Risk-adjusted Precision Reconstruction in Gastric Outlet Obstruction: A Prospective Cohort Demonstrating Superior Composite Delayed Gastric Emptying Outcomes with Roux-En-Y Gastrojejunostomy

‘Cross‐section gastroenterostomy’ in patients with irresectable periampullary carcinoma

Delayed gastric emptying (DGE) is the most common complication of robot-assisted pancreatoduodenectomy (RPD). Large differences exist in DGE rate between centers and it remains unclear to what extent these are associated with surgical technique. This study assessed differences in DGE rate after RPD and predictors for DGE, including gastrojejunostomy (GJ) technique. Binational, multicenter retrospective cohort study including patients undergoing RPD from seven centers in the United States of America (USA) and the Netherlands (NL) (2011-2023). Data were retrospectively obtained from prospectively maintained databases. Multivariable analysis determined predictors for DGE, including GJ technique. Primary outcomes were DGE (ISGPS grade B/C), primary DGE (i.e., no other abdominal complications), and secondary DGE. Overall, 1,842 patients undergoing RPD were included (USA 1,342, NL 500). Conversion rate was 5.0%, median hospital stay 8days (6-13), and in-hospital/30-day mortality 1.5%. The rate of DGE grade B/C was 14.8%, primary DGE 5.7% (relative 38.9%), and secondary DGE 9.0% (relative 61.1%). The rates of DGE grade B/C (10.4% vs 26.8%, p < 0.001) and secondary DGE (4.4% vs 21.7%, p < 0.001) were lower in USA compared to NL, whereas the rate of primary DGE was comparable (6.0% vs 5.1%, p = 0.481). Overall, 1,259 (68.6%) GJs were sutured and 576 (31.4%) stapled. Sutured GJ was associated with a higher rate of DGE grade B/C (adjusted risk 18% vs 9%, p < 0.001) and primary DGE (adjusted risk 7% vs 3%, p < 0.001) compared to stapled GJ. This binational multicenter study found that DGE following RPD is mostly secondary to other complications. The association of stapled GJ with lower DGE rates should be confirmed by randomized studies. The most effective strategy to reduce the rate of DGE after RPD would be to prevent the causal underlying complications, particularly POPF.

Comparing conventional and partial partitioning gastrojejunostomy in malignant and benign gastric conditions: a systematic review and meta-analysis

Objective To investigate the risk factors of delayed gastric emptying (DGE) after pancreaticoduodenectomy, in order to provide a theoretical basis for prevention and treatment of this complication. Methods The term DGE was searched in Pubmed, Medline, EMBASE, Cochrane Library, CNKI, Wanfang, and published literatures were collected to determine the risk factors of DGE after pancreaticoduodenectomy. The Review Manager 5.3 software was used in the analysis. Results A total of 52 articles were included. The results of Meta-analysis showed that age and preoperative bilirubin levels did not significantly influence the incidence of DGE. Preoperative cholangitis (OR=3.39, 95%CI 1.97~5.82), hypoalbuminemia (OR=2.53, 95%CI 1.59~4.02), and intraoperative blood loss of more than 1L (OR=1.98, 95%CI 1.18~3.33) significantly increased the incidence of DGE. Pyloric resection (RR=2.06, 95% CI 1.05~4.05), antecolic reconstruction (RR=0.74, 95%CI 0.56~0.99) and Braun enteroenterostomy (OR=0.36, 95%CI 0.17~0.77) significantly decreased the risk of DGE. When compared with Roux-en-Y enteroenterostomy, Billroth Ⅱ enteroenterostomy reduced the incidence of clinically relevant DGE (RR=0.30, 95%CI 0.11~0.79). Postoperative pancreatic fistula (OR=3.84, 95%CI 2.71~5.44) and intra-abdominal infection/abscess (OR=3.95, 95%CI 2.87~5.43) were significantly associated with a high incidence of DGE. Conclusions Hypoalbuminemia, cholangitis, large blood loss, and postoperative abdominal complications were the risk factors of DGE. Pyloric resection, antecolic reconstruction, Billroth Ⅱ enteroenterostomy, and Braun enteroenterostomy significantly reduced the incidence of DGE. Subgroup analysis showed that differences on DGE definition in studies might be an important cause for the heterogeneity in the results of the different studies. Key words: Pancreaticoduodenectomy; Delayed gastric emptying; Meta-analysis

Endoscopic placement of enteral self-expandable metallic stents is an alternative to surgical gastrojejunostomy (GJ) for palliation of malignant gastric outlet obstruction (GOO). Factors associated with clinical outcomes are not known. The aims of this study are to compare the overall complication rate and effectiveness (duration of oral intake) between endoscopic stenting (ES) and GJ in patients with GOO and identify predictors of clinical outcomes. This was a retrospective cohort study at a single tertiary academic center. Patients who underwent ES or GJ for treatment of GOO between 1/2001 and 12/2010 were identified using an institutional claims database. The electronic medical records for each patient were reviewed. Univariate and multivariate logistic regression analyses were performed to study the association of treatment outcomes with patient factors and cancer therapy. 120 patients had ES while 227 had GJ. Technical success was higher for GJ (99 vs. 96 %, p = 0.004). Complication rates were higher in the GJ group (22.10 vs. 11.66 %, p = 0.02). Reintervention was more common with ES [adjusted odds ratio (OR) 9.18, p < 0.0001]. Mean length of hospital stay (LOHS) was shorter (adjusted p = 0.005) in the ES compared with the GJ group. However, mean hospital charges, including reinterventions, were greater in the ES group (US $34,250 vs. US $27,599, p = 0.03). ES and GJ had comparable reintervention-free time in patients who had reintervention (88 vs. 106 days, respectively, p = 0.79). Chemotherapy [adjusted hazard ratio (HR) 3 > 0.57, p = 0.04] and radiation therapy (adjusted HR 0.35, p = 0.03) were associated with significantly longer duration of oral intake after ES or GJ. ES is associated with fewer complications, shorter LOHS, but higher reintervention rates and overall charges.

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. 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. 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 28.7days, respectively. After endoscopic intervention with therapeutic intent to primary DGE patients, we observed that patients tolerated solid meal after 12hours in grade B and after 26hours in grade C patients. 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.

Objective To explore the optimal management strategies for unresectable advanced pancreatic head carcinoma without preoperative gastric outlet obstruction(GOO).Methods Clinical data of 441 cases of advanced pancreatic head carcinoma without GOO undergoing surgery from Jan 2001 to Dec 2010 were analyzed retrospectively.Results Among the 441 cases of advanced pancreatic head carcinoma without GOO,101 patients received simple Roux-en-Y cholecystojejunostomy (group A),133 patients received simple Roux-en-Y choledochojejunostomy (group B),83 patients received Roux-en-Y cholecystojejunostomy combined gastrojejunostomy(group C) and the other 124 patients received Roux-en-Y choledochojejunostomy combined gastrojejunostomy (group D).The postoperative recurrent obstructive jaundice rates were 7.9％ and 6.0％ in group A and C,respectively; the postoperative de novo GOO rates were 8.9％ and 8.3％ in group A and B,respectively; there were no differences in median survivals among the four groups (F =1.933,P =0.123).Conclusions Choledochojejunostomy is effective for the reduction of recurrent obstructive jaundice for advanced pancreatic head carcinoma patients without GOO,combined prophylactic gastrojejunostomy during surgical biliary drainage could decrease the rate of postoperative GO0.Cholecystojejunostomy could be only applied for patients with poor health or when choledochojejunostomy is a taboo. Key words: Pancreatic neoplasms ; Anastomosis, surgical ; Choledochostomy

The main advantage of the Roux-en-Y (RY) operation is that it prevents bile and pancreatic juice from reaching the gastric mucosa, although the gastrojejunostomy may cause functional delayed gastric emptying (DGE), known as RY stasis syndrome. Rho-shaped Roux-en-Y reconstruction (rRY), an RY reconstruction with a rho-shaped anastomosis, is an established operation that has been found to be effective in preventing DGE. We conducted the randomized trial of RY versus rRY reconstruction after gastric cancer resection. The primary endpoint was the frequency of DGE, and secondary endpoints were the length of postoperative hospital stay, morbidity, and nutritional status. Seventy patients were enrolled, with 35 in each group. The incidences of postoperative mortality and morbidity did not differ significantly between the two groups. There were no significant differences in nutritional status between the two groups after discharge. Delayed gastric emptying occurred in two patients (6%) in the RY group and four patients (11%) in the rRY group (P = 0.67). Logistic regression analysis revealed that truncal vagotomy was significantly associated with DGE inhibition. Our findings showed that RY reconstruction after gastrectomy may be as simple and sufficient as conventional reconstruction.

Objective: Percutaneous endoscopic gastrojejunostomy (PEGJ) has become the method of choice to achieve an enteral access route in patients who require long-term enteral nutrition, especially in patients with delayed gastric emptying. Here, we discuss a successful approach for PEGJ used in our hospital. Materials and Methods: Thirteen of 145 percutaneous endoscopic gastrostomy patients (9%) with delayed gastric emptying had indications for PEGJ, which was performed in two steps. Percutaneous endoscopic gastrostomy (PEG) was performed first, and feeding was started through the PEG tube 24 hours later. PEG was converted to PEGJ because of delayed gastric emptying. Under fluoroscopic guidance to confirm the tube position, a stiffened jejunal tube was passed through the PEG tube and pushed downward as deep as possible to the jejunum. Feeding was accomplished by continuous infusion using a feeding pump in all patients. A daily follow-up of the patients was carried out during the hospitalization period. Result Thirteen PEG patients underwent 37 attempts at feeding tube placement. Thirty-three initial procedures were successful and eventually all procedures succeeded in these patients. Therefore, there was a successful rate in initial placement of feeding tubes of 89% (33/37) in these patients. The average time was about 20 minutes for the PEG placement and about 10 minutes for the PEGJ placement. Enteral nutrition with a polymeric diet was initiated the day after the PEGJ placement. All patients obtained good enteral feeding through the PEGJ, and 10 patients achieved the nutrition goal four days later. The average duration of enteral nutrition through the PEGJ was 68 days. Only one patient developed aspiration pneumonia. There were some minor complications including peristomal infection in two patients and gastrojejunostomy tube replacements in two patients. No death resulted from a PEGJ-related complication. Conclusion: PEGJ provides a better choice for a long-term nutritional support, especially in patients with delayed gastric emptying. PEGJ shows good efficacy and safety when combined with good enteral nutrition support, can reduce aspiration pneumonia, and has a low complication rate compared with previously described methods.

Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pylorus ring is resected and most of the stomach is preserved, has been performed recently in Japan. This study was undertaken to clarify the incidence of delayed gastric emptying (DGE) after SSPPD at a high-volume hospital and to determine the independent factors that influence the development of DGE after SSPPD. Between 2002 and 2011, 201 consecutive patients underwent standardized SSPPD. After SSPPD, DGE (defined according to the International Study Group of Pancreatic Surgery) was analyzed, and associated variables were assessed by univariate and multivariate analyses, retrospectively. Clinically significant DGE (grades B and C) occurred in 35 (17 %) of the 201 patients; 26 patients had other accompanying abdominal complications (secondary DGE), and pancreatic leakage was the sole risk factor for DGE (odds ratio 6.63, 95 % CI 2.86-15.74; p < 0.001). Only nine (4 % of all patients) of the 35 patients with clinically significant DGE were classified as having DGE that had arisen without any obvious etiology (primary DGE). DGE after SSPPD is strongly linked to the occurrence of other postoperative intra-abdominal complications such as pancreatic fistula. The incidence rate of primary DGE after SSPPD was 4 %. Although the ISGPS classification of DGE is clearly applicable, the grades do not explain why DGE occurs. Primary and secondary DGE should therefore be defined separately.

Fifty-seven patients with carcinoma of the pancreas underwent gastrojejunostomy (GJ) alone or in conjunction with biliary bypass. The mortality rate for GJ alone was 18%; for the combined biliary and duodenal bypass operation it was 5%. Fifteen patients (26%) had delayed gastric emptying (DGE) postoperatively for periods extending from nine to 31 days (average, 16 days); five patients (33%) died. Eight (57%) of 14 patients with preoperative duodenal obstruction and five (42%) of 12 patients with retrocolic GJ experienced DGE postoperatively. Stomal diameter in the patients with DGE averaged 6.5 cm, and 8.4 cm was the average in those without DGE. We conclude that DGE is a frequent and serious problem after GJ for patients with unresectable pancreatic cancer.

delayed gastric emptying (DGE) is the most common complication after pancreaticoduodenectomy (PD) and it occurs in 50% of cases. the endpoint was to determine if there were any differences in the incidence of DGE between Roux-en-Y gastrojejunostomy (ReY) and Billroth II gastrojejunostomy (BII) in PD with pancreaticogastrostomy (PG). this was a case-control prospective randomized study of all PD cases between 2013 and 2016. Sixty-four patients were included, 32 in each group. An intention-to-treat statistical analysis was performed. no significant differences were found with regard to morbidity and mortality or hospital stay. DGE was present in 25% of the patients in the BII group in comparison to 15.6% in the ReY group, which was not statistically significant (p = 0.35). There was a higher percentage of patients with primary DGE in the BII group, 12.5% versus 6.2%, but this was not statistically significant (p = 0.53). No difference in DGE severity was observed. Male gender (OR 8.38 [1.1; 129]), abdominal complications (OR 15 [1.7; 396.9]), pre-operative malnutrition (OR 99.7 [3.3, 11,126]) and hemorrhage (OR 9.4 [1.37, 107.94]) were the main risk factors for DGE according to the multivariate analysis. there were no significant differences in the incidence or severity of DGE between BII or ReY after PD with PG.

Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). The aim of the present meta-analysis was to evaluate the effect of Billroth-II(B-II) versus Roux-en-Y (R-Y) reconstruction for gastrojejunostomy on DGE after PD. A systematic literature search was performed using the electronic database MEDLINE (via PubMed and OVID), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) of the Cochrane Library to select pertinent randomized controlled trials (RCTs) on this topic from January 1990 to January 2020. The primary outcome was identified as postoperative DGE. Subgroup analysis was established to compare the incidence of grade B and C DGE. Software Revman 5.3 was used for the statistical analysis, summary statistics were calculated using fixed effect model or random effect model. Five RCTs including a total of 612 patients were eligible for this meta-analysis. The incidence of grade B and C DGE was significantly lower with the B-II reconstruction than with the R-Y reconstruction (8.0% vs. 14.8%, OR=0.49, 95% CI: 0.26-0.95, P=0.03) and the B-II reconstruction took a shorter operation time (WMD=-7.18, 95% CI: [-13.09, -1.27], P=0,02). No statistically significant difference was found between the two reconstruction methods in terms of the incidence of postoperative pancreatic fistula (POPF), bile leak, intra-abdominal abscess, postoperative pneumonia and the length of postoperative hospital stay. B-II reconstruction after PD has a lower incidence of grade B and C DGE and shorter operation time compared with R-Y reconstruction.

Delayed gastric emptying after gastric surgery

Impact of carcinomatosis and ascites status on long-term outcomes of palliative treatment for patients with gastric outlet obstruction caused by unresectable gastric cancer: stent placement versus palliative gastrojejunostomy