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Wang Z, Liu C, Hu K, Zuo M, Tian Z, Wei Y, Zhou Q, Li Q. Postoperative delayed gastric emptying: may gut microbiota play a role? Front Cell Infect Microbiol 2024; 14:1449530. [PMID: 39193506 PMCID: PMC11347441 DOI: 10.3389/fcimb.2024.1449530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 07/22/2024] [Indexed: 08/29/2024] Open
Abstract
Postoperative delayed gastric emptying is a prevalent complication following surgical procedures, imposing heavy physical and financial burdens on patients. However, current treatment options remain suboptimal. In recent years, an increasing number of studies have highlighted that the gut microbiota and its metabolites are closely associated with postoperative complications. Various factors can disrupt the gut microbiome after surgery. This review discusses the potential mechanisms by which the gut microbiota and their metabolites may contribute to the pathogenesis of postoperative delayed gastric emptying. However, the current knowledge base is limited in terms of fully understanding the exact mechanisms involved. It is therefore evident that further research is required to fully elucidate the role of the gut microbiome in postoperative delayed gastric emptying, with the aim of uncovering new possibilities for preventive measures and therapeutic treatments.
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Affiliation(s)
- Zhiyi Wang
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
- Department of Oncology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Chuanbo Liu
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
| | - Kaiwen Hu
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
| | - Minghuan Zuo
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
| | - Zhen Tian
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
| | - Yue Wei
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
| | - Qin Zhou
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
| | - Quanwang Li
- Graduate School of Beijing, University of Chinese Medicine, Beijing, China
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Sabogal JC, Conde Monroy D, Rey Chaves CE, Ayala D, González J. Delayed gastric emptying after pancreatoduodenectomy: an analysis of risk factors. Updates Surg 2024; 76:1247-1255. [PMID: 38598061 PMCID: PMC11341576 DOI: 10.1007/s13304-024-01795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy. Preoperative factors are limited and controversial. This study aims to identify associated factors related to this complication in the Colombian population. METHODS A retrospective review of a prospectively collected database was conducted. All patients over 18 years of age who underwent pancreaticoduodenectomy were included. Associations with DGE syndrome were evaluated with logistic regression analysis, Odds ratio, and b-coefficient were provided when appropriate. RESULTS 205 patients were included. Male patients constituted 54.15% (n = 111). 53 patients (25.85%) were diagnosed with DGE syndrome. Smoking habit (OR 17.58 p 0.00 95% CI 7.62-40.51), hydromorphone use > 0.6 mg/daily (OR 11.04 p 0.03 95% CI 1.26-96.66), bilirubin levels > 6 mg/dL (OR 2.51 p 0.02 95% CI 1.12-5.61), and pancreatic fistula type B (OR 2.72 p 0.02 CI 1.74-10.00). DISCUSSION Smoking history, opioid use (hydromorphone > 0.6 mg/Daily), type B pancreatic fistula, and bilirubin levels > 6 mg/dL should be considered as risk factors for DGE.
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Affiliation(s)
- Juan Carlos Sabogal
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Danny Conde Monroy
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Carlos Eduardo Rey Chaves
- Estudiante de Posgrado Cirugía General, Facultad de Medicina, Pontificia Universidad Javeriana, Carrera 6A #51A-48, 111711, Bogotá D.C, Colombia.
| | - Daniela Ayala
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
| | - Juliana González
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
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Meng L, Li J, Ouyang G, Li Y, Cai Y, Wu Z, Peng B. Delayed gastric emptying after laparoscopic pancreaticoduodenectomy: a single-center experience of 827 cases. BMC Surg 2024; 24:145. [PMID: 38734631 PMCID: PMC11088113 DOI: 10.1186/s12893-024-02447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) commonly occurs after pancreaticoduodenectomy (PD). Risk factors for DGE have been reported in open PD but are rarely reported in laparoscopic PD (LPD). This study was designed to evaluate the perioperative risk factors for DGE and secondary DGE after LPD in a single center. METHODS This retrospective cohort study included patients who underwent LPD between October 2014 and April 2023. Demographic data, preoperative, intraoperative, and postoperative data were collected. The risk factors for DGE and secondary DGE were analyzed. RESULTS A total of 827 consecutive patients underwent LPD. One hundred and forty-two patients (17.2%) developed DGE of any type. Sixty-five patients (7.9%) had type A, 62 (7.5%) had type B, and the remaining 15 (1.8%) had type C DGE. Preoperative biliary drainage (p = 0.032), blood loss (p = 0.014), and 90-day any major complication with Dindo-Clavien score ≥ III (p < 0.001) were independent significant risk factors for DGE. Seventy-six (53.5%) patients were diagnosed with primary DGE, whereas 66 (46.5%) patients had DGE secondary to concomitant complications. Higher body mass index, soft pancreatic texture, and perioperative transfusion were independent risk factors for secondary DGE. Hospital stay and drainage tube removal time were significantly longer in the DGE and secondary DGE groups. CONCLUSION Identifying patients at an increased risk of DGE and secondary DGE can be used to intervene earlier, avoid potential risk factors, and make more informed clinical decisions to shorten the duration of perioperative management.
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Affiliation(s)
- Lingwei Meng
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
- Departments of General Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, Sichuan Province, China
| | - Jun Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Guoqing Ouyang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yongbin Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
- Departments of General Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, Sichuan Province, China
| | - Yunqiang Cai
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Zhong Wu
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Bing Peng
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.
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Fu Z, Gao S, Wu X, Qin J, Dang Z, Wang H, Han J, Ren Y, Zhu L, Ye X, Shi X, Yin X, Shi M, Wang J, Liu X, Guo S, Zheng K, Jin G. Hand-sewn gastrojejunal anastomosis reduces delayed gastric emptying after pancreaticoduodenectomy: A single-center retrospective clinical study of 1,077 consecutive patients. Surgery 2024; 175:1140-1146. [PMID: 38290878 DOI: 10.1016/j.surg.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/08/2023] [Accepted: 12/01/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Hand-sewn anastomosis and stapled anastomosis are the 2 main types of gastrojejunal anastomotic methods in pancreaticoduodenectomy. There is ongoing debate regarding the most effective anastomotic method for reducing delayed gastric emptying after pancreaticoduodenectomy. This study aims to identify factors that influence delayed gastric emptying after pancreaticoduodenectomy and assess the impact of different anastomotic methods on delayed gastric emptying. METHODS The study included 1,077 patients who had undergone either hand-sewn anastomosis (n = 734) or stapled anastomosis (n = 343) during pancreaticoduodenectomy between December 2016 and November 2021 at our department. We retrospectively analyzed the clinical data, and a 1:1 propensity score matching was performed to balance confounding variables. RESULTS After propensity score matching, 320 patients were included in each group. Compared with the stapled anastomosis group, the hand-sewn anastomosis group had a significantly lower incidence of delayed gastric emptying (28 [8.8%] vs 55 [17.2%], P = .001) and upper gastrointestinal tract bleeding (6 [1.9%] vs 17 [5.3%], P = .02). Additionally, the hand-sewn anastomosis group had a significantly reduced postoperative length of stay and lower hospitalization expenses. However, the hand-sewn anastomosis group had a significantly longer operative time, which was consistent with the analysis before propensity score matching. Logistic regression analysis showed that stapled anastomosis, intra-abdominal infection, and clinically relevant postoperative pancreatic fistula were independent prognostic factors for delayed gastric emptying. CONCLUSION Hand-sewn anastomosis was associated with a lower incidence rate of clinically relevant delayed gastric emptying after pancreaticoduodenectomy. Stapled anastomosis, intra-abdominal infection, and clinically relevant postoperative pancreatic fistula could increase the incidence of postoperative clinically relevant delayed gastric emptying. Hand-sewn anastomosis should be considered by surgeons to reduce the occurrence of postoperative delayed gastric emptying and improve patient outcomes.
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Affiliation(s)
- Zhendong Fu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China; Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Suizhi Gao
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xinqian Wu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jianwei Qin
- Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Zheng Dang
- Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Huan Wang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jiawei Han
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Yiwei Ren
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Lingyu Zhu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaofei Ye
- Department of Medical Statistics, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaohan Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaoyi Yin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Meilong Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jian Wang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xinyu Liu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Shiwei Guo
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Kailian Zheng
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China.
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Ni P, Mayo H, Fernández-Del Castillo C, Elamin S, Brown DR, Mino-Kenudson M, Krishnan K, Casey B, Lafaro K, Lennon AM, Afghani E, Hernandez-Barco YG. Impact of preoperative endoscopic procedures on adverse event rates after surgical resection for main-duct and mixed-type intraductal papillary mucinous neoplasms (IPMNs). Pancreatology 2024; 24:152-159. [PMID: 37981524 DOI: 10.1016/j.pan.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 10/08/2023] [Accepted: 11/11/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Main-duct (MD-) and mixed-type (MT-) IPMNs harbor an increased risk of pancreatic cancer and warrant surgical resection. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are important in the diagnosis of IPMNs. The aim of this study was to investigate whether endoscopic procedures manipulating the MD impact postoperative adverse events in patients with MD- and MT-IPMNs. METHODS We performed a retrospective study of 369 patients who underwent resections for MD- or MT-IPMN at two tertiary centers (2000-2019). Multivariable logistic regression analyses were performed for postoperative adverse events to compare the risks between intervention (ERCP, EUS-FNA with branch duct (BD) aspirated, EUS-FNA with MD aspirated from the duct directly or cyst/mass arising from MD) versus no-intervention group. RESULTS 33.1 % of patients had a preoperative ERCP and 69.4 % had EUS-FNA. Postoperative adverse events included: 30-day readmission (12.7 %), delayed gastric emptying (13.8 %), pancreatic fistula (10.3 %), abdominal abscess (5.7 %), cardiopulmonary adverse events (11.4 %), and mortality (1.4 %). The model was adjusted for potential confounders. There were no significant differences between the ERCP and no-ERCP groups for specific adverse events. Compared to no-EUS-FNA groups, groups of EUS-FNA with BD aspiration and EUS-FNA with MD aspiration from the main pancreatic duct directly or cyst/mass arising from MD did not show a significant increase in specific adverse events. CONCLUSIONS Postoperative adverse events were not significantly increased among patients who had ERCP or EUS-FNA before surgical resection for MD- or MT-IPMNs. Endoscopic procedures directly sampling the MD can be safely pursued for diagnostic purposes in selected cases.
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Affiliation(s)
- Peiyun Ni
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Harrison Mayo
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Sami Elamin
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Douglas R Brown
- Harvard-MIT Health Sciences and Technology, Harvard Medical School, Boston, MA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Brenna Casey
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Kelly Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anne Marie Lennon
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elham Afghani
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wu XD, Yan HJ, Xu YM, Zhao SY, Zhang XD, Lv L, Zhu KL. Effect and mechanism of needleless transcutaneous neuromodulation on gastrointestinal function after pancreaticoduodenectomy. Scand J Gastroenterol 2024; 59:133-141. [PMID: 37752679 DOI: 10.1080/00365521.2023.2261060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Gastrointestinal motility disorders tend to develop after pancreaticoduodenectomy (PD). The objectives of this study were: (1) to investigate the impact of needleless transcutaneous neuromodulation (TN) on the postoperative recuperation following pancreaticoduodenectomy (PD), and (2) to explore the underlying mechanisms by which TN facilitates the recovery of gastrointestinal function after PD. METHODS A total of 41 patients scheduled for PD were randomized into two groups: the TN group (n = 21) and the Sham-TN group (n = 20). TN was performed at acupoints ST-36 and PC-6 twice daily for 1 h from the postoperative day 1 (POD1) to day 7. Sham-TN was performed at non-acupoints. Subsequent assessments incorporated both heart rate variation and dynamic electrogastrography to quantify alterations in vagal activity (HF) and gastric pacing activity. RESULTS 1)TN significantly decreased the duration of the first passage of flatus (p < 0.001) and defecation (p < 0.01) as well as the time required to resume diet (p < 0.001) when compared to sham-TN;2)Compared with sham-TN, TN increased the proportion of regular gastric pacing activity (p < 0.01);3) From POD1 to POD7, there was a discernible augmentation in HF induced by TN stimulation(p < 0.01);4) TN significantly decreased serum IL-6 levels from POD1 to POD7 (p < 0.001);5) TN was an independent predictor of shortened hospital stay(β = - 0.349, p = 0.035). CONCLUSION Needleless TN accelerates the recovery of gastrointestinal function and reduces the risk of delayed gastric emptying in patients after PD by enhancing vagal activity and controlling the inflammatory response.
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Affiliation(s)
- Xu-Dong Wu
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Huan-Jun Yan
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Yue-Mei Xu
- Gastroenterology, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Shuang-Ying Zhao
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Xiao-Dong Zhang
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Li- Lv
- Department of Infectious Diseases, Zhejiang University School of Medicine, Hangzhou, China
| | - Ke-Lei Zhu
- Hepatopancreatobiliary Surgery, The Affiliated People's Hospital of Ningbo University, Ningbo University, Ningbo, China
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Zdanowski AH, Wennerblom J, Rystedt J, Andersson B, Tingstedt B, Williamsson C. Predictive Factors for Delayed Gastric Emptying After Pancreatoduodenectomy: A Swedish National Registry-Based Study. World J Surg 2023; 47:3289-3297. [PMID: 37702776 PMCID: PMC10694105 DOI: 10.1007/s00268-023-07175-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy (PD). DGE causes prolonged hospital stay and a decrease in quality of life. This study analyzes predictive factors for development of DGE after PD, also in the absence of surgical complications. METHOD Data from the Swedish National Pancreatic Cancer Registry for patients undergoing standard and pylorus preserving open PD from January 2010 until June 30, 2018, were collected. Data were analyzed in two groups, no DGE and DGE. A subgroup of patients with DGE but without surgical complications was compared to patients without DGE or any other surgical complication. RESULTS In total, 2503 patients were included, of which 470 (19%) had DGE. In the DGE group, 238 had other coexisting surgical complications and 232 had not. Postoperative pancreatic fistula (OR = 4.22, p < 0.001), surgical infection (OR = 1.44, p = 0.013), heart disease (OR = 1.32, p = 0.023) and medical complications (OR = 1.35, p = 0.025) increased the risk for DGE. A standard PD compared with pylorus preserving resection (OR = 1.69, p = 0.001) and a reconstruction with a pancreaticojejunostomy compared with a pancreaticogastrostomy (OR = 1.83, p < 0.001) increased the risk. For patients without surgical complications, a standard PD and reconstruction with pancreaticojejunostomy still increased the risk for DGE. CONCLUSION DGE is more common after standard PD compared to pylorus preserving PD and after reconstruction with PJ compared to PG in this national cohort, both in the presence of other surgical complications as well as in the absence of other complications.
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Affiliation(s)
- A Hörberg Zdanowski
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - J Wennerblom
- Department of Surgery, Institute of Clinical Sciences Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - J Rystedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - B Tingstedt
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - Caroline Williamsson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden.
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Gu Z, Du Y, Wang P, Zheng X, He J, Wang C, Zhang J. Development and validation of a novel nomogram to predict postoperative pancreatic fistula after pancreatoduodenectomy using lasso-logistic regression: an international multi-institutional observational study. Int J Surg 2023; 109:4027-4040. [PMID: 37678279 PMCID: PMC10720876 DOI: 10.1097/js9.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/04/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Existing prediction models for clinically relevant postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) lack discriminatory power or are too complex. This study aimed to develop a simple nomogram that could accurately predict clinically relevant POPF after PD. METHODS A high-volume, multicenter cohort of patients who underwent PD from the American College of Surgeons-National Surgical Quality Improvement Program database in the United States during 2014-2017 was used as the model training cohort ( n =3609), and patients who underwent PD from the Pancreatic Center of the National Cancer Center Hospital in China during 2014-2019 were used as the external validation cohort ( n =1347). The study used lasso penalized regression to screen large-scale variables, then logistic regression was performed to screen the variables and build a model. Finally, a prediction nomogram for clinically relevant POPF was established based on the logistic model, and polynomial equations were extracted. The performance of the nomogram was evaluated by receiver operating characteristic curve, calibration curve, and decision curve analysis. RESULTS In the training and validation cohorts, there were 16.7% (601/3609) and 16.6% (224/1347) of patients who developed clinically relevant POPF, respectively. After screening using lasso and logistic regression, only six predictors were independently associated with clinically relevant POPF, including two preoperative indicators (weight and pancreatic duct size), one intraoperative indicator (pancreatic texture), and three postoperative indicators (deep surgical site infection, delayed gastric emptying, and pathology). The prediction of the new nomogram was accurate, with an area under the curve of 0.855 (95% CI: 0.702-0.853) in the external validation cohort, and the predictive performance was superior to three previously proposed POPF risk score models (all P <0.001, likelihood ratio test). CONCLUSIONS A reliable lasso-logistic method was applied to establish a novel nomogram based on six readily available indicators, achieving a sustained, dynamic, and precise POPF prediction for PD patients. With a limited number of variables and easy clinical application, this new model will enable surgeons to proactively predict, identify, and manage pancreatic fistulas to obtain better outcomes from this daunting postoperative complication.
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Affiliation(s)
- Zongting Gu
- Department of Hepatobiliary and Pancreatic Surgery and Minimally Invasive Surgery, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang
| | - Yongxing Du
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Peng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Xiaohao Zheng
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Jin He
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Chengfeng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
- Shanxi Province Cancer Hospital/ Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences/Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, People’s Republic of China
| | - Jianwei Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
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Martín S, Secanella L, Sorribas M, Peláez N, Salord S, Lopez-Urdiales R, Fabregat J, Busquets J. Study of risk factors for delayed gastric emptying after partial pancretoduodenectomy. Cir Esp 2023; 101:657-664. [PMID: 36716958 DOI: 10.1016/j.cireng.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 09/21/2022] [Accepted: 10/30/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Delayed gastric emptying is one of the most frequent complications after pancreatoduodenectomy. METHODS We performed an analysis of risk factors for delayed gastric emptying on a prospective database of 390 patients operated on between 2013 and 2021. A comparative retrospective study was carried out between patients with and without delayed gastric emptying and subsequently a study of risk factors for delayed gastric emptying using univariate and multivariate logistic regression models. RESULTS The incidence of delayed gastric emptying in the overall series was 28%. The morbidity of the group was 63%, and postoperative mortality was 3.1%. Focusing on delayed gastric emptying, the median age (73 years vs 68 years, P < 0.001) and preoperative creatinine (75 vs 65.5, P < 0.001) were higher in the group with this complication. The study of risk factors showed that age over 60 years (P = 0.002) and pancreatic fistula (P < 0.001) were risk factors for delayed gastric emptying. CONCLUSION The presence of pancreatic fistula is confirmed as a risk factor for slow gastric emptying after pancreaticoduodenectomy. In addition, age over 60 years is shown to be a risk factor for slow gastric emptying.
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Affiliation(s)
- S Martín
- General and Digestive Surgery Service, Viladecans Hospital, Viladecans, Spain
| | - Ll Secanella
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain
| | - M Sorribas
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain
| | - N Peláez
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain
| | - S Salord
- Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain; Department of Digestive Diseases Unit. Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain
| | - R Lopez-Urdiales
- Department of Endocrinology and Nutrition, Bellvitge University Hospital, Barcelona, Spain
| | - J Fabregat
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain; Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain
| | - J Busquets
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona L'Hospitalet de Llobregat, Barcelona, Spain; Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, Spain.
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10
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Arora L, Reddy VV, Gavini SK, Chandrakasan C. Impact of route of reconstruction of gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A prospective randomized study. Ann Hepatobiliary Pancreat Surg 2023; 27:287-291. [PMID: 37066756 PMCID: PMC10472118 DOI: 10.14701/ahbps.22-123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 04/18/2023] Open
Abstract
Backgrounds/Aims Pancreaticoduodenectomy (PD) is commonly performed pancreatic procedure for tumors of periampullary region. Delayed gastric emptying (DGE) and pancreatic fistula are the most common specific complications following PD. DGE can lead to significant morbidity, resulting in prolonged hospital stay and increased cost. Various factors might influence the occurrence of DGE. We hypothesized that kinking of jejunal limb could be a cause of DGE post PD. Methods Antecolic (AC) and retrocolic (RC) side-to-side gastrojejunostomy (GJ) groups in classical PD were compared for the occurrence of DGE in a prospective study. All patients who underwent PD between April 2019 and September 2020 in a tertiary care center in south India were included in this study. Results After classic PD, RC GJ was found to be superior to AC in terms of DGE rate (26.7% vs. 71.9%) and hospital stay (9 days vs. 11 days). Conclusions Route of reconstruction of GJ can influence the occurrence of DGE as RC anastomosis in classical PD provides the most straight route for gastric emptying.
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Affiliation(s)
- Lokesh Arora
- Department of Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India
| | - Vutukuru Venkatarami Reddy
- Department of Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India
| | - Sivarama Krishna Gavini
- Department of Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India
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11
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Li TY, Qin C, Zhao BB, Yang XY, Li ZR, Wang YY, Guo JC, Han XL, Dai MH, Wang WB. Risk stratification of clinically relevant delayed gastric emptying after pancreaticoduodenectomy. BMC Surg 2023; 23:222. [PMID: 37559107 PMCID: PMC10413504 DOI: 10.1186/s12893-023-02110-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 07/18/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) remains one of the major complications after pancreaticoduodenectomy (PD), with discrepant reports of its contributing factors. This study aimed to develop a nomogram to identify potential predictors and predict the probability of DGE after PD. METHODS This retrospective study enrolled 422 consecutive patients who underwent PD from January 2019 to December 2021 at our institution. The LASSO algorithm and multivariate logistic regression were performed to identify independent risk and protective factors associated with clinically relevant delayed gastric emptying (CR-DGE). A nomogram was established based on the selected variables. Then, the calibration curve, ROC curve, decision curve analysis (DCA), and clinical impact curve (CIC) were applied to evaluate the predictive performance of our model. Finally, an independent cohort of 45 consecutive patients from January 2022 to March 2022 was enrolled to further validate the nomogram. RESULTS Among 422 patients, CR-DGE occurred in 94 patients (22.2%). A previous history of chronic gastropathy, intraoperative plasma transfusion ≥ 400 ml, end-to-side gastrointestinal anastomosis, intra-abdominal infection, incisional infection, and clinically relevant postoperative pancreatic fistula (CR-POPF) were identified as risk predictors. Minimally invasive pancreaticoduodenectomy (MIPD) was demonstrated to be a protective predictor of CR-DGE. The areas under the curve (AUCs) were 0.768 (95% CI, 0.706-0.830) in the development cohort, 0.766 (95% CI, 0.671-0.861) in the validation cohort, and 0.787 (95% CI, 0.633-0.940) in the independent cohort. Then, we built a simplified scale based on our nomogram for risk stratification. CONCLUSIONS Our study identified seven predictors and constructed a validated nomogram that effectively predicted CR-DGE for patients who underwent PD.
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Affiliation(s)
- Tian-Yu Li
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cheng Qin
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bang-Bo Zhao
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Ying Yang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ze-Ru Li
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan-Yang Wang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun-Chao Guo
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xian-Lin Han
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng-Hua Dai
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Wei-Bin Wang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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12
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Panni U, Srivastava R, Bewley A, Williams GA, Fields RC, Sanford DE, Hawkins WG, Leigh N, Hammill CW. Postoperative Proton Pump Inhibitors are associated with a significantly higher rate of delayed gastric emptying after pancreatoduodenectomy. HPB (Oxford) 2023; 25:659-666. [PMID: 36872110 DOI: 10.1016/j.hpb.2023.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 12/29/2022] [Accepted: 02/21/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Proton pump inhibitors (PPIs) are effective in reducing marginal ulcers after pancreatoduodenectomy. However, their impact on perioperative complications has not been defined. METHODS We retrospectively analyzed the effect of postoperative PPIs on 90-day perioperative outcomes in all patients who underwent pancreatoduodenectomy at our institution from April 2017 to December 2020. RESULTS 284 patients were included; 206 (72.5%) received perioperative PPIs, 78 (27.5%) did not. The two cohorts were similar in demographics and operative variables. Postoperatively, the PPI cohort had significantly higher rates of overall complications (74.3% vs. 53.8%) and delayed gastric emptying (28.6% vs. 11.5%), p < 0.05. However, no differences in infectious complications, postoperative pancreatic fistula, or anastomotic leaks were seen. On multivariate analysis, PPI was independently associated with a higher risk of overall complications (OR 2.46, CI 1.33-4.54) and delayed gastric emptying (OR 2.73, CI 1.26-5.91), p = 0.011. Four patients developed marginal ulcers within 90-days postoperatively; all were in the group who received PPIs. CONCLUSION Postoperative proton pump inhibitor use was associated with a significantly higher rate of overall complications and delayed gastric emptying after pancreatoduodenectomy.
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Affiliation(s)
- Usman Panni
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Rohit Srivastava
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Alice Bewley
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Gregory A Williams
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - William G Hawkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Natasha Leigh
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA.
| | - Chet W Hammill
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University in St. Louis School of Medicine, St. Louis, MO 63110, USA
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13
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Hypoalbuminemia and advanced age are risk factors for delayed gastric emptying after pancreaticoduodenectomy. NUTR HOSP 2023. [PMID: 36880742 DOI: 10.20960/nh.04287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy. It could be related to some baseline patient-related characteristics. This study aims to assess the predictive factors associated to DGE in the cohort of patients included in the PAUDA clinical trial. METHODS this study was a retrospective analysis based on the 80 patients included in a randomized clinical trial conducted and published by our group. A descriptive analysis and a bivariate regression model were carried out. Some factors were further scrutinized for associations using the Pearson correlation coefficient and, finally, a multiple regression model using a stepwise selection of variables was conducted. RESULTS DGE was diagnosed in 36 (45 %) out of 80 patients (DGE group). The number of patients older than 60 years old in the DGE group was greater than in the group without DGE (32 vs 28 patients, p = 0.009]. Likewise, the number of patients with a preoperative albumin < 35 g/L (18 vs 11 patients, p = 0.036); preoperative bilirubin > 200 µmol/L (14 vs 8 patients, p = 0.039); postoperative haemorrhage (7 vs 1 patients, p = 0.011); postoperative intraabdominal abscess (12 vs 5 patients, p = 0.017); and postoperative biliary fistula (5 vs 0 patients, p = 0.011), was also greater in the DGE group. Two risk factors were associated with DGE: the patient's age at the time of surgery and preoperative hypoalbuminemia (serum albumin concentration ≤ 35g/L). CONCLUSIONS the patient's age at the time of surgery and the preoperative nutritional status are independent risk factors to the development of DGE after pancreatoduodenectomy.
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14
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Marchegiani G, Di Gioia A, Giuliani T, Lovo M, Vico E, Cereda M, Bassi C, Gianotti L, Salvia R. Delayed gastric emptying after pancreatoduodenectomy: One complication, two different entities. Surgery 2023; 173:1240-1247. [PMID: 36702659 DOI: 10.1016/j.surg.2022.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/09/2022] [Accepted: 12/13/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy associated with a low complication burden but a prolonged hospital stay. The present study aimed to characterize DGE, with a particular focus on its subtypes and related predictors. METHODS A 2-center retrospective analysis was performed including consecutive pancreatoduodenectomy over 5 years. Primary delayed gastric emptying (pDGE) and secondary delayed gastric emptying (sDGE) were defined according to the presence of concomitant causing factors. Predictors of DGE, pDGE and sDGE were assessed through logistic regression. RESULTS Out of 1,170 patients considered, 188 developed delayed gastric emptying (16.1%). Most DGE (71.8%) were secondary. sDGE resolved later (P = .007), with hospital stay, duration of total parenteral nutrition, and of enteral nutrition being longer than for pDGE (all P < .005). Smoking status, total operative time, indication for surgery other than pancreatic cancer, estimated blood loss, and soft pancreatic texture were independent predictors of DGE. In the subgroup analysis of pDGE, smoking was the only independent predictor, whereas pylorus-preservation was a protective factor. Smoking, indication for surgery, estimated blood loss, soft gland texture, and main pancreatic duct diameter were independent predictors of sDGE. CONCLUSION DGE after pancreatoduodenectomy consists of 2 different subtypes. The primary form resolves earlier, and its occurrence might be reduced by pylorus preservation. For the secondary form, clinicians should focus on preventing and treating other trigger complications. The diagnosis of the DGE subtype has critical therapeutic implications and paves the way for further systematic studies.
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Affiliation(s)
- Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy. https://twitter.com/Gio_Marchegiani
| | - Anthony Di Gioia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy. https://twitter.com/Anth_DiGioia
| | - Tommaso Giuliani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy. https://twitter.com/Tom_Giuliani_MD
| | - Michela Lovo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy
| | - Eleonora Vico
- Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Marco Cereda
- Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy.
| | - Luca Gianotti
- Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy. https://twitter.com/SalviaRobi
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15
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Pandey AK, Sharma AK, Singh K, Kaistha S, Rakesh C, Karthik G, Dash S. To compare the outcomes of pancreaticojejunostomy and pancreaticogastrostomy reconstruction after pancreaticoduodenectomy: A prospective observational study. Med J Armed Forces India 2023; 79:64-71. [PMID: 36605340 PMCID: PMC9807657 DOI: 10.1016/j.mjafi.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/17/2021] [Indexed: 02/07/2023] Open
Abstract
Background We have been in constant search of novel innovations to decrease the high morbidity after Pancreaticoduodenectomy (PD). Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the two different methods of reconstruction after PD. However, the existing data is ambiguous in supporting either of them as the preferred technique of reconstruction. Methods This was a single-center prospective observational study that included 64 patients who underwent PD over two years. We compared PG with PJ as a method of reconstruction after PD. The primary objective was to assess whether PG decreases the rate of postoperative pancreatic fistula (POPF) rates or not. Secondary objectives comprised analysis of perioperative outcomes, 30-day and 90-day mortality. Results Pancreatic fistula was significantly lower in PG as compared to the PJ group (24% vs. 47%) with a p-value of 0.027. The incidence of clinically pertinent (grade B) fistula was only 3% in the PG group and 32% in the PJ group. PG group had a higher incidence of post pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE). No statistically significant difference was seen between either group need for blood transfusion, re-exploration, re-admissions, ICU stay, or length of hospital stay, and 30-day and 90-day mortality. Pancreatic texture and high BMI were independent predictors for pancreatic fistula. Conclusion PG when compared to PJ for reconstruction after PD, decreases the rate of POPF significantly; however, it is associated with an elevated risk of DGE and PPH. There was no difference in 30-day and 90-day mortality between both the treatment groups.
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Affiliation(s)
| | | | - K.J. Singh
- Department of GI Surgery, Command Hospital, Chandigargh, India
| | - Sumesh Kaistha
- Department of GI Surgery, Army Hospital (R&R), Delhi, India
| | - C.R. Rakesh
- Department of GI Surgery, Command Hospital (Air Force), Bengaluru, India
| | | | - S.C. Dash
- Dean Academics & Deputy Commandant, Army Hospital (R&R), Delhi, India
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16
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Zeinalpour A, Berjouei HZ, Gholizadeh B. Effect of Jejunostomy Feeding Tube Placement on Complications and Outcome of Pancreaticoduodenectomy Procedures. MAEDICA 2022; 17:840-845. [PMID: 36818256 PMCID: PMC9923061 DOI: 10.26574/maedica.2022.17.4.840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Objective:The aim of this study was to compare the perioperative outcomes and complications between pancreaticoduodenectomy (PD) candidates with and without jejunostomy tube (J-tube) feeding. Materials and methods:This retrospective cohort study was performed on 48 patient candidates for PD, with or without J-tube placement during surgery, in Shahid Modarres Hospital, Tehran, Iran, between 2013 and 2021. Two groups were matched for age, gender, history of heart, endocrine, hypertension and kidney diseases, and drug use. A 12 French jejunal feeding tube was placed at 20-30 cm distal to gastrojejunostomy anastomosis. Outcomes, including biliary leak, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), surgical site infection (SSI), intra-abdominal infection, duration of nasogastric tube (NGT) stay, postoperative (PO) tolerance length, need for total parenteral nutrition (TPN), hospitalization length, and mortality rate, were assessed. Results:There were eight cases with leak (37.5% J-tube group, of which six (75%) were pancreatic type and two (25%) biliary type. There were 11 (22.9%) patients with DGE (54.5% in J-tube group). There was no significant inter-group difference in SSI (P=0.340), intra-abdominal infection managed non-invasively (P=0.369), intra-abdominal abscess managed by percutaneous drainage (P=0.158), patients requiring TPN (P=0.447), NGT placement duration (P=0.088), PO tolerance time (P=0.327), hospital stay (P=0.760) and mortality rate (P=0.851). Conclusion:J-tube placement after PD for pancreatic cancer may be associated with increased postoperative complications. The conclusion of the present study is that there is no difference between performing and not performing the J-tube placement method in terms of complications and consequences.
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Affiliation(s)
- Adel Zeinalpour
- Department of General Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Clinical Research Development Center, Shahid Modarres Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Zolfaghari Berjouei
- Department of General Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Barmak Gholizadeh
- Department of General Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Clinical Research Development Center, Shahid Modarres Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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17
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Dominguez OH, Grigorian A, Wolf RF, Imagawa DK, Nahmias JT, Jutric Z. Delayed gastric emptying is associated with increased risk of mortality in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. Updates Surg 2022; 75:523-530. [PMID: 36309940 PMCID: PMC10042927 DOI: 10.1007/s13304-022-01404-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/03/2022] [Indexed: 11/25/2022]
Abstract
AbstractDelayed gastric emptying (DGE) is common in patients undergoing pancreaticoduodenectomy (PD). The effect of DGE on mortality is less clear. We sought to identify predictors of mortality in patients undergoing PD for pancreatic adenocarcinoma hypothesizing DGE to independently increase risk of 30-day mortality. The ACS-NSQIP targeted pancreatectomy database (2014–2017) was queried for patients with pancreatic adenocarcinoma undergoing PD. A multivariable logistic regression analysis was performed. Separate sensitivity analyses were performed adjusting for postoperative pancreatic fistula (POPF) grades A–C. Out of 8011 patients undergoing PD, 1246 had DGE (15.6%). About 8.5% of patients with DGE had no oral intake by postoperative day-14. The DGE group had a longer median operative duration (373 vs. 362 min, p = 0.019), and a longer hospital length of stay (16.5 vs. 8 days, p < 0.001). After adjusting for age, gender, comorbidities, preoperative chemotherapy, preoperative radiation, open versus laparoscopic approach, vascular resection, deep surgical space infection (DSSI), postoperative percutaneous drain placement, and development of a POPF, DGE was associated with an increased risk for 30-day mortality (OR 3.25, 2.16–4.88, p < 0.001). On sub-analysis, grades A and B POPF were not associated with risk of mortality while grade C POPF was associated with increased risk of mortality (OR 5.64, 2.24–14.17, p < 0.001). The rate of DGE in patients undergoing PD in this large database was over 15%. DGE is associated with greater than three times the increased associated risk of mortality, even when controlling for POPF, DSSI, and other known predictors of mortality.
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Affiliation(s)
- Oscar Hernandez Dominguez
- Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Areg Grigorian
- Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Ronald F Wolf
- Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - David K Imagawa
- Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Jeffry T Nahmias
- Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA
| | - Zeljka Jutric
- Division of Hepatobiliary and Pancreas Surgery and Islet Cell Transplantation, Department of Surgery, Irvine Medical Center, University of California, 333 The City Blvd West, Suite 1600, Orange, CA, 92868-3298, USA.
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18
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Ali Ibrahim EMN, El-Shazli MA, Kandeel A, Nabil A. Dynamics Changes of Solids Gastric Emptying Post -Pancreaticoduodenectomy. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND: Gastric emptying (GE) is one of the common post-operative complications after pancreaticoduodenectomy (PD). Multiple factors have been involved in this complication. Dynamic studies such as GE scintigraphy (GES) have informed us about changes in the behavior of the stomach before and after the operation.
AIM: The objective of this study is a short-term scintigraphic evaluation of GE in post-PD patients for solid food before (baseline) and after the operation for 30 days.
METHODS: Between April 2016 and September 2019, 30 patients who underwent PD were investigated for the effect on GE of solids. GE scan GES was performed for the evaluation of solids in GE on pre-operative and post-operative day 30. The operative time, blood loss, the specimens’ pathology and resection margins, the interpretation of the GES study, and finally the hospital course data were all gathered and subjected to statistical analysis.
RESULTS: Nineteen patients developed delayed GE (DGE) while four developed rapid GE or dumping. The type of pancreatic reconstruction affected the GE dynamics. DGE was evident in all cases with pancreaticogastrostomy (PG), while it was observed only in 4 patients of 15 with pancreaticojejunostomy (PJ). Seven cases developed a post-operative pancreatic fistula (POPF), 3 after PG versus 4 after PJ, and were all successfully managed conservatively.
CONCLUSION: The reconstruction method of the remnant pancreas could affect the dynamics of GE. The DGE to solids was witnessed more in cases reconstructed by PG and less in cases with PJ. Post-operative complications associated, such as POPF, are factors associated with DGE.
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19
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Risk Factor Identification for Delayed Gastric Emptying after Distal Pancreatectomy-An Evaluation of 1688 Patients Based on the German StuDoQ|Pancreas Registry. J Clin Med 2022; 11:jcm11195539. [PMID: 36233403 PMCID: PMC9572291 DOI: 10.3390/jcm11195539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/17/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade “A” was reported for 98 (61.3%), grade “B” for 41 (25.6%) and grade “C” for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, “abscesses with invasive therapy” (p < 0.001), “other surgical complications” (p < 0.001), prolonged “stays in ICU” (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance.
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Abstract
OBJECTIVES Delayed gastric emptying (DGE) is a complication that affects the length of hospitalization and associated cost after pancreaticoduodenectomy (PD). The reported risk factors for DGE were controversial. This study aimed to identify risk factors for the development of DGE after PD. METHODS The patients who underwent PD between October 2010 and October 2020 were retrospectively examined. Multivariate analysis was performed to predict the variables causing DGE. RESULTS In total, 225 patients underwent PD. The pylorus preserving PD was applied to 151 patients (67%), whereas standard PD to 74 (33%). The DGE was detected in 26 patients (11.5%). The majority of cases were classified as grade A (57.7%), whereas 38.4% as grade B and 3.9% as grade C. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 3.48; 95% confidence interval [CI], 1.45-8.34; P = 0.05), the preoperative biliary stent (OR, 2.5; 95% CI, 1.04-5.99; P = 0.039), and the pylorus resection (OR, 3.05; 95% CI, 1.28-7.25; P = 0.012) were independently associated with DGE. CONCLUSIONS We demonstrated that implementation of the preoperative stent, pylorus resection, and diabetes mellitus are independent risk factors for DGE. Pylorus preservation should remain the standard of care in PD.
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Schrempf MC, Pinto DRM, Wolf S, Geissler B, Sommer F, Hoffmann M, Vlasenko D, Gutschon J, Anthuber M. Intraoperative endoluminal pyloromyotomy for reduction of delayed gastric emptying after pylorus preserving partial pancreaticoduodenectomy (PORRIDGE trial): study protocol for a randomised controlled trial. Trials 2022; 23:74. [PMID: 35078510 PMCID: PMC8787914 DOI: 10.1186/s13063-022-06032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 01/15/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Pylorus-preserving pancreaticoduodenectomy (ppPD) is a standard surgical procedure for the treatment of resectable neoplasms of the periampullary region. One of the most common postoperative complications after ppPD is delayed gastric emptying (DGE) which reduces quality of life, prevents a timely return to a solid oral diet and prolongs the length of hospital stay. In a retrospective analysis, intraoperative endoluminal pyloromyotomy was associated with a reduced rate of DGE. The aim of this study is to investigate the effect of intraoperative endoluminal pyloromyotomy on postoperative DGE after ppPD in a randomised and controlled setting.
Methods
This randomised trial features parallel group design with a 1:1 allocation ratio and a superiority hypothesis. Patients with a minimum age of 18 years and an indication for ppPD are eligible to participate in this study and will be randomised intraoperatively to receive either endoluminal pyloromyotomy or atraumatic stretching of the pylorus. The sample size calculation (n=64 per study arm) is based on retrospective data. The primary endpoint is the rate of DGE within 30 days. Secondary endpoints are quality of life, operation time, estimated blood loss, length of hospital stay, morbidity and mortality.
Discussion
DGE after ppPD is a common complication with an incomplete understood aetiology. Prevention of DGE could improve outcomes and enhance quality of life after one of the most common procedures in pancreatic surgery. This trial will expand the existing evidence on intraoperative pyloromyotomy, and the results will provide additional data on a simple surgical technique that could reduce the incidence of postoperative DGE.
Trial registration
German Clinical Trials RegisterDRKS00013503. Registered on 27 December 2017.
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22
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Kapoor D, Barreto SG, Perwaiz A, Singh A, Chaudhary A. Can we predict the need for nutritional support following pancreatoduodenectomy? Pancreatology 2022; 22:160-167. [PMID: 34893447 DOI: 10.1016/j.pan.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/08/2021] [Accepted: 11/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The practice of routine placement of a tube jejunostomy at the time of pancreatoduodenectomy has given way to a more selective approach. However, the indications of establishing enteral access at the time of surgery remain poorly defined. This study aimed to assess the preoperative and intraoperative factors associated with the need for nutritional support after pancreatoduodenectomy, to guide decision-making for the establishment of intraoperative feeding access. METHODS Retrospective study, analyzing the data of 562 consecutive patients, who underwent pancreatoduodenectomy between March 2013 to December 2020. Univariate and multiple logistic regression analysis was carried out to ascertain the factors associated with the initiation of and need for nutritional support for more than 7 days postop. The utility of tube jejunostomy was studied in patients in whom it was performed. RESULTS Of 562 patients, 105 (18.7%) needed nutritional support. A tube jejunostomy was performed in 46 (8.2%) patients, parenteral nutrition was used in 83 (14.8%), and nasojejunal tube placed in 28 (4.9%) patients. On logistic regression analysis, age, serum albumin <3.0 gm/dl and operative blood loss were independently associated with the initiation of supportive nutrition, while preoperative gastric outlet obstruction (OR 3.105, 95% CI1.201-8.032, p = 0.019) and serum albumin <3.0 gm/dl (OR 2.669, 95% CI 1.131-6.300, p = 0.025) were associated with the need for prolonged nutritional support. The maximal benefit of tube jejunostomy was in patients with mental health disorders (83.3%). CONCLUSION Tube jejunostomy for nutritional support after pancreatoduodenectomy can be considered in patients with preoperative gastric outlet obstruction, serum albumin <3.0 gm/dl and mental health disorders.
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Affiliation(s)
- Deeksha Kapoor
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Savio George Barreto
- Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
| | - Azhar Perwaiz
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Amanjeet Singh
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Adarsh Chaudhary
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
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Fahlbusch T, Luu AM, Höhn P, Klinger C, Werner J, Keck T, Friess H, Köninger J, Kraus T, Alsfasser G, Padberg W, Ritz JP, Uhl W, Belyaev O. Impact of pylorus preservation on delayed gastric emptying after pancreaticoduodenectomy-analysis of 5,000 patients based on the German StuDoQ|Pancreas-Registry. Gland Surg 2022; 11:67-76. [PMID: 35242670 PMCID: PMC8825530 DOI: 10.21037/gs-21-645] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/15/2021] [Indexed: 08/11/2023]
Abstract
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".
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Affiliation(s)
- Tim Fahlbusch
- St. Josef Hospital, Department of General and Visceral Surgery, Ruhr-University Bochum, Germany
| | - Andreas Minh Luu
- St. Josef Hospital, Department of General and Visceral Surgery, Ruhr-University Bochum, Germany
| | - Philipp Höhn
- St. Josef Hospital, Department of General and Visceral Surgery, Ruhr-University Bochum, Germany
| | - Carsten Klinger
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, Berlin, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, University Hospital Munich, LMU, Munich, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, TUM München, Germany
| | - Jörg Köninger
- Klinik für Allgemein-, Viszeral-, Thorax- und Transplantationschirurgie, Katharinenhospital, Stuttgart, Germany
| | - Thomas Kraus
- Allgemein-, Viszeral- und Minimalinvasive Chirurgie, Nordwestkrankenhaus Frankfurt, Frankfurt am Main, Germany
| | - Guido Alsfasser
- Abteilung für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsmedizin Rostock, Rostock, Germany
| | - Winfried Padberg
- Allgemein-, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen Marburg, Standort Gießen, Gießen, Germany
| | - Jörg Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, Helios Kliniken Schwerin, Schwerin, Germany
| | - Waldemar Uhl
- St. Josef Hospital, Department of General and Visceral Surgery, Ruhr-University Bochum, Germany
| | - Orlin Belyaev
- St. Josef Hospital, Department of General and Visceral Surgery, Ruhr-University Bochum, Germany
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Ammar K, Varghese C, K T, Prabakaran V, Robinson S, Pathak S, Dasari BVM, Pandanaboyana S. Impact of routine nasogastric decompression versus no nasogastric decompression after pancreaticoduodenectomy on perioperative outcomes: meta-analysis. BJS Open 2021; 5:6472792. [PMID: 34932101 PMCID: PMC8691053 DOI: 10.1093/bjsopen/zrab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/03/2021] [Indexed: 12/28/2022] Open
Abstract
Background Consensus on the use of nasogastric decompression (NGD) after pancreaticoduodenectomy (PD) is lacking. This meta-analysis reviewed current evidence on the impact of routine NGD versus no NGD after PD on perioperative outcomes. Methods PubMed, Medline, Scopus, Embase and Cochrane databases were searched for studies reporting on the role of NGD after PD on perioperative outcomes. Data up to January 2021were retrieved and analysed. Results Eight studies were included, with a total of 1301 patients enrolled, of whom 668 had routine NGD. Routine NGD was associated with a higher incidence of overall delayed gastric emptying (DGE) (odds ratio (OR) 2.51, 95 per cent c.i. 1.12 to 5.63, I2 = 83 per cent; P = 0.03) and clinically relevant DGE (OR 3.64, 95 per cent c.i. 1.83 to 7.25, I2 = 54 per cent; P < 0.01), a higher rate of Clavien–Dindo grade II or higher complications (OR 3.12, 95 per cent c.i. 1.05 to 9.28, I2 = 88 per cent; P = 0.04) and increased length of hospital stay (mean difference 2.67, 95 per cent c.i. 0.60 to 4.75, I2 = 97 per cent; P = 0.02). There were no significant differences in overall complications (OR 1.07, 95 per cent c.i. 0.79 to 1.46, I2 = 0 per cent; P = 0.66) or postoperative pancreatic fistula (OR 1.21, 95 per cent c.i. 0.86 to 1.72, I2 = 0 per cent; P = 0.28) between patients with or those without routine NGD. Conclusion Routine NGD was associated with increased rates of DGE, major complications and longer length of stay after PD.
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Affiliation(s)
- Khaled Ammar
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,Department of Hepato-Pancreato-Biliary Surgery, National Liver Institute, Menoufia University, Shebin El Kom, Egypt
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Thejasvin K
- Department of Surgery, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Viswakumar Prabakaran
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Stuart Robinson
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Samir Pathak
- Department of Hepatobiliary and Pancreatic Surgery, St James Hospital, Leeds, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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25
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Nishio RT, Pacheco-Jr AM, Moricz AD, Silva RA. WHAT FACTORS CONTRIBUTE TO DELAYED GASTRIC EMPTYING AFTER DUODENOPANCREATECTOMY WITH PILORIC PRESERVATION? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2021; 34:e1592. [PMID: 34669882 PMCID: PMC8521836 DOI: 10.1590/0102-672020210002e1592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/28/2021] [Indexed: 12/23/2022]
Abstract
Background: The delay in gastric emptying is the second most frequent complication after duodenopancreatectomy with pyloric preservation, that increases hospitalization time and hospital costs.
Aim: To identify factors that contribute to the appearance the delay in this surgical procedure.
Method: Ninety-five patients were submitted to duodenopancreatectomy with pyloric preservation. After retrospective analysis of the medical records, it was observed that 60 had prolonged hospitalization due to complications. Thus, univariate and multivariate logistic regression were used to analyze predictors of delayed gastric emptying.
Results: Delay was present in 65% (n=39) and pancreatic fistula in 38.3% (n=23). Univariate analysis revealed that the presence of pancreatic complications (pancreatic fistula, p=0.01), other intracavitary complications with the appearance of abdominal collections (p=0.03) and hypoalbuminemia (p=0.06) were responsible, also confirmed by the multivariate analysis. In those who presented delay without a determined cause, it was observed that high levels of total bilirubin (p=0.01) and direct bilirubin (p=0.01) could be related to it.
Conclusion: The delay in gastric emptying in patients undergoing duodenopancreatectomy with pyloric preservation is due to intracavitary complications.
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Affiliation(s)
- Ricardo Tadashi Nishio
- Department of Surgery, Faculty of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil
| | | | - André de Moricz
- Department of Surgery, Faculty of Medical Sciences, Santa Casa de São Paulo, São Paulo, SP, Brazil
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26
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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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Cho HY, Kim H, Yoon S, Lee HJ, Kim H, Lee HC, Kim WH, Jang JY. Effect of sugammadex on the recovery of gastrointestional motility after open pancreaticoduodenectomy: a single-center retrospective study. Minerva Anestesiol 2021; 87:1100-1108. [PMID: 34337915 DOI: 10.23736/s0375-9393.21.15668-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND This study aimed to investigate the association between sugammadex use and the occurrence of delayed passage of first flatus and oral intake tolerance following open pancreaticoduodenectomy (PD). METHODS We reviewed consecutive patients who underwent open PD between 2015 and 2019; subsequently, they were divided into the sugammadex (group S) and neostigmine with anticholinergics (group N) groups based on the reversal agent used. We performed stabilized inverse probability of treatment weighting (IPTW) analysis to adjust for baseline differences between the groups. We compared the delayed passage of first flatus, oral intake tolerance, and other postoperative outcomes between the groups before and after IPTW. RESULTS Of the 736 included patients, 309 (42.0%) received sugammadex. Stabilized IPTW revealed a significantly lower occurrence of delayed passage of first flatus in group S (19.5%) compared to group N (27.7%) (OR 0.61, 95% CI: 0.43-0.86, P = 0.005). Further, there was a significantly lower occurrence of delayed oral intake tolerance in group S (18.9%) than in group N (28.0%) (OR 0.65, 95% CI: 0.46-0.92, P = 0.016). CONCLUSIONS Compared to previous reversal agents, sugammadex use was significantly associated with a decrease in the occurrence of prolonged time to first flatus and oral intake tolerance following open PD.
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Affiliation(s)
- Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyerin Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea - .,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Won H Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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28
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Ju JW, Park SJ, Yoon S, Lee HJ, Kim H, Lee HC, Kim WH, Jang JY. Detrimental effect of intraoperative hypothermia on pancreatic fistula after pancreaticoduodenectomy: A single-centre retrospective study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:983-992. [PMID: 34174019 DOI: 10.1002/jhbp.1017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/01/2021] [Accepted: 06/15/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although perioperative hypothermia was found to be associated with gastrointestinal anastomotic leakage in preclinical studies, its association with postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy was never evaluated. We investigated the association between intraoperative hypothermia and clinically relevant (CR)-POPF following pancreaticoduodenectomy. METHODS We retrospectively reviewed 2163 consecutive patients who underwent pancreaticoduodenectomy during 2007-2019. Based on intraoperative time-weighted average core temperature, patients were grouped into normothermia (36.0-37.5°C), mild hypothermia (35.0-<36.0°C), and severe hypothermia (<35°C). We conducted multivariable logistic regression analysis for CR-POPF, a propensity score analysis using inverse probability of treatment weighting (IPTW) to adjust the baseline differences between the three groups, followed by multivariable logistic regression with IPTW for CR-POPF. RESULTS Among the 2008 patients analysed, 1118 (55.7%) and 120 (6.0%) had mild and severe hypothermia, respectively, and 14.2% overall incidence of CR-POPF. Severe intraoperative hypothermia was significantly associated with CR-POPF before and after IPTW (before: odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.03-3.09, P = .038; after: OR 2.48, 95% CI: 1.28-4.81, P = .007); however, mild hypothermia had no significant associations. CONCLUSION Severe intraoperative hypothermia is significantly associated with the occurrence of CR-POPF following pancreaticoduodenectomy, suggesting that hypothermia is deleterious on pancreaticojejunal anastomotic healing.
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Affiliation(s)
- Jae-Woo Ju
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - So Jung Park
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Susie Yoon
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho-Jin Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyung-Chul Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Won Ho Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Al Abbas AI, Borrebach JD, Pitt HA, Bellon J, Hogg ME, Zeh HJ, Zureikat AH. Development of a Novel Pancreatoduodenectomy-Specific Risk Calculator: an Analysis of 10,000 Patients. J Gastrointest Surg 2021; 25:1503-1511. [PMID: 32671801 DOI: 10.1007/s11605-020-04725-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 06/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is often performed in frail patients and is associated with significant morbidity. The five-factor modified frailty index (mFI-5) has been utilized to predict adverse postoperative outcomes, but has not been tested in PD. We aimed to develop risk tools to generate and predict 30-day outcomes after PD and compare their performance with the mFI-5. Risk tools were then used to generate a PD-specific calculator. METHODS Elective PDs from the 2014-2016 ACS NSQIP® Procedure Targeted Pancreatectomy PUFs were identified. Multivariable logistic regression models were constructed to predict postoperative mortality, any complication, serious complication, clinically relevant postoperative pancreatic fistula (CR-POPF), and discharge not-to-home. Predictive accuracy was evaluated through repeated stratified tenfold cross-validation and compared to the mFI-5. RESULTS Nine thousand eight hundred sixty-seven PDs were captured. Nine risk factors were retained: sex, age, BMI, DM, HTN, ASA classification, pancreatic duct size, gland texture, and adenocarcinoma. Cross-validated C-indices ranged from 0.49 to 0.61 for the mFI-5 and 0.63 to 0.75 for our risk models. The best-performing model was for discharge not-to-home (C = 0.75), and the model delivering the largest increase in predictive accuracy was for CR-POPF (CmFI-5/Model = 0.49/0.70). A user-friendly risk calculator was created predicting the five outcomes of interest. CONCLUSION We have created a PD-specific risk calculator that outperforms the mFI-5. This calculator may serve as a useful adjunct in shared decision-making for patients and surgeons.
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Affiliation(s)
- Amr I Al Abbas
- Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Henry A Pitt
- Temple University Health System, Philadelphia, PA, USA
| | | | | | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA.
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30
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Yoon S, Kim H, Cho HY, Lee HJ, Kim H, Lee HC, Jang JY. Effect of postoperative non-steroidal anti-inflammatory drugs on anastomotic leakage after pancreaticoduodenectomy. Korean J Anesthesiol 2021; 75:61-70. [PMID: 34024090 PMCID: PMC8831434 DOI: 10.4097/kja.21096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Although the association between an increase in anastomotic leakage (AL) and non-steroidal anti-inflammatory drugs (NSAIDs) has been reported in gastrointestinal surgeries, this issue has rarely been addressed for pancreaticoduodenectomy (PD). We aimed to investigate the association between postoperative NSAIDs administration and clinically relevant AL (CR-AL) following PD. Method We retrospectively evaluated 2,163 consecutive patients who underwent PD between 2007 and 2019. The patients were divided into two groups: patients who received and did not receive NSAIDs by postoperative day (POD) 5. We conducted a propensity score analysis using inverse probability of treatment weighting (IPTW) to adjust the baseline differences between both groups. We compared the occurrence of CR-AL and other postoperative outcomes before and after IPTW. Further, we used the multivariable binary logistic regression method for a sensitivity analysis for CR-AL. Results A total of 2,136 patients were included in the analysis. Of these, 222 (10.4%) received NSAIDs by POD 5. The overall occurrence rate of CR-AL was 14.9%. After IPTW, postoperative NSAIDs were significantly associated with CR-AL (odds ratio [OR] 1.24, 95% confidence interval [CI], 1.05-1.47; P=0.012), prolonged postoperative hospitalization (OR 1.31, 95% CI 1.14-1.50, P<0.001), and unplanned readmission within 30 days postoperatively (OR 1.48, 95% CI 1.15-1.91, P=0.002). However, this association was not consistent in the sensitivity analysis. Conclusion Postoperative NSAIDs use was significantly associated with an increase in CR-AL incidence following PD. However, sensitivity analysis failed to show its association, which precludes a firm conclusion of its detrimental effect.
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Affiliation(s)
- Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyerin Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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Varghese C, Bhat S, Wang THH, O'Grady G, Pandanaboyana S. Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials. BJS Open 2021; 5:6275938. [PMID: 33989392 PMCID: PMC8121488 DOI: 10.1093/bjsopen/zrab035] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/10/2021] [Indexed: 12/18/2022] Open
Abstract
Introduction Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several RCTs have explored operative strategies to minimize DGE, however, the optimal combination of gastric resection approach, anastomotic route, configuration and the use of enteroenterostomy remains unclear. Methods MEDLINE, Embase and CENTRAL databases were systematically searched for RCTs comparing gastric resection (classic Whipple, pylorus-resecting, pylorus-preserving), anastomotic route (antecolic, retrocolic), configuration (loop gastroenterostomy/Billroth II, Roux-en-Y), and use of enteroenterostomy (Braun). A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimizing DGE. Results Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6 per cent (647 patients). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35 per cent of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32 per cent of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (odds ratio 2.10, 95 per cent credibility interval (cr.i.) 0.92 to 4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when this was used (odds ratio 1.90, 95 per cent cr.i. 0.92 to 3.90). Having a Braun enteroenterostomy ranked the best in 96 per cent of comparisons. Conclusion Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE. Preregistration PROSPERO submitted 23 December 2020. CRD42021227637
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Affiliation(s)
- C Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - S Bhat
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - T H-H Wang
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - G O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - S Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Morita Y, Sakaguchi T, Ida S, Muraki R, Kitajima R, Furuhashi S, Takeda M, Kikuchi H, Hiramatsu Y, Takeuchi H. Comprehensive strategy for perioperative care of pancreaticoduodenectomy according to the risk stratification by pancreatic fistula and delayed gastric emptying. Asian J Surg 2021; 45:172-178. [PMID: 33933358 DOI: 10.1016/j.asjsur.2021.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/02/2021] [Accepted: 04/15/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND/OBJECTIVE Pancreaticoduodenectomy (PD) is highly invasive with unsatisfactory postoperative complication rates. Nutritional and fluid management after major surgery attracts much attention with regard to the reduction in severe postoperative complications. We retrospectively analyzed PD cases and proposed a novel strategy for perioperative fluid and nutritional therapy according to the risk stratification by pancreatic fistula (PF) and delayed gastric emptying (DGE). METHODS Between 2003 and 2018, 140 patients underwent PD at our institute of which 134 patients were enrolled. We evaluated the clinicopathological factors affecting severe (≥10%) body weight loss (BWL), factors affecting the incidence of PF and intraabdominal complications (IAC), and factors related to DGE. RESULTS Multivariate analysis indicated that male sex, severe PF, and DGE are significant risk factors for BWL ≥10%. PF and IAC were predominantly observed in male patients and those with non-pancreatic cancer. A fluid balance ≥6000 ml on postoperative day 2 was the sole risk factor for primary DGE. Secondary DGE significantly correlated with stomach preserving PD. Importantly, the average BWL was around 15% in grade B or C secondary DGE. CONCLUSION Severe postoperative complications resulted in significant BWL. Enteral feeding is unnecessary in cases with a hard pancreas and dilated pancreatic duct if appropriate perioperative fluid management is performed. Secondary DGE followed by PF or IAC is unavoidable to some extent, especially in the case of soft pancreas with a fine pancreatic duct. In such cases, enteral feeding with tube ileostomy should be considered, and stomach preserving PD is likely to be harmful.
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Affiliation(s)
- Yoshifumi Morita
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan.
| | | | - Shinya Ida
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Ryuta Muraki
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Ryo Kitajima
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Satoru Furuhashi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Makoto Takeda
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hirotoshi Kikuchi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yoshihiro Hiramatsu
- Department of Perioperative Functioning Care & Support, Hamamatsu University School of Medicine, Japan
| | - Hiroya Takeuchi
- Second Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Pencovich N, Nevo N, Weiser R, Bonder E, Bogoch Y, Nachmany I. Postoperative Rise of Circulating Mitochondrial DNA Is Associated with Inflammatory Response in Patients following Pancreaticoduodenectomy. Eur Surg Res 2021; 62:18-24. [PMID: 33902043 DOI: 10.1159/000514661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 01/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Accumulation of plasma mitochondrial DNA (mtDNA) following severe trauma has been shown to correlate with the development of systemic inflammatory response syndrome (SIRS) and may predict mortality. Our objective was to investigate the relationship between levels of circulatory mtDNA following pancreaticoduodenectomy (PD) and the postoperative course. METHODS Levels of plasma mtDNA were assessed by real-time PCR of the mitochondrial genes ND1 and COX3 in 23 consecutive patients who underwent PD 1 day prior to surgery, within 8 h after surgery, and on postoperative day (POD)1 and POD5. The abundance of mtDNA was assessed relative to preoperative levels and in relation to parameters reflecting the postoperative clinical course. RESULTS When pooled for all patients, the circulating mtDNA levels were significantly increased after surgery. However, while a significant (at least >2-fold and up to >20-fold) rise was noted in 11 patients, no change in mtDNA levels was noted in the other 12 following surgery. Postoperative rise in circulating mtDNA was associated with an increased rate of postoperative fever until day 5, decreased hemoglobin and albumin levels, and increased white blood cell counts. These patients also suffered from increased rates of delayed gastric emptying. No significant differences were demonstrated in other postoperative parameters. CONCLUSION Circulating mtDNA surge is associated with an inflammatory response following PD and may potentially be used as an early marker for postoperative course. Studies of larger patient cohorts are warranted.
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Affiliation(s)
- Niv Pencovich
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Nevo
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roi Weiser
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ekaterina Bonder
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yoel Bogoch
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ido Nachmany
- Department of General Surgery B, Division of Surgery, Tel-Aviv Sourasky Medical Center, The Nikolas and Elizabeth Shlezak Fund for Experimental Surgery, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Gastrostomy as a Preemptive Measure after Pancreatoduodenectomy against Delayed Gastric Emptying: A Small Case Series and a Review of the Literature. Case Rep Surg 2021; 2021:6649914. [PMID: 33680529 PMCID: PMC7925062 DOI: 10.1155/2021/6649914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/01/2021] [Accepted: 02/10/2021] [Indexed: 12/02/2022] Open
Abstract
Delayed gastric emptying (DGE) is a common (20–30%) postoperative complication following pancreatoduodenectomy (PD) (Parmar et al., 2013). Various causes and preemptive measures have been suggested to decrease the occurrence of DGE. We added a simple step in the procedure of 26 consecutive pancreatic head resections, which seems to alleviate DGE and has never been highlighted before.
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35
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Ozgun YM, Oter V, Piskin E, Colakoglu MK, Aydin O, Aksoy E, Dalgic T, Bostanci EB. Treatment Modalities and the Role of Endoscopy for Delayed Gastric Emptying After Whipple Operation: Analysis of 53 Patients. Am Surg 2021; 88:273-279. [PMID: 33517709 DOI: 10.1177/0003134821989037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after Whipple surgery. This situation delays postoperative oral food intake and prolongs hospitalization. Postoperative DGE often develops due to complications such as intra-abdominal abscess, collections, and anastomosis leaks, and these are called secondary DGE. The pathogenesis of primary DGE is still unknown, and there are insufficient data in the literature about the treatment. In this study, patients undergoing Whipple operation were examined separately as primary and secondary DGE. We discussed the causes and treatments of these patients, and also we aimed to present the therapeutic effect of endoscopy for primary DGE after the Whipple procedure. METHODS From March 2014 to March 2018, data of 262 patients who underwent the Whipple procedure were collected prospectively. We observed that postoperative DGE developed in 53 (21.7%) patients. We retrospectively divided the patients by etiology into 2 groups as primary and secondary and graded DGE according to the International Study Group of Pancreatic Surgery. We defined patients who did not have secondary causes such as intra-abdominal abscess as primary DGE. Appropriate interventional procedures were performed for patients with secondary causes. We performed endoscopic intervention with therapeutic intent for patients who had primary DGE. RESULTS The overall rate of DGE was 21.7% (n = 53) among 262 patients undergoing the Whipple procedure. It was observed that in 31 (58.5%) of these 53 patients, DGE was developed due to secondary causes. Interventional procedures were performed to these patients when necessary. A total of 22 (41.5%) patients developed primary DGE. Of these, 9 patients were grade A, 7 were grade B, and 6 were grade C. The mean duration of hospitalization for secondary DGE and primary DGE was 20.36 and 28.7 days, respectively. After endoscopic intervention with therapeutic intent to primary DGE patients, we observed that patients tolerated solid meal after 12 hours in grade B and after 26 hours in grade C patients. CONCLUSION Delayed gastric emptying, which is a common complication after Whipple operation and which deteriorates the quality of life and prolongs the duration of hospital stay, should be treated according to the cause. In secondary DGE, treatment modalities must be focused on intra-abdominal causes such as hematoma, collection, and abcess. We suggest that the primary DGE which is unresponsive to medical treatments could be treated endoscopically. After endoscopic intervention, patients with primary DGE can be started oral intake on the same day and discharged more quickly.
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Affiliation(s)
- Yigit Mehmet Ozgun
- Department of Gastroenterological Surgery, 536164Ankara City Hospital, Ankara, Turkey
| | - Volkan Oter
- Department of Gastroenterological Surgery, 536164Ankara City Hospital, Ankara, Turkey
| | - Erol Piskin
- Department of Gastroenterological Surgery, 536164Ankara City Hospital, Ankara, Turkey
| | | | - Osman Aydin
- Department of Gastroenterological Surgery, 536164Ankara City Hospital, Ankara, Turkey
| | - Erol Aksoy
- Department of Gastroenterological Surgery, 536164Ankara City Hospital, Ankara, Turkey
| | - Tahsin Dalgic
- Department of Gastroenterological Surgery, 536164Ankara City Hospital, Ankara, Turkey
| | - Erdal Birol Bostanci
- Department of Gastroenterological Surgery, Ankara City Hospital, Health of Science University, Ankara, Turkey
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36
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Cakir M, Akinci M, Akturk OM. 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. Medeni Med J 2020; 35:181-187. [PMID: 33110669 PMCID: PMC7584264 DOI: 10.5222/mmj.2020.02222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/13/2020] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Mikail Cakir
- University of Health Sciences Haseki Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Muzaffer Akinci
- University of Health Sciences Haseki Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Okan Murat Akturk
- University of Health Sciences Haseki Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
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Schrempf MC, Pinto DRM, Gutschon J, Schmid C, Hoffmann M, Geissler B, Wolf S, Sommer F, Anthuber M. Intraoperative endoluminal pyloromyotomy as a novel approach to reduce delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy-a retrospective study. Langenbecks Arch Surg 2020; 406:1103-1110. [PMID: 33057756 PMCID: PMC8208917 DOI: 10.1007/s00423-020-02008-5] [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] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/01/2020] [Indexed: 01/26/2023]
Abstract
Background Delayed gastric emptying (DGE) is one of the most common complications after pylorus-preserving partial pancreaticoduodenectomy (ppPD). The aim of this retrospective study was to assess whether an intraoperative pyloromyotomy during ppPD prior to the creation of duodenojejunostomy reduces DGE. Methods Patients who underwent pylorus-preserving pancreaticoduodenectomy between January 2015 and December 2017 were divided into two groups on the basis of whether an intraoperative pyloromyotomy was performed (pyloromyotomy (PM) group) or not (no pyloromyotomy (NP) group). The primary endpoint was DGE according to the ISGPS definition. The confirmatory analysis of the primary endpoint was performed with multivariate analysis. Results One hundred and ten patients were included in the statistical analysis. Pyloromyotomy was performed in 44 of 110 (40%) cases. DGE of any grade was present in 62 patients (56.4%). The DGE rate was lower in the PM group (40.9%) compared with the NP group (66.7%), and pyloromyotomy was associated with a reduced risk for DGE in univariate (OR 0.35, 95% CI 0.16–0.76; P = 0.008) and multivariate analyses (OR 0.32, 95% CI 0.13–0.77; P = 0.011). The presence of an intra-abdominal complication was an independent risk factor for DGE in the multivariate analysis (OR 5.54, 95% CI 2.00–15.36; P = 0.001). Conclusion Intraoperative endoluminal pyloromyotomy during ppPD was associated with a reduced risk for DGE in this retrospective study. Pyloromyotomy should be considered a simple technique that can potentially reduce DGE rates after ppPD.
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Affiliation(s)
- Matthias C Schrempf
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany.
| | - David R M Pinto
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Johanna Gutschon
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Christoph Schmid
- Department of Hematology and Oncology, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Michael Hoffmann
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Bernd Geissler
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Sebastian Wolf
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Florian Sommer
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Matthias Anthuber
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
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Ausania F, Senra P, Meléndez R, Caballeiro R, Ouviña R, Casal-Núñez E. Prehabilitation in patients undergoing pancreaticoduodenectomy: a randomized controlled trial. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 111:603-608. [PMID: 31232076 DOI: 10.17235/reed.2019.6182/2019] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION prehabilitation has been proposed as an effective tool to prevent postoperative complications in patients undergoing major abdominal surgery. However, no studies have demonstrated its effectiveness in pancreatic surgical patients. The aim of this study was to assess the impact of prehabilitation on postoperative complications in patients undergoing a pancreaticoduodenectomy (PD). METHODS this was a randomized controlled trial. Eligible candidates who accepted to participate were randomized to the control (standard care) or intervention (standard care + prehabilitation) group. All patients with pancreatic or periampullary tumors who were candidates for pancreaticoduodenectomy were included. Patients who received neoadjuvant treatment were excluded. Prehabilitation covered three actions: a) nutritional support; b) control of diabetes and exocrine pancreatic insufficiency; and c) physical and respiratory training. The main study outcome was the proportion of patients who suffered postoperative complications. Secondary outcomes included the occurrence of specific complications (pancreatic leak and delayed gastric emptying) and hospital stay. RESULTS forty patients were included in the analysis. Twenty-two patients were randomized to the control arm and 18, to the intervention group. No statistically significant differences were observed in terms of overall and major complications between the prehabilitation and standard care groups. Pancreatic leak was not statistically different between the groups (11% vs 27%, p = 0.204). However, DGE was significantly lower in the prehabilitation group (5.6% vs 40.9% in the standard care group, p = 0.01). CONCLUSION prehabilitation did not reduce postoperative complications following pancreaticoduodenectomy. However, a reduction in DGE was observed. Further studies are needed to validate the role and the timing of prehabilitation in high-risk patients.
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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40
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Snyder RA, Ewing JA, Parikh AA. Delayed gastric emptying after pancreaticoduodenectomy: A study of the national surgical quality improvement program. Pancreatology 2020; 20:205-210. [PMID: 31875832 DOI: 10.1016/j.pan.2019.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/22/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) remains common after pancreaticoduodenectomy (PD). Risk factors for DGE have been difficult to identify due to a lack of a standard definition. The purpose of this study was to identify factors associated with DGE using a standard definition across a national cohort of patients. METHODS A retrospective cohort study of patients who underwent PD from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific module was performed. Multivariable (MV) regression was used to determine perioperative risk factors for DGE. RESULTS Of 10,249 patients undergoing PD, 16.6% developed DGE and were older (65.3 vs. 64.3 years), more often male (62.5% vs. 51.9%), overweight/obese (66.7% vs. 61.3%), and American Society of Anesthesiologist (ASA) class 3 (80.0% vs. 76.0%). Rates of pylorus preservation (41.4% vs. 38.7%) were higher, and median operative time (373 vs. 354 min) longer. On MV analysis, age≥65 years [OR 1.26 (95%CI 1.13-1.41)], male sex [OR 1.54 (95%CI 1.38-1.72), body mass index (BMI) > 30 [OR 1.22 (95%CI 1.06-1.40)], ASA class≥3 [OR 1.24 (95%CI 1.08-1.42)], pylorus preservation [OR 1.08 (95%CI 1.02-1.14)], and longer operative time [OR 1.26 (95%CI 1.13-1.40)] remained associated with DGE. Preoperative chemotherapy was associated with decreased risk of DGE [OR 0.77 (95%CI 0.64-0.93)]. CONCLUSION In this national, multicenter cohort of patients undergoing PD, 16.6% of patients developed DGE based on a standardized definition. Perioperative factors including age, BMI, ASA class, pylorus preservation, and operative time were associated with increased risk of DGE. Further research is warranted to identify opportunities for prevention via preoperative rehabilitation strategies and treatment.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, University of South Carolina School of Medicine- Greenville, Greenville, SC, USA; Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Joseph A Ewing
- Department of Surgery, University of South Carolina School of Medicine- Greenville, Greenville, SC, USA
| | - Alexander A Parikh
- Department of Surgery, University of South Carolina School of Medicine- Greenville, Greenville, SC, USA; Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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Population pharmacokinetics of vactosertib, a new TGF-β receptor type Ι inhibitor, in patients with advanced solid tumors. Cancer Chemother Pharmacol 2019; 85:173-183. [DOI: 10.1007/s00280-019-03979-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/17/2019] [Indexed: 12/18/2022]
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Shintakuya R, Sasaki M, Nakamitsu A, Kohyama M, Tazaki T, Sugiyama Y, Hirano T, Kaiki Y. Sarcopenia is an independent predictor of delayed gastric emptying following pancreaticoduodenectomy: a retrospective study. ANZ J Surg 2019; 89:E433-E437. [DOI: 10.1111/ans.15379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Ryuta Shintakuya
- Department of SurgeryJA Hiroshima General Hospital Hatsukaichi Hiroshima Japan
| | - Masaru Sasaki
- Department of SurgeryJA Hiroshima General Hospital Hatsukaichi Hiroshima Japan
| | - Atsushi Nakamitsu
- Department of SurgeryJA Hiroshima General Hospital Hatsukaichi Hiroshima Japan
| | - Mohei Kohyama
- Department of SurgeryJA Hiroshima General Hospital Hatsukaichi Hiroshima Japan
| | - Tatsuya Tazaki
- Department of SurgeryJA Hiroshima General Hospital Hatsukaichi Hiroshima Japan
| | - Yoichi Sugiyama
- Department of SurgeryJA Hiroshima General Hospital Hatsukaichi Hiroshima Japan
| | - Toshinori Hirano
- Department of SurgeryJA Hiroshima General Hospital Hatsukaichi Hiroshima Japan
| | - Yuki Kaiki
- Department of SurgeryJA Hiroshima General Hospital Hatsukaichi Hiroshima Japan
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Long-term Quality of Life and Gastrointestinal Functional Outcomes After Pancreaticoduodenectomy. Ann Surg 2019; 268:657-664. [PMID: 30199443 DOI: 10.1097/sla.0000000000002962] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To perform a comprehensive assessment of long-term quality of life (QOL) and gastrointestinal (GI) function in patients following pancreaticoduodenectomy (PD). SUMMARY OF BACKGROUND DATA Survival after PD has greatly improved and thus has resulted in a larger population of survivors, yet long-term QOL and GI function after PD is largely unknown. METHODS Patients were identified from a global online support group. QOL was measured using the Short Form-36, while GI function was assessed using the Gastrointestinal Symptom Rating Scale. QOL and GI function were analyzed across subgroups based on time after PD. QOL was compared with preoperative measurements and with established values of a general healthy population (GHP). Multivariate linear regression was used to identify predictors of QOL. RESULTS Of the 7605 members of the online support group, 1102 responded to the questionnaire with 927 responders meeting inclusion criteria. Seven hundred seventeen (77.3%) of these responders underwent PD for malignancy. Mean age was 57 ± 12 years and 327 (35%) were male. At the time of survey, patients were 2.0 (0.7, 4.3) years out from surgery, with a maximum 30.7-year response following PD. Emotional and physical domains of QOL improved with time and surpassed preoperative levels between 6 months and 1 year after PD (both P < 0.001). Each GI symptom worsened over time (all P < 0.001). Independent predictors of general QOL in long-term survivors (> 5 years) included total GSRS score [β = -1.70 (-1.91, -1.50)], female sex [β = 3.58 (0.67, 6.46)], and being a cancer survivor [β = 3.93 (0.60, 7.25)]. CONCLUSIONS Long-term QOL following PD improves over time, however never approaches that of a GHP. GI dysfunction persists in long-term survivors and is an independent predictor of poor QOL. Long-term physical, psychosocial, and GI functional support after PD is encouraged.
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Lu JW, Ding HF, Wu XN, Liu XM, Wang B, Wu Z, Lv Y, Zhang XF. Intra-abdominal hemorrhage following 739 consecutive pancreaticoduodenectomy: Risk factors and treatments. J Gastroenterol Hepatol 2019; 34:1100-1107. [PMID: 30511762 DOI: 10.1111/jgh.14560] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/29/2018] [Accepted: 11/23/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Post-pancreaticoduodenectomy hemorrhage (PPH) is a potentially lethal complication. The objective of this study was to explore the risk factors of PPH and to evaluate the treatment options. METHODS Clinical data of 739 consecutive patients undergoing pancreaticoduodenectomy between 2009 and 2017 were collected from a prospectively maintained database. Univariate and multivariate analysis was performed by logistic regression model to evaluate potential risk factors associated with early and late PPH. RESULTS The morbidity of PPH was 8.7% (64/739), while the mortality was 12.5% (8/64). Twenty-two (34.4%) patients developed PPH within postoperative day 1 (early PPH) whereas 42 (65.6%) patients after postoperative day 1 (late PPH). No significant risk factor was identified associated with early PPH, whereas pancreatic duct diameter < 0.4 cm, and intra-abdominal complications, such as pancreatic fistula, intra-abdominal abscess, and delayed gastric emptying, were independently correlated with late PPH. There were 10 (15.6%) grade A, 28 (43.8%) grade B, and 26 (40.6%) grade C bleedings. The bleeding sites were verified by endoscopy, angiography, and/or exploratory laparotomy in 23 of 54 (42.6%) patients with grade B or C hemorrhage. Seven out of nine (78%) patients with arterial bleeding were cured by angiography and embolization, while 10 of 11 (90.9%) patients with anastomotic, venous, or retroperitoneum bleeding were rescued by laparotomy. Ten patients with grade A and 22 patients with grade B or C hemorrhage were treated successfully by blood transfusion and hemostatic medications. CONCLUSIONS Hemorrhage following pancreaticoduodenectomy is a common and lethal complication. Treatment strategies should be tailored according to different etiologies.
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Affiliation(s)
- Jian-Wen Lu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hong-Fan Ding
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xiao-Ning Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xue-Min Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Bo Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Predictors and outcomes of jejunostomy tube placement at the time of pancreatoduodenectomy. Surgery 2019; 165:1136-1143. [DOI: 10.1016/j.surg.2019.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/06/2019] [Accepted: 03/03/2019] [Indexed: 12/18/2022]
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Ellis RJ, Gupta AR, Hewitt DB, Merkow RP, Cohen ME, Ko CY, Bilimoria KY, Bentrem DJ, Yang AD. Risk factors for post-pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra-abdominal infection. J Surg Oncol 2019; 119:925-931. [PMID: 30737792 PMCID: PMC7747058 DOI: 10.1002/jso.25398] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/08/2019] [Accepted: 01/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), but the rate of DGE in the absence of other intra-abdominal complications is poorly understood. The objectives of this study were to define the incidence of DGE and identify risk factors for DGE in patients without pancreatic fistula or other intra-abdominal infections. METHODS Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy variables to identify patients with DGE following PD without evidence of fistula or intra-abdominal infection. Multivariable models were developed to assess preoperative, intraoperative, and technical factors associated with DGE. RESULTS The rate of DGE was 11.7% in 10502 cases without pancreatic fistula or intra-abdominal infection. Patients were more likely to develop DGE if age ≥75 (odds ratio [OR], 1.22; P = 0.003), male (OR, 1.29; P < 0.001), underwent pylorus-sparing PD (OR, 1.27; P = 0.004), or had a prolonged operative time (OR, 1.38 if greater than seven vs less than 5 hours; P = 0.005). Factors not associated with DGE included BMI, pathologic indication, and surgical approach. CONCLUSION The incidence of DGE after PD is notable even in patients without other abdominal complications. Identification of patients at increased risk for DGE may aid patient counseling as well as decisions regarding surgical technique, enteral feeding access, and enhanced-recovery pathways.
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Affiliation(s)
- Ryan J. Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Aakash R. Gupta
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - D. Brock Hewitt
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan P. Merkow
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Mark E. Cohen
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Clifford Y. Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Karl Y. Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - David J. Bentrem
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Anthony D. Yang
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
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Yücesoy AN. A modified single jejunal loop reconstruction by performing proximal gastrojejunostomy after Whipple's pancreticoduodenectomy in a low-volume hospital. Ann Hepatobiliary Pancreat Surg 2019; 23:65-68. [PMID: 30863810 PMCID: PMC6405367 DOI: 10.14701/ahbps.2019.23.1.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/28/2018] [Accepted: 10/04/2018] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims It is needed to ensure bowel and biliary tract continuity after pancreaticoduodenectomies. It is possible to find a variety of reconstruction methods in literature. Methods We realized a modified reconstruction method by performing proximal gastrojejunostomy, on a jejunal loop after Whipple's pancreticoduodenectomy, with surgical succes in 7 patients with pancreatic head or periampullary carcinomas in a low-volume hospital 2009–2017. Results A modified jejunal loop reconstruction method, was performed in 7 patients after Whipple's pancreaticoduodenectomy. We had no perioperative mortality. Pancreatic fistula treated with medical attempts was observed following post-operative pancreatitis in a patient. No marginal ulceration was observed. Delayed gastric emptying was not observed, except for post-operative acute pancreatitis and pancreatic fistula developing in a patient. Conclusions A modified reconstruction method by performing proximal gastrojejunostomy on a jejunal loop, can be considered as alternative reconstructive surgical procedure after pancreaticoduodenectomy.
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Affiliation(s)
- Ali Naki Yücesoy
- General Surgery Department, Batı Bahat Hospital, Istanbul, Turkey
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Kakaei F, Fakhri MA, Azizi A, Asvadi Kermani T, Tarvirdizade K, Sanei B. Effects of antecolic versus retrocolic duodenojejunostomy on delayed gastric emptying after pyloric preserving pancreaticoduodenectomy in patients with periampullary tumors. Asian J Surg 2019; 42:963-968. [PMID: 30792049 DOI: 10.1016/j.asjsur.2019.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/15/2019] [Accepted: 01/18/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/OBJECTIVE Delayed gastric emptying (DGE) is one of the most frequent complications after pyloric preserving pancreaticoduodenectomy (PPPD). The aim of this study is to evaluate the effect of antecolic versus retrocolic reconstruction of gastroentric anastomosis on DGE after PPPD. METHODS 30 patients with diagnosis of operable periampullary malignancies who candidate for PPPD, randomized in two equal groups. Gastroentric reconstruction were done in two methods: antecolic and retrocolic. All data were collected by the same person who was completely blinded to the type of the procedure. Duration of the surgery, volume of bleeding and total volume of intraoperative blood product transfusion, time to nasogastric tube (NGT) removal, time to solid fluid toleration, volume of NGT secretions, need for NGT reinsertion, daily nausea after NGT extraction, fistula or leakage, gastric leakage, biliary leakage, postoperative abdominal or gastrointestinal bleeding requiring another operation, wound infection, intra-abdominal abscess, and any other systemic complications were measured and then analysed with SPSS software. RESULTS According to the results, there was no significant differences between antecolic and retrocolic groups in terms of DGE (p = 0.75). Also, there were no significant differences between two groups in terms of duration of operation, volume of bleeding, blood product requirement, volume of NGT secretions, time to NGT removal, number of NGT re-insertion, time to tolerate solid foods, number of days of vomiting after NGT removal, total hospital stay. CONCLUSION The route of gastroentric (antecolic and retrocolic) reconstruction has no impact on DGE after PPPD.
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Affiliation(s)
- Farzad Kakaei
- Department of General and Vascular Surgery, Tabriz University of Medical Science, Tabriz, Iran.
| | | | - Arsalan Azizi
- Department of General and Vascular Surgery, Tabriz University of Medical Science, Tabriz, Iran.
| | - Touraj Asvadi Kermani
- Department of General and Vascular Surgery, Tabriz University of Medical Science, Tabriz, Iran.
| | | | - Behnam Sanei
- Department of Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
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Sulzer JK, Sastry AV, Meyer LM, Cochran A, Buhrman WC, Baker EH, Martinie JB, Iannitti DA, Vrochides D. The impact of intraoperative goal-directed fluid therapy on complications after pancreaticoduodenectomy. Ann Med Surg (Lond) 2018; 36:23-28. [PMID: 30370053 PMCID: PMC6199772 DOI: 10.1016/j.amsu.2018.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Optimal fluid balance is critical to minimize anastomotic edema in patients undergoing pancreaticoduodenectomy. We examined the effects of decreased fluid administration on rates of postoperative pancreatic leak and delayed gastric emptying. METHODS Retrospective study of 105 patients undergoing pancreaticoduodenectomy at a single institution from January 2015 through July 2016. Stroke volume variation (SVV) was tracked and titrated during the procedure. A comparative analysis of postoperative complications was performed between patients with a median SVV < 12 during the extirpative and reconstructive phases of the procedure compared with patients with an SVV ≥ 12. RESULTS Of 64 patients who met selection criteria, 42 (65.6%) had a SVV < 12 and 22 (34.4%) had a SVV ≥ 12. Patients with an SVV ≥ 12 during the extirpative phase of the procedure had lower rates of postoperative pancreatic leaks compared to patients with an SVV < 12 (5.9% vs 21.3%)). Patients with an SVV ≥ 12 during the extirpative phase had lower rates of postoperative delayed gastric emptying compared to patients with an SVV < 12 (41.2% vs 46.8%). CONCLUSION Goal-directed fluid restriction before the reconstructive phase of pancreaticoduodenectomy may contribute to lower postoperative rates of pancreatic leak and delayed gastric emptying.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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50
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Gagnière J, Le Roy B, Veziant J, Pereira B, Narayan RR, Pezet D, Buc E, Dupré A. Pancreaticoduodenectomy with right gastric vessels preservation: impact on intraoperative and postoperative outcomes. ANZ J Surg 2018; 89:E147-E152. [PMID: 30497109 DOI: 10.1111/ans.14956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/27/2018] [Accepted: 10/07/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Sympathetic denervation of the antropyloric area combined with relative devascularization from division of the right gastric vessels (RGV) during pancreaticoduodenectomy (PD) could predispose to delayed gastric emptying (DGE). Therefore, some authors advocated for RGV preservation (RGVP), where feasibility and utility for the prevention of post-operative DGE have never been investigated. METHODS From 2011 to 2014, patients who underwent classic Whipple PD (CWPD, n = 34), standard pylorus-preserving PD (PPPD, n = 44) or PPPD with RGVP (n = 22) were retrospectively analysed. RESULTS RGVP was not possible in 12% of the cases because of an intraoperative injury of the RGV. There was no difference between CWPD, standard PPPD and PPPD with RGVP in terms of intraoperative blood loss, operative time, number of lymph node harvested and resection margins. Post-operative morbidity and mortality were comparable between the three groups, including rate (27%, 34% and 32%, P = 0.77) and severity of DGE, delay in removing nasogastric tube and use of prokinetics. Hospital stay was similar in all the compared groups. CONCLUSION This is the first study comparing post-operative outcomes after PPPD with RGVP, standard PPPD and CWPD. Although feasible and safe, RGVP during PPPD appeared to offer no obvious clinical benefit in terms of preventing post-operative complications, especially DGE.
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Affiliation(s)
- Johan Gagnière
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.,U1071 Inserm/Clermont Auvergne University, Clermont-Ferrand, France
| | - Bertrand Le Roy
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Julie Veziant
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics, Délégation à la Recherche Clinique et à l'Innovation, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Raja R Narayan
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Denis Pezet
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France.,U1071 Inserm/Clermont Auvergne University, Clermont-Ferrand, France
| | - Emmanuel Buc
- Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélien Dupré
- Department of Surgery, Léon Bérard Cancer Center, Lyon, France
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