which mandates careful and precise haemostasis of the stapled line. Considering the current limited evidence, no definitive conclusion can be drawn. Future research is required.
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Affiliation(s)
- Shahin Hajibandeh
- Department of General Surgery, North Manchester General Hospital, Manchester, UK.
| | - Shahab Hajibandeh
- Department of General Surgery, Salford Royal NHS Foundation Trust, Salford, UK.
| | | | - Sohail Malik
- Department of General Surgery, North Manchester General Hospital, Manchester, UK.
| | - Moustafa Mansour
- Department of General Surgery, North Manchester General Hospital, Manchester, UK.
| | - Ambareen Kausar
- Department of Hepato-Pancreato-Biliary surgery, Royal Blackburn Hospital, Blackburn, UK.
| | - Daren Subar
- Department of Hepato-Pancreato-Biliary surgery, Royal Blackburn Hospital, Blackburn, UK.
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Futagawa Y, Kanehira M, Furukawa K, Kitamura H, Yoshida S, Usuba T, Misawa T, Okamoto T, Yanaga K. Impact of delayed gastric emptying after pancreaticoduodenectomy on survival. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:466-474. [DOI: 10.1002/jhbp.482] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Yasuro Futagawa
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
| | - Masaru Kanehira
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
| | - Kenei Furukawa
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
| | - Hiroaki Kitamura
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
| | - Seiya Yoshida
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
| | - Teruyuki Usuba
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
| | - Takeyuki Misawa
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
| | - Tomoyoshi Okamoto
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
| | - Katsuhiko Yanaga
- Department of Surgery; The Jikei University School of Medicine; 3-25-8 Nishishimbashi, Minato-ku Tokyo 105-8461 Japan
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Does the Ileal Brake Contribute to Delayed Gastric Emptying After Pancreatoduodenectomy? Dig Dis Sci 2017; 62:319-335. [PMID: 27995402 DOI: 10.1007/s10620-016-4402-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 11/29/2016] [Indexed: 12/18/2022]
Abstract
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.
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Hwang HK, Lee SH, Han DH, Choi SH, Kang CM, Lee WJ. Impact of Braun anastomosis on reducing delayed gastric emptying following pancreaticoduodenectomy: a prospective, randomized controlled trial. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:364-72. [PMID: 27038406 DOI: 10.1002/jhbp.349] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The present study investigates the clinical impact of Braun anastomosis on delayed gastric emptying (DGE) after pylorus-preserving pancreaticoduodenectomy (PPPD). METHODS From February 2013 to June 2014, 60 patients were recruited for this randomized controlled trial. The incidence of DGE and its risk factors were analyzed according to whether or not Braun anastomosis was used after PPPD. RESULTS Thirty patients were respectively enrolled in No-Braun group and Braun group. A comparative analysis between the two groups showed no differences in sex, diagnosis, operation time, hospital stay, or postoperative complications, including pancreatic fistula. Overall DGE developed in eight patients (26.7%) in the Braun group and in 14 patients (46.7%) in the No-Braun group (P = 0.108). However, clinically relevant DGE (grades B and C) was marginally more frequent in the No-Braun group (23.3% vs. 3.3%, P = 0.052). In a multivariable analysis, No-Braun anastomosis was an independent risk factor for developing clinically relevant DGE (odds ratio = 16.489; 95% confidence interval: 1.287-211.195; P = 0.031). CONCLUSION The overall DGE occurrence was not different between the two groups. However, No-Braun anastomosis was an independent risk factor for developing clinically relevant DGE.
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Affiliation(s)
- Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Sung Hwan Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Dai Hoon Han
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
| | - Sung Hoon Choi
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea.
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu,, Seoul, 120-752, South Korea
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Schulze T, Heidecke CD. [Treatment of postoperative impairment of gastrointestinal motility, cholangitis and pancreatitis]. Chirurg 2016; 86:540-6. [PMID: 25986675 DOI: 10.1007/s00104-015-0004-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- T Schulze
- Klinik und Poliklinik für Allgemeine Chirurgie, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Deutschland,
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Lermite E, Wu T, Sauvanet A, Mariette C, Paye F, Muscari F, Cunha AS, Sastre B, Arnaud JP, Pessaux P. Postoperative biological and clinical outcomes following uncomplicated pancreaticoduodenectomy. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:23-31. [PMID: 26925147 PMCID: PMC4767268 DOI: 10.14701/kjhbps.2016.20.1.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/21/2015] [Accepted: 10/23/2015] [Indexed: 01/04/2023]
Abstract
Backgrounds/Aims The aim of this study was to describe clinical and biological changes in a group of patients who underwent pancreaticoduodenectomy (PD) without any complication during the postoperative period. These changes reflect the "natural history" of PD, and a deviation should be considered as a warning sign. Methods Between January 2000 and December 2009, 131 patients underwent PD. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. Postoperative variables were validated using an external prospective database of 158 patients. Results The mean postoperative length of hospital stay was 20.3±4 days. The mean number of days until removal of nasogastric tube was 6.3±1.6 days. The maximal fall in hemoglobin level occurred on day 3 and began to increase after postoperative day (POD) 5, in patients with or without transfusions. The white blood cell count increased on POD 1 and persisted until POD 7. There was a marked rise in aminotransferase levels at POD 3. The peak was significantly higher in patients with hepatic pedicle occlusion (866±236 IU/L versus 146±48 IU/L; p<0.001). For both γ-glutamyl transpeptidase and alkaline phosphatase, there was a fall on POD1, which persisted until POD 5, followed with a stabilization. Bilirubin decreased progressively from POD 1 onwards. Conclusions This study facilitates a standardized biological and clinical pathway of follow-up. Patients who do not follow this recovery indicator could be at risk of complications and additional exams should be made to prevent consequences of such complications.
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Affiliation(s)
- Emilie Lermite
- Service de Chirurgie digestive, Hôpital universitaire d'Angers - Université d'Angers, France
| | - Tao Wu
- Digestive surgery, Hospital of Kunming - Medical University - Kunming - China
| | - Alain Sauvanet
- Service de Chirurgie Hépatobiliopancréatique, Hôpital Beaujon - Université Paris VII, France
| | - Christophe Mariette
- Service de Chirurgie digestive et oncologique, Hôpital Claude Huriez - Université de Lille, France
| | - François Paye
- Service de Chirurgie générale et digestive, Hôpital Saint-antoine - UPMC Paris VI, France
| | - Fabrice Muscari
- Service de Chirurgie digestive et de transplantation, Hôpital Rangueil - Université de Toulouse, France
| | - Antonio Sa Cunha
- Service de Chirurgie digestive, Hôpital Haut Levêque - Université de Bordeaux, France
| | - Bernard Sastre
- Service de Chirurgie digestive, Hôpital de la Timone - Université de Marseille, France
| | - Jean-Pierre Arnaud
- Service de Chirurgie digestive, Hôpital universitaire d'Angers - Université d'Angers, France
| | - Patrick Pessaux
- Unité de Chirurgie Hépatobiliaire et Pancréatique, Nouvel Hôpital Civil, Université de Strasbourg, IHU MixSurg, IRCAD, France
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Sakamoto Y, Hori S, Oguro S, Arita J, Kishi Y, Nara S, Esaki M, Saiura A, Shimada K, Yamanaka T, Kosuge T. Delayed Gastric Emptying After Stapled Versus Hand-Sewn Anastomosis of Duodenojejunostomy in Pylorus-Preserving Pancreaticoduodenectomy: a Randomized Controlled trial. J Gastrointest Surg 2016; 20:595-603. [PMID: 26403716 DOI: 10.1007/s11605-015-2961-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/16/2015] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Shutaro Hori
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Seiji Oguro
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Junichi Arita
- Department of Gastrointestinal Surgery, Cancer Institute Ariake Hospital, Japanese Foundation for Cancer Research, Koto-ku, Tokyo, Japan
| | - Yoji Kishi
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Satoshi Nara
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Minoru Esaki
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Akio Saiura
- Department of Gastrointestinal Surgery, Cancer Institute Ariake Hospital, Japanese Foundation for Cancer Research, Koto-ku, Tokyo, Japan
| | - Kazuaki Shimada
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | | | - Tomoo Kosuge
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
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Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand? Indian J Surg 2015; 77:409-25. [PMID: 26722205 DOI: 10.1007/s12262-015-1366-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
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.
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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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Skipenko OG, Bedzhanjan K, Shatverjan D, Bagmet K, Chardarov K. [Prevention of gastrostasis after pancreaticoduodenal resection: new technique of gastroenterostomy]. Khirurgiia (Mosk) 2015:17-30. [PMID: 26081183 DOI: 10.17116/hirurgia2015417-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It was performed a retrospective comparative analysis of treatment results of 113 patients with pancreatic head and periampular cancer. The main group consisted of 58 patients in whom pancreaticoduodenal resection was performed according to an original technique of Russian Scientific Center of Surgery. Control group included 55 patients who underwent end-to-side gastrojejunostomy reconstruction. We have analyzed immediate postoperative complications in 2 groups without taking into consideration nosological forms of the disease. Pancreaticojejunostomy failure was diagnosed postoperatively in 5 (8.6%) patients in main group and in 10 (18.2%) patients in control group. There was no hepaticoentero- and gastroenterostomy failure in patients who underwent new technique of gastrojejunostomy while these events were observed in 8 (14.5%) and 3 (5.5%) patients respectively in control group. Mortality was 1.7% (n=1) in main group and 5.5% (n=3) in control group (p=0.29). Mild degree of gastrostasis (A class) was observed in 54 (93.7%) patients of main group and in 34 (61.8%) patients of control group (p=0.0004). There was B class of gastrostasis in 4 (6.9%) patients of main group. Severe gastrostasis (C class) was not revealed in any observation. In control group B class of gastrostasis was diagnosed in 14 (25.5%) patients, severe degree - in 7 (12.7%) patients. Univariant analysis showed hemotransfusion (p=0.037), pancreatic fistula (p=0.001), enteric fistula (p=0.005) and reconstruction technique (p=0.00004) as predictors of gastrostasis. Multivariant analysis defined pancreatic fistula (p=0.01), enteric fistula (p=0.04) and reconstruction technique (p=0.001) as significant predictors of gastrostasis. Thus, our study revealed significant decreasing gastrostasis incidence in case of original technique in comparison with conventional anastomosis, as well as demonstrated effect of anastomoses failure on augmentation of gastrostasis frequency after pancreaticoduodenal resection. Further randomized investigations are necessary to confirm our results.
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Affiliation(s)
- O G Skipenko
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Bedzhanjan
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - D Shatverjan
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Bagmet
- acad. B.V. Petrovskiy Russian Research Surgery Center
| | - K Chardarov
- acad. B.V. Petrovskiy Russian Research Surgery Center
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Braun enteroenterostomy reduces delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: a retrospective review. Am J Surg 2015; 209:369-77. [DOI: 10.1016/j.amjsurg.2014.05.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 04/30/2014] [Accepted: 05/15/2014] [Indexed: 02/06/2023]
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The effect of pylorus removal on delayed gastric emptying after pancreaticoduodenectomy: a meta-analysis of 2,599 patients. PLoS One 2014; 9:e108380. [PMID: 25272034 PMCID: PMC4182728 DOI: 10.1371/journal.pone.0108380] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 08/19/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Delayed gastric emptying is a serious complication of pancreaticoduodenectomy. The effect of pylorus removal on delayed gastric emptying has not been well evaluated. STUDY DESIGN We searched five databases (PubMed, EMBASE and the Cochrane Central Register of Controlled Trials, Scopus and Web of Science) up to July 2014. The meta-regression analysis was performed to evaluate any factors accountable for the heterogeneity. Publication bias was assessed by Egger's test, and corrected by Duval's trim and fill method. Subgroup analyses were conducted for different surgical techniques of pyloric removal. Other intraoperative and postoperative parameters were compared between two groups. RESULTS We included 27 studies involving 2,599 patients, with a moderate-high heterogeneity for primary outcome (I(2) = 63%). Meta-regression analysis showed that four variables primarily contributed to the heterogeneity, namely nasogastric tube intubation time, solid food start time, preoperative diabetes percentage and the number of patients in pylorus-preserving group. After excluding four studies, the remaining twenty-three studies showed reduced heterogeneity (I(2) = 51%). Then we used Duval's trim and fill method to correct publication bias. The corrected MH odds ratio was 0.78 (95% CI: 0.52-1.17). A subgroup analysis showed that pylorus removal tends to reduce delayed gastric emptying incidence for subtotal stomach-preserving pancreaticoduodenectomy or pylorus-resecting pancreaticoduodenectomy, compared with pylorus-preserving group. However, standard Whipple procedure failed to show any significant reduction of DGE compared with pylorus-removal group. No significant differences were observed in terms of length of hospital stay, infection and pancreatic fistula; however, pylorus removal resulted in longer operation time, more blood loss and higher mortality. CONCLUSION The pylorus removal does not significantly reduce the overall incidence of delayed gastric emptying. Subtotal stomach-preserving pancreaticoduodenectomy or pylorus-resecting pancreaticoduodenectomy tends to reduce delayed gastric emptying incidence, but needs further validation.
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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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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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Yang C, Wu HS, Chen XL, Wang CY, Gou SM, Xiao J, He ZQ, Chen QJ, Li YF. Pylorus-preserving versus pylorus-resecting pancreaticoduodenectomy for periampullary and pancreatic carcinoma: a meta-analysis. PLoS One 2014; 9:e90316. [PMID: 24603478 PMCID: PMC3946060 DOI: 10.1371/journal.pone.0090316] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/28/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The aim of this meta-analysis was to compare the long-term survival, mortality, morbidity and the operation-related events in patients with periampullary and pancreatic carcinoma undergoing pylorus-preserving pancreaticoduodenectomy (PPPD) and pylorus-resecting pancreaticoduodenectomy (PRPD). METHOD A systematic search of literature databases (Cochrane Library, PubMed, EMBASE and Web of Science) was performed to identify studies. Outcome measures comparing PPPD versus PRPD for periampullary and pancreatic carcinoma were long-term survival, mortality, morbidity (overall morbidity, delayed gastric emptying [DGE], pancreatic fistula, wound infection, postoperative bleeding, biliary leakage, ascites and gastroenterostomy leakage) and operation related events (hospital stays, operating time, intraoperative blood loss and red blood cell transfusions). RESULTS Eight randomized controlled trials (RCTs) including 622 patients were identified and included in the analysis. Among these patients, it revealed no difference in long-term survival between the PPPD and PRPD groups (HR = 0.23, p = 0.11). There was a lower rate of DGE (RR = 2.35, p = 0.04, 95% CI, 1.06-5.21) with PRPD. Mortality, overall morbidity, pancreatic fistula, wound infection, postoperative bleeding, biliary leakage, ascites and gastroenterostomy leakage were not significantly different between the groups. PPPDs were performed more quickly than PRPDs (WMD = 53.25 minutes, p = 0.01, 95% CI, 12.53-93.97); and there was less estimated intraoperative blood loss (WMD = 365.21 ml, p = 0.006, 95% CI, 102.71-627.71) and fewer red blood cell transfusions (WMD = 0.29 U, p = 0.003, 95% CI, 0.10-0.48) in patients undergoing PPPD. The hospital stays showed no significant difference. CONCLUSIONS PPPD had advantages over PRPD in operating time, intraoperative blood loss and red blood cell transfusions, but had a significantly higher rate of DGE for periampullary and pancreatic carcinoma. PPPD and PRPD had comparable mortality and morbidity including pancreatic fistulas, wound infections, postoperative bleeding, biliary leakage, ascites and gastroenterostomy leakage. Our conclusions were limited by the available data. Further evaluations of high-quality RCTs are needed.
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Affiliation(s)
- Chong Yang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - He-Shui Wu
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Xing-Lin Chen
- Key Laboratory of Geriatrics of Health Ministry, Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Chun-You Wang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Shan-Miao Gou
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jun Xiao
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Zhi-Qiang He
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Qi-Jun Chen
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Yong-Feng Li
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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Penumadu P, Barreto SG, Goel M, Shrikhande SV. Pancreatoduodenectomy - preventing complications. Indian J Surg Oncol 2014; 6:6-15. [PMID: 25937757 DOI: 10.1007/s13193-013-0286-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/30/2013] [Indexed: 02/07/2023] Open
Abstract
Increased awareness of periampullary & pancreatic head cancers, and the accompanying improved outcomes following pancreatoduodenectomy (PD), has possibly led to an increase in patients seeking treatment for the same. While there has definitely been a reduction in morbidity rates following PD in the last few decades, this decline has not mirrored the drastic fall in mortality. Amongst the foremost in the factors responsible for this reduction in mortality is the standardization of surgical technique and development of dedicated teams to manage all aspects of this demanding procedure. This review intends to provide the reader with an overview of major complications following this major surgery and measures to prevent them based on the authors' experience.
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Affiliation(s)
- Prasanth Penumadu
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Center, Mumbai, India
| | - Savio G Barreto
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Center, Mumbai, India ; GI Surgery, GI Oncology & Bariatric Surgery, Medanta Institute of Hepatobiliary & Digestive Sciences, Medanta, The Medicity, Gurgaon, India
| | - Mahesh Goel
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Center, Mumbai, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Center, Mumbai, India ; Department of Surgical Oncology, Convener, GI Disease Management Group, Tata Memorial Centre, Ernest Borges Marg, Parel, Mumbai, 400012 India
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Hackert T, Hinz U, Hartwig W, Strobel O, Fritz S, Schneider L, Werner J, Büchler MW. Pylorus resection in partial pancreaticoduodenectomy: impact on delayed gastric emptying. Am J Surg 2013; 206:296-9. [PMID: 23806827 DOI: 10.1016/j.amjsurg.2012.10.042] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 08/31/2012] [Accepted: 10/04/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Partial pancreaticoduodenectomy (PD) is complicated by postoperative delayed gastric emptying (DGE) in up to 45% of patients. The aim of this study was to evaluate the impact of pylorus resection on DGE following PD. METHODS Forty PD patients underwent pylorus resection with complete stomach preservation (prPD). They were compared with a pair-matched group of PD patients with pylorus preservation (ppPD) in a 1:1 ratio (age, sex, histopathology). The objectives were operative parameters, DGE incidence, morbidity, and length of hospital stay. RESULTS DGE incidence was significantly lower after prPD (15.0% vs 42.5%; P = .0066). Operative parameters and surgical morbidity (other than DGE) were not different (27.5% prPD vs 30.0% ppPD). There was a trend toward a shorter hospital stay in the prPD group. CONCLUSIONS Resection of the pylorus with stomach preservation significantly reduces the frequency of DGE after PD without showing any disadvantage when compared with standard ppPD. This finding could be of high relevance for the clinical practice in routine PD and should consequently be investigated in a large randomized multicenter trial to create further evidence.
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Affiliation(s)
- Thilo Hackert
- Department of Surgery, University of Heidelberg, Germany.
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Lermite E, Sommacale D, Piardi T, Arnaud JP, Sauvanet A, Dejong CHC, Pessaux P. Complications after pancreatic resection: diagnosis, prevention and management. Clin Res Hepatol Gastroenterol 2013; 37:230-9. [PMID: 23415988 DOI: 10.1016/j.clinre.2013.01.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 01/06/2013] [Accepted: 01/09/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Emilie Lermite
- Department of Digestive Surgery, CHU Angers, Angers University, Angers, France
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Sourrouille I, Gaujoux S, Lacave G, Bert F, Dokmak S, Belghiti J, Paugam-Burtz C, Sauvanet A. Five days of postoperative antimicrobial therapy decreases infectious complications following pancreaticoduodenectomy in patients at risk for bile contamination. HPB (Oxford) 2013; 15:473-80. [PMID: 23458261 PMCID: PMC3664052 DOI: 10.1111/hpb.12012] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 10/15/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Pancreaticoduodenectomy (PD) is associated with high morbidity, in part as a result of infectious complications increased by preoperative bile contamination. The aim of the present study was to assess the effect on the incidence of infectious complications of short-term antimicrobial therapy (AMT) in high-risk patients. METHODS Patients with a high risk for positive intraoperative bile culture (i.e. those with ampulloma or pancreatic adenocarcinoma with preoperative endoscopic procedures) (high-risk group, n = 99) were compared with low-risk patients (i.e. those with pancreatic adenocarcinoma without preoperative endoscopic procedures) (low-risk group, n = 76). The high-risk group received a 5-day course of perioperative AMT secondarily adapted to the bile antibiogram. The low-risk group received only the usual antimicrobial prophylaxis. RESULTS Positive bile cultures were significantly more frequent in high-risk patients (81% versus 12%; P < 0.001). The overall rate of infectious complications was lower in the high-risk group (29% versus 46%; P = 0.018). The statistically significant decrease in the rate of infectious complications reflected reduced rates of urinary tract infections, pulmonary infections and septicaemia. Rates of wound infection (3% versus 5%; P = 0.639) and intra-abdominal abscess (7% versus 7%; P = 0.886) were similar in the high- and low-risk groups, as was the need for curative AMT. CONCLUSIONS This exploratory study suggests that a postoperative short course of AMT in patients at high risk for biliary contamination reduces the overall rate of infectious complications after PD. The adaptation of perioperative antimicrobial policy to the patient's risk for bile contamination seems promising and should be further evaluated.
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Affiliation(s)
- Isabelle Sourrouille
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Sebastien Gaujoux
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France
| | - Guillaume Lacave
- Department of Anesthesiology and Critical Care Medicine, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - François Bert
- Department of Bacteriology, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Safi Dokmak
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Jacques Belghiti
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France
| | - Catherine Paugam-Burtz
- Department of Bacteriology, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France,Unit 773, National Institute of Health and Medical Research (INSERM)Paris, France
| | - Alain Sauvanet
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France,Correspondence Alain Sauvanet, Department of Hepatobiliary and Pancreatic Surgery, Hospital Beaujon, 100 Boulevard du Général Leclerc, 92110 Clichy, France. Tel: + 33 1 40 87 58 95. Fax: + 33 1 40 87 17 24. E-mail:
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Berry AJ. Pancreatic surgery: indications, complications, and implications for nutrition intervention. Nutr Clin Pract 2013; 28:330-57. [PMID: 23609476 DOI: 10.1177/0884533612470845] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Amy J Berry
- University of Virginia Health System, Surgical Nutrition Support/Nutrition Services, Charlottesville, VA 22908-0673, USA.
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Fernández-Cruz L, Sabater L, Fabregat J, Boggi U. Complicaciones después de una pancreaticoduodenectomía. Cir Esp 2012; 90:222-32. [DOI: 10.1016/j.ciresp.2011.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 03/23/2011] [Accepted: 04/04/2011] [Indexed: 12/18/2022]
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Kim YH. Management and prevention of delayed gastric emptying after pancreaticoduodenectomy. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2012; 16:1-6. [PMID: 26388898 PMCID: PMC4575017 DOI: 10.14701/kjhbps.2012.16.1.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 02/05/2012] [Accepted: 02/11/2012] [Indexed: 12/17/2022]
Abstract
Although technical advances have been made in pancreaticoduodenectomy, the incidence of delayed gastric emptying (DGE) is reported as being high. Postoperative DGE is not fatal, but often results in prolonging the length of patients' stay in hospital, increasing their medical expenses, and further lowering their quality of life. DGE is a complex process caused by disorder and incoordination of various factors in charge of gastric mobility, such as smooth muscle cells (myogenic), enteric neuron (hormonal), and autonomic nervous system (neural). DGE often occurs after operative maneuvers that cause the loss of organs responsible for gastric motility and emptying or kinetic muscular or neuromuscular ischemia. To prevent DGE, it is most important to develop and universalize a standardized surgical technique in a way to reduce factors that are considered to cause DGE after pancreaticoduodenectomy. Moreover, if it is suspected that DGE occurred after pancreaticoduodenectomy, a differential diagnosis from diseases with similar symptoms via an accurate diagnostic approach should be implemented.
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Affiliation(s)
- Yong Hoon Kim
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Keimyung University School of Medicine, Daegu, Korea
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Analysis of risk factors for delayed gastric emptying (DGE) after 387 pancreaticoduodenectomies with usage of 70 stapled reconstructions. J Gastrointest Surg 2011; 15:1789-97. [PMID: 21826550 DOI: 10.1007/s11605-011-1498-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 03/23/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most troublesome complications after pancreaticoduodenectomy (PD). METHODS Between 2004 and 2009, 387 patients underwent PD and of these, 302 patients (78%) underwent pylorus-preserving PD. The stapled reconstruction of duodeno- or gastrojejunostomy was introduced in 2006, and 70 patients (18%) underwent stapled Roux-en-Y reconstruction. Postoperative DGE was defined based on the International Study Group on Pancreatic Surgery classification, and grade B or C DGE was considered to be clinically relevant. Risk factors for DGE were evaluated using univariate and multivariate analyses. RESULTS Four patients died in the hospital (1.0%). Postoperative DGE was found in 70 patients (18%). DGE was less frequently seen in stapled reconstruction than in hand-sewn reconstruction (7.2% vs. 21%, P < 0.001), and in single-layer anastomosis than in double-layer anastomosis (12% vs. 24%, P = 0.02). The multivariate logistic regression analysis revealed that the independent risk factors for DGE were postoperative pancreatic fistula (risk ratio [RR] 2.4, P = 0.002), hand-sewn reconstruction (RR 2.9, P = 0.03) and male (RR 2.2, P = 0.02). CONCLUSION The method of alimentary reconstruction affected the occurrence of DGE. The incidence of DGE was less in stapled reconstruction than in hand-sewn reconstruction.
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Pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: the clinical impact of a new surgical procedure; pylorus-resecting pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:755-61. [DOI: 10.1007/s00534-011-0427-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Dicken BJ, Sergi C, Rescorla FJ, Breckler F, Sigalet D. Medical management of motility disorders in patients with intestinal failure: a focus on necrotizing enterocolitis, gastroschisis, and intestinal atresia. J Pediatr Surg 2011; 46:1618-30. [PMID: 21843732 DOI: 10.1016/j.jpedsurg.2011.04.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 03/31/2011] [Accepted: 04/05/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intestinal failure (IF) is the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development. It may occur secondary to a loss of bowel length, disorders of motility, or both. Short bowel syndrome (SBS) is a malabsorptive state resulting from surgical resection, congenital defect, or diseases associated with loss of absorptive surface area. A particularly vexing problem is associated with whole bowel and/or segmental intestinal dysmotility. Motility disorders within the context of SBS and IF may relate to rapid intestinal transit secondary to loss of intestinal length, dysmotility associated with loss or poor antegrade peristalsis, or gastroparesis. Therapy may be classified into medical (prokinetic and antidiarrheal agents) and surgical to deal with the overdistended poorly motile bowel. METHODS We performed a systematic review of the literature pertaining to IF, SBS, and dysmotility in the pediatric population with gastroschisis, necrotizing enterocolitis, and intestinal atresia. In addition to the available treatment options, we have provided a review of the literature and a summary of the available evidence. CONCLUSION Despite relatively poor level of evidence regarding the application of promotility and antidiarrheal medications in patients with SBS and IF, these agents continue to be used. Herein, we provide a review of the physiology and pathophysiology of intestinal motility/dysmotility and available strategies for the use of promotility and antidiarrheal agents in patients with IF/SBS.
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Affiliation(s)
- Bryan J Dicken
- Division of Pediatric Surgery, Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada.
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Delayed gastric emptying after pancreaticoduodenectomy: influence of the orthotopic technique of reconstruction and intestinal motilin receptor expression. J Gastrointest Surg 2011; 15:1158-67. [PMID: 21547592 DOI: 10.1007/s11605-011-1554-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 04/21/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is still a common postoperative complication after pancreaticoduodenectomy (PD). Because different reconstruction techniques after PD and the influence of motilin receptor expression are controversially discussed, the present study analyzed the influence of a total orthotopic reconstruction technique on DGE after PD. METHODS Data from patients undergoing PD and reconstruction using a total orthotopic technique were reviewed, and correlations between DGE and clinico-pathological variables were analyzed. Motilin receptor expression was measured within the duodenum, jejunum, and terminal ileum. RESULTS Three hundred seven patients received orthotopic reconstruction using a single jejunal loop. DGE grade B or C could be observed in 16.6% of the patients. DGE was significantly associated with the severity of a postoperative pancreatic fistula, the need for a reoperation, wound infections, and vascular complications. Furthermore, these parameters correlated significantly with the grade of DGE. The density of motilin receptor expression decreased significantly behind the duodenum in aboral direction. CONCLUSIONS The orthotopic reconstruction after PD is the shortest distance without resection of a jejunal segment, preserves the greatest length of jejunum and thus the highest density of motilin receptors, and should therefore be recommended to reduce the incidence of DGE after PD.
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[Surgical treatment of pancreatic adenocarcinoma by cephalic duodenopancreatectomy (Part 1). Post-surgical complications in 204 cases in a reference hospital]. Cir Esp 2011; 88:299-307. [PMID: 20663494 DOI: 10.1016/j.ciresp.2010.05.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 04/22/2010] [Accepted: 05/09/2010] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Cephalic duodenopancreatectomy (CDP) is the treatment of choice in cancer of the head of the pancreas. However, it continues to have a high post-surgical morbidity and mortality. The aim of this article is to define variables that influence post-surgical morbidity and mortality after cephalic duodenopancreatectomy due to pancreatic adenocarcinoma (PA) cancer of the head of the pancreas (CHP). MATERIAL AND METHODS The variables were prospectively collected form patients operated on between 1991 and 2007, in order to investigate the factors of higher morbidity. RESULTS A total of 204 patients had been intervened due to PA, of whom 57 were older than 70 years. Of these patients, 119 had a CPD, 11 extended lymphadenectomy, 66 with pyloric conservation, and 8 with extension to total pancreatectomy due to involvement of the section margin. Portal or mesenteric vein resection was included in 35 cases. Post-surgical complications were detected in 45% of cases, the most frequent being: slow gastric emptying (20%), surgical wound infection (17%), pancreatic fistula (10%), and serious medical complications (8%). Further surgery was required in 13%, and the over post-surgical mortality was 7%. A patient age greater than 70 years, post-surgical haemoperitoneum, gastroenteric dehiscence, and the presence of medical complications were post-surgical mortality risk factors in the multivariate analysis. Pancreatic fistula was not a factor associated with post-surgical mortality. CONCLUSIONS Cephalic duodenopancreatectomy is a safe technique but with a considerable morbidity. Patients over 70 years of age must be carefully selected before considering surgery. Serious medical complications must be treated aggressively to avoid an unfavourable progression.
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Pylorus Ring Resection Reduces Delayed Gastric Emptying in Patients Undergoing Pancreatoduodenectomy. Ann Surg 2011; 253:495-501. [DOI: 10.1097/sla.0b013e31820d98f1] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Kawai M, Yamaue H. Analysis of clinical trials evaluating complications after pancreaticoduodenectomy: a new era of pancreatic surgery. Surg Today 2010; 40:1011-7. [PMID: 21046497 DOI: 10.1007/s00595-009-4245-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 09/16/2009] [Indexed: 12/18/2022]
Abstract
Pancreatic fistula and delayed gastric emptying (DGE) are the major postoperative complications of pancreaticoduodenectomy (PD). Pancreatic fistula is life-threatening and DGE, while not life-threatening, prolongs the hospital stay, increasing costs and compromising quality of life. To establish the current consensus of pancreatic fistula and DGE after PD, we analyzed the results of randomized controlled trials (RCTs) designed to prevent these postoperative complications. Five RCTs comparing PD with pylorus-preserving pancreaticoduodenectomy (PpPD) performed for periampullary tumors showed that the two procedures were equally effective with respect to morbidity, mortality, and survival. We reviewed 15 RCTs, 2 prospective nonrandomized studies, and 2 meta-analyses of operative techniques and postoperative management designed to prevent pancreatic fistula. The results of the RCTs designed to prevent pancreatic fistula recommended duct-to-mucosa pancreaticojejunostomy or one-layer end-to-side pancreaticojejunostomy, equally. We also reviewed five RCTs of operative techniques and postoperative management designed to prevent DGE, which revealed that the antecolic route for duodenojejunostomy significantly reduced the incidence of DGE. Further RCTs to study innovative approaches to prevent postoperative complications after PD are warranted.
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Affiliation(s)
- Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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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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