Braun Enteroenterostomy Following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

Dunking Pancreaticojejunostomy With Braun's Jejunojejunostomy: Perioperative Outcomes of a Hundred Pancreaticoduodenectomies

Background The optimal surgical technique for pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD) is still debated. Dunking and duct-to-mucosa PJ are the most commonly adopted techniques. Incorporating Braun's jejunojejunostomy (JJ) could reduce the incidence and severity of delayed gastric emptying (DGE). This retrospective descriptive study seeks to clarify the outcomes of dunking PJ with Braun's JJ in 100 PD patients. Methodology We retrospectively reviewed 100 patients who underwent PDs in a single unit of the Department of Surgical Gastroenterology of Tribhuvan University Teaching Hospital from October 2012 to February 2023. Demographic and historical data, indications, procedure-related data, complications, and mortality data were collected and analyzed. Results The mean age was 50.96 ± 14.97 years, and 64 (64%) were males. The most common indication was ampullary carcinoma (53, 53%) followed by distal cholangiocarcinoma (18, 18%) and pancreatic ductal adenocarcinoma (7, 7%). Operative time was 5.83 ± 1.09 hours, intraoperative blood loss was 515 ± 194 mL, and the average time for PJ and Braun's JJ was 22 ± 6 and 15 ± 3 minutes, respectively. Soft pancreas was encountered in 52 (52%) patients and clinically significant postoperative pancreatic fistula (Grade B, C) was seen in 23 (23%). Postpancreatectomy hemorrhage was seen in 21 (21%) patients (Grades A: 3, B: 12, C: 6). DGE (Grade B) occurred in two (2%) patients, and bile leak was observed in 4% of patients (Grades A: 1, B: 2, C: 1). Major complications (Clavien-Dindo ≥IIIA) occurred in 24%, and 11 patients died. Conclusions The dunking technique is easily adaptable, less time-consuming, and can be performed in the pancreas of any texture or duct size but is associated with an increased incidence of post-pancreatectomy hemorrhage. Incorporation of Braun's anastomosis lowers DGE, allows early initiation of feeding, and reduces complication rates.

Billroth II anastomosis combined with brown anastomosis reduce reflux gastritis in gastric cancer patients

BACKGROUND

The surgeon performing a distal gastrectomy, has an arsenal of reconstruction techniques at his disposal, Billroth II among them. Braun anastomosis performed during a Billroth II procedure has shown evidence of superiority over typical Billroth II, in terms of survival, with no impact on postoperative morbidity and mortality.

AIM

To compare Billroth II vs Billroth II and Braun following distal gastrectomy, regarding their postoperative course.

METHODS

Patients who underwent distal gastrectomy during 2002-2021, were separated into two groups, depending on the surgical technique used (Billroth II: 74 patients and Billroth II and Braun: 28 patients). The daily output of the nasogastric tube (NGT), the postoperative day that NGT was removed and the day the patient started per os feeding were recorded. Postoperative complications were at the same time noted. Data were then statistically analyzed.

RESULTS

There was difference in the mean NGT removal day and the mean start feeding day. Mean total postoperative NGT output was lower in Braun group (399.17 mL vs 1102.78 mL) and it was statistically significant (P < 0.0001). Mean daily postoperative NGT output was also statistically significantly lower in Braun group. According to the postoperative follow up 40 patient experienced bile reflux and alkaline gastritis from the Billroth II group, while 9 patients who underwent Billroth II and Braun anastomosis were presented with the same conditions (P < 0.05).

CONCLUSION

There was evidence of superiority of Billroth II and Braun vs typical Billroth II in terms of bile reflux, alkaline gastritis and NGT output.

Duodenojejunostomy following failed gastrojejunostomy in superior mesenteric artery syndrome: A case report

INTRODUCTION

Superior mesenteric artery (SMA) syndrome is a rare duodenal-vascular anatomic disorder leading to external compression on the duodenum. The first step of treatment usually is conservative, and in the case of failure, surgical management is the treatment choice. Treatment success with duodenojejunostomy after failure in gastrojejunostomy can show the uniqueness of this article.

CASE PRESENTATION

A 14-year-old boy came to our hospital with a complaint of epigastric pain, nausea, bilious vomiting, and weight loss since 6 months ago. Conservation therapy and laparotomic Braun anastomosis and gastrojejunostomy was performed due to the SMA syndrome diagnosis 2.5 months before the admission. At our hospital, an alteration of gastrojejunostomy by duodenojejunostomy employing a diamond-shaped anastomosis between the third portion of the duodenum (D3) and a part of jejunum that was placed 15 cm away from the ligament Treitz was done. A significantly dilated stomach and the first three parts of the duodenum were observed during the procedure. After the second surgical intervention, the general condition of the patient dramatically improved.

CLINICAL DISCUSSION

Conservative treatment, including nasogastric tube decompression, postural changes, and nutritional support with hyperalimentation, has a variable success rate. However, in some cases, surgery may be necessary. Surgeons prefer laparoscopic duodenojejunostomy due to its outstanding success rate, ranging from 80 % to 100 %. But, in some case reports it is suggested that gastrojejunostomy could be done in cases with severe duodenal dilation instead of duodenojejunostomy. The initial gastrojejunostomy failed because of ongoing symptoms, which was finally revised with a duodenojejunostomy.

CONCLUSION

It is suggested to use duodenojejunostomy after failure of gastrojejunostomy or it can be employed as the first surgical option even in cases with severe dilation. Because it is a more efficient correction with fewer complications than gastrojejunostomy.

A Single-site Interventional Study on the Contemporary Relevance of Braun Enteroenterostomy After Pancreaticoduodenectomy

BACKGROUND/AIM

Braun enteroenterostomy following pancreaticoduodenectomy is a standard procedure. It has been reported to decrease bile reflux and vomiting, prevent reflux gastritis and delay gastric emptying (DGE). However, some reports suggest that the incidence of DGE is unaffected with this procedure. Therefore, in this study, we aimed to investigate whether Braun enteroenterostomy was effective after pancreaticoduodenectomy.

PATIENTS AND METHODS

A total of 145 patients who underwent pancreaticoduodenectomy were enrolled and divided into 2 groups i.e., 51 patients with Braun enteroenterostomy (B group) and 94 patients without Braun enteroenterostomy (non-B group). We compared the perioperative data of the patients. Patients who reported postoperative symptoms underwent gastrointestinal endoscopic evaluation.

RESULTS

The incidence of DGE was 7.4% (7/94) and 1.9% (1/51) in the non-B and B groups, respectively (p=0.36), with no significant difference between the groups. During follow-up, some patients reported symptoms including epigastralgia, nausea and melena. The incidence of these symptoms was 27.7% (26 patients; 26/94) and 23.5% (12 patients; 12/51) in non-B and B groups, respectively. Regarding gastrointestinal endoscopic findings, the incidence of anastomotic ulcer was 7.7% (2/26) and 16.7% (2/12) in non-B and B groups, respectively (p=0.40). Bile reflux incidence was 30.8% (8/26) and 0% (0/12) in non-B and B groups, respectively (p=0.03).

CONCLUSION

Though Braun enteroenterostomy was related to bile reflux, it did not affect the incidence of anastomotic and gastric ulcers or DGE. Therefore, it may not be a necessary procedure after pancreaticoduodenectomy.

Impact of pylorus preservation on delayed gastric emptying after pancreaticoduodenectomy-analysis of 5,000 patients based on the German StuDoQ|Pancreas-Registry

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after pancreatic head resection. It leads to increased length of hospital stay, high costs for healthcare systems and reduced quality of life. The primary aim of the study was to assess the impact of pylorus preservation, respectively resection on the occurrence of DGE in patients undergoing pancreaticoduodenectomy (PD).

METHODS

All cases of pylorus-resecting PD (PRPD) and pylorus-preserving PD (PPPD) entered in the StuDoQ|Pancreas nationwide registry of the German Society of General and Visceral Surgery from 01/01/2014 until 31/12/2018 including demographics, surgical techniques, histopathological and perioperative data were retrospectively analyzed. This study was approved by the ethics committee of the Ruhr-University Bochum, Germany.

RESULTS

Data of 5,080 patients were enrolled. PPPD was the method of choice (70.4%). Pylorus preservation had no impact on the occurrence of DGE (20.3% vs. 21.5%, P=0.33), but further risk factors could be identified. The comparison of PPPD and PRPD groups showed statistically significant differences in the surgical approach (primary open approach, 94.8% vs. 98.0%, P<0.001), duration of surgery (326.4 vs. 352.1 minutes, P<0.001), technique of pancreatic anastomosis (pancreaticojejunostomy vs. pancreaticojejunostomy), 78.6% vs. 85.2%, P<0.001).

CONCLUSIONS

Patient factors, intraoperative factors, duration of surgery and postoperative factors (postoperative pancreatic fistula, biliary leakage and other surgical complications) were identified as risk factors for DGE. Future research should focus on register-based, prospective, randomised-controlled studies such as the currently recruiting "PyloResPres trial".

Roux-en-Y versus single loop reconstruction in pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications.

METHODS

A systematic review and meta-analysis was conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

RESULTS

Fourteen studies were identified including four randomised controlled trials (RCTs) and 10 observational studies reporting a total of 2,031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction.

DISCUSSION

Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomised studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.

Delayed Gastric Emptying as a Complication of Whipple's Procedure: Could it be Much Less Frequent than Anticipated? Could the Definition Be Revised? A Single Center Experience

Objective

Whipple's procedure for periampullary tumors has significant risks and complications. Delayed gastric emptying has the highest rate. Although the International Study Group of Pancreatic Surgery defined (ISGPS) this entity, multiple definitions still exist among authors. This study aims to revise the definition.

Method

Seventy-three consecutive patients were analyzed for complications, particularly delayed gastric emptying. All patients underwent a standardized surgery. Procedures used for total pancreatectomies and benign diseases were excluded.

Results

A total of 73 patients were included in the study. Intra-abdominal complications were observed in 15 (20.6%) patients. Grade C delayed gastric emptying was observed in only one (1.4%) patient. Grade A and B disease were observed in three (4.1%) patients. However, they responded well to conservative methods, causing no extra morbidity.

Conclusion

Grade A and B delayed gastric emptying can be observed after any gastrointestinal surgery. These patients respond well to simple conservative methods with nasogastric intubation. Drainage of the intra-abdominal collection resolves the emptying problem (if any). Only grade C disease without other intra-abdominal complications can be accepted as a complication of this procedure. ISGPS definition does not include the cause. Thus, the definition and grading can be revised.

Efferent Loop Syndrome in a Post-pancreatoduodenectomy Patient Due to Exuberant Foreign Body Giant Cell Reaction Mimicking Cancer: A Case Report

Efferent loop syndrome has been rarely reported after pancreatoduodenectomy. In those cases that have been reported, the majority presented late and recurrence or peritoneal metastases were found to be the usual causes. Foreign body giant cell reactions (FBGCR) also rarely develop into masses that are large enough to cause problems or mimic malignancy. This report presents a case of a middle-aged female who underwent completion extended cholecystectomy for carcinoma of the gallbladder. Whipple's pancreatoduodenectomy was also performed at the same surgery due to presence of a hard mass at the cystic duct stump that was densely adherent to the common bile duct and duodenal cap. This was later found to be FBGCR. The patient underwent re-exploration just three weeks later for efferent loop syndrome, the cause of which was again found to be a mass due to FBGCR that was not previously present. Despite a difficult initial treatment phase, the patient is disease free and doing well after two and half years of completing treatment for the carcinoma gallbladder.

Braun anastomosis lowers the incidence of delayed gastric emptying following pancreaticoduodenectomy: a meta-analysis

Background

Delayed gastric emptying (DGE) is one of the most frequent complications following pancreaticoduodenectomy. This meta-analysis aimed to evaluate the impact of Braun enteroenterostomy on DGE following pancreaticoduodenectomy.

Methods

A systematic review of the literature was performed to identify relevant studies. Statistical analysis was carried out using Review Manager software 5.3.

Results

Eleven studies involving 1672 patients (1005 in Braun group and 667 in non-Braun group) were included in the meta-analysis. Braun enteroenterostomy was associated with a statistically significant reduction in overall DGE (odds ratios [OR] 0.32, 95% confidence intervals [CI] 0.24 to 0.43; P <0.001), clinically significant DGE (OR 0.27, 95% CI 0.15 to 0.51; P <0.001), bile leak (OR 0.50, 95% CI 0.29 to 0.86; P = 0.01), and length of hospital stay (weighted mean difference -1.66, 95% CI -2.95 to 00.37; P = 0.01).

Conclusions

Braun enteroenterostomy minimizes the rate and severity of DGE following pancreaticoduodenectomy.

PANCREATODUODENECTOMY: BRAZILIAN PRACTICE PATTERNS

Background:

Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative.

Aim:

To understand the Brazilian practice patterns for pancreatoduodenectomy.

Method:

A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery.

Results:

A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube.

Conclusion:

Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.

The "Colonial Wig" pancreaticojejunostomy: zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) remains common and morbid after pancreaticoduodenectomy (PD). A major advance in the study of POPF is the fistula risk score (FRS).

METHODS

We analyzed 48 consecutive patients undergoing PD. The "Colonial Wig" pancreaticojejunostomy (CWPJ) technique was used in the last 22 PDs, we compared 22 CWPJ to 26 conventional PDs.

RESULTS

Postoperative morbidity was 49% (27% Clavien grade >2). The median length of hospital stay was 11 days. In the first 26 PDs, the PJ was performed according to standard techniques and the clinically relevant POPF (CR-POPF) rate was 15%, similar to the FRS-predicted rate (14%). In the next 22 PJs, the CWPJ was employed. Although the FRS-predicted rates were similar in these two groups (14% vs 13%), the CR-POPF rate in the CWPJ group was 0 (P=0.052).

CONCLUSION

Early experience with the CWPJ is encouraging, and this anastomosis may be a safe and effective way to lower POPF rates.

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

BACKGROUND

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

DATA SOURCE

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

RESULTS

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

CONCLUSIONS

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

Erratum: Braun Enteroenterostomy Following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis: Erratum

[This corrects the article DOI: 10.1097/MD.0000000000001254.].