Pylorus-Preservation Pancreatoduodenectomy Is Associated with Higher Rate of Delayed Gastric Emptying in Patients with Intermediate/High Risk for Pancreatic Fistula

Abstract

INTRODUCTION: The association between delayed gastric emptying (DGE) and pylorus-preserving pancreatoduodenectomy (PPPD) vs classic pancreatoduodenectomy (PD) remains controversial. This study aims to identify preoperative and intraoperative factors associated with DGE based on the well-established pancreatic fistula risk score (FRS). We hypothesized that a stratified approach to surgical technique selection may be beneficial given the association of DGE with postoperative pancreatic fistula (POPF). METHODS: The 2014 to 2019 NSQIP pancreatectomy Participant User Data File (PUF) was queried for patients who underwent PPPD or PD. Multivariable logistic regression assessed perioperative characteristics associated with DGE. Sensitivity analyses stratified patients into negligible/low (FRS ≤2) or intermediate/high (FRS ≥3) cohorts based on their risk for clinically relevant POPF (CR-POPF). RESULTS: DGE was present in 15.5% of the overall cohort (N = 2,197/14,181), in 16.3% (N = 948/5,799) of the PPPD group, and in 14.9% (N = 1,249/8,382) of the classic PD group; 6.4% of patients (N = 903/14,181) were in the negligible/low-risk and 93.6% (N = 13,278) were in the intermediate/high-risk CR-POPF subgroups. In adjusted analysis of the overall cohort, patients who underwent PPPD were more likely to develop DGE (odds ratio [OR] 1.1, p = 0.02). In the negligible/low-risk CR-POPF subgroup, there was no association between DGE and PPPD (OR 1.05, p = 0.82). In the intermediate/high-risk CR-POPF subgroup, PPPD was significantly associated with DGE (OR 1.1, p = 0.04; Table). Table. - Predicting Delayed Gastric Emptying after Pylorus-Preserving vs Classic Pancreaticoduodenectomy, Stratified by Fistula Risk Score Surgical approach, pylorus preserving vs classic pancreatoduodenectomy Risk of clinically relevant- postoperative pancreatic fistula Adjusted odds ratio* 95% CI p Value Overall 1.11 1.01–1.22 0.02 Negligible/low risk 1.05 0.69–1.60 0.82 Intermediate/high risk 1.11 1.01–1.22 0.04 *Adjusted for age, sex, race, ASA class, history of comorbidities (eg smoking, hypertension, diabetes, blood disorder, weight loss, jaundice), preoperative stent placement, preoperative chemotherapy/radiation therapy, drain placement, pancreas gland texture, and duct size. CONCLUSION: Pylorus preservation in PD may have greater odds for developing DGE, driven by an increased association in patients who are at intermediate/high risk for CR-POPF. Use of the FRS for intraoperative decision-making regarding management of the pylorus may help minimize postoperative morbidity.