International Study Group Of Pancreatic Surgery Research Articles

Flange Gastroenterostomy Results in Reduction in Delayed Gastric Emptying after Standard Pancreaticoduodenectomy: A Prospective Cohort Study

Delayed gastric emptying (DGE) is a common serious problem after pancreaticoduodenectomy (PD). Flange gastrojejunostomy (FL-GE) is a previously described technique that creates an internal flange in a hand-sewn gastroenterostomy. Results of FL-GE on incidence and severity of DGE after PD are presented. Data were extracted from a prospective database of PD. Standard PD with antrectomy were performed with flange gastroenterostomy (FL-GE) or other techniques (NonFL-GE) at a single institution. The International Study Group of Pancreatic Surgery (ISGPS) definition of DGE was used, and DGE severity was graded based on the ISGPS grading system and the Modified Accordion Grading System (MAGS). There were 215 standard PDs performed. Sixty-eight (32%) were FL-GE and 147 (68%) were NonFL-GE. Delayed gastric emptying rates in FL-GE and NonFL-GE were 9% and 23%, respectively (p= 0.012). Differences in severity of DGE were even more prominent: 29% of DGEs in the NonFL-GE group were ISGPS grade C vs 0% in FL-GE. Also, 35% of DGEs in the NonFL-GE group were MAGS 3 vs 0% in FL-GE. Because of some differences in sex and inflammatory complications between groups, a propensity score analysis was performed, creating 57 matched patients in the FL-GE and NonFL-GE groups. The incidence of DGE remained significantly different in the groups (5% in FL-GE vs 18% in NonFL-GE; p= 0.039). In this cohort study, the flange technique was associated with a marked reduction in theincidence of DGE after PD.

Outcomes after extended pancreatectomy in patients with borderline resectable and locally advanced pancreatic cancer.

In the recent International Study Group of Pancreatic Surgery (ISGPS) consensus on extended pancreatectomy, several issues on perioperative outcome and long-term survival remained unclear. Robust data on outcomes are sparse. The present study aimed to assess the outcome of extended pancreatectomy for borderline resectable and locally advanced pancreatic cancer. A consecutive series of patients with primary pancreatic adenocarcinoma undergoing extended pancreatectomies, as defined by the new ISGPS consensus, were compared with patients who had a standard pancreatectomy. Univariable and multivariable analysis was performed to identify risk factors for perioperative mortality and characteristics associated with survival. Long-term outcome was assessed by means of Kaplan-Meier analysis. The 611 patients who had an extended pancreatectomy had significantly greater surgical morbidity than the 1217 patients who underwent a standard resection (42·7 versus 34·2 per cent respectively), and higher 30-day mortality (4·3 versus 1·8 per cent) and in-hospital mortality (7·5 versus 3·6 per cent) rates. Operating time of 300 min or more, extended total pancreatectomy, and ASA fitness grade of III or IV were associated with increased in-hospital mortality in multivariable analysis, whereas resections involving the colon, portal vein or arteries were not. Median survival and 5-year overall survival rate were reduced in patients having extended pancreatectomy compared with those undergoing a standard resection (16·1 versus 23·6 months, and 11·3 versus 20·6 per cent, respectively). Older age, G3/4 tumours, two or more positive lymph nodes, macroscopic positive resection margins, duration of surgery of 420 min or above, and blood loss of 1000 ml or more were independently associated with decreased overall survival. Extended resections are associated with increased perioperative morbidity and mortality, particularly when extended total pancreatectomy is performed. Favourable long-term outcome is achieved in some patients.

Borderline resectable pancreatic cancer

This study evaluated 30-day morbidity and mortality and assessed pancreas-specific complications in patients with major pancreatic injuries who underwent a distal pancreatectomy.Records of 107 consecutive patients who underwent a distal pancreatectomy at a Level 1 Trauma Centre in Cape Town between January 1982 and December 2011 were reviewed. Primary endpoints were postoperative morbidity and death. Complications were graded according to the Clavien–Dindo severity classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions.A total of 107 patients [94 men, median age 26, median RTS 7.8, 69 penetrating injuries (63 gunshot wounds, 6 stabs wounds), 38 blunt injuries] underwent distal pancreatectomy. Overall mortality was 12%, 16% for gunshot injuries, 8% for blunt trauma and 0% in patients who had stab wounds. Eighty patients had a post-operative complication. A pancreatic leak (n = 26) was the most common pancreatic related complication. Median postoperative stay in 28 patients with no or grade I complications was 9 days; in 11 patients with grade II complications was 18 days; in 14 grade IIIa, 31 days; in 19 grade IIIb, 38 days; in 8 grade IVa, 33 days in 14 grade IVb, and in 13 grade V the duration of postoperative stay was 14 ± 39.4 days.Overall mortality for distal pancreatectomy was 12%. Pancreatic leak was a common cause of morbidity. Length of hospitalisation increased with increasing Clavien–Dindo severity grading. There was a significant difference in the duration of hospitalisation in patients with no or grade I complications compared to those with grade II–IV injuries (p < 0.05).

Delayed Gastric Emptying after Pancreatic Surgery: Analysis of Factors Determinant for the Short-term Outcome.

Delayed gastric emptying (DGE) frequently complicates pancreatoduodenectomy (PD). Mainly DGE develops as consequence of postoperative intra-abdominal complications (secondary), while the incidence of primary DGE (i.e., not related to surgical complications) has rarely been studied. Moreover, the pathogenesis of DGE is complex and needs to be further elucidated. The present study aimed at highlighting potential mechanisms behind primary and above all secondary DGE by studying a variety of different pancreatic surgical procedures. During the time period 2008-2011, 327 patients underwent pancreatic resective procedures at Karolinska University Hospital. Of these, 242 were PD and 56 tail resections, 17 had a duodenal preserving pancreatectomy for chronic pancreatitis, and 15 patients with familial duodenal polyposis had a pancreas preserving duodenectomy. All postoperative courses were assessed and scored according to Clavien-Dindo. The presence of DGE was evaluated and recorded according to the definition launched by the International Study Group for Pancreatic Surgery (ISGPS). Crude associations were studied in a univariate model, followed by a multivariate analysis of the respective factors. The associations were presented as odds ratios (ORs) with 95% confidence intervals (CIs). In total DGE emerged during the postoperative course in about 40% of the PD cases. About half of those (n = 47) were scored as being primary. The majority of the primary DGEs were classified as A (n = 26) and only four as grade C, whereas among the secondary cases significantly more patients were scored as grade C (p < 0.01). In those submitted to a pancreatic body and tail resection 25% reported DGE. The distribution of the different grades of DGE in patients with a tail resection followed the same pattern with a predominance of Grade A cases with an equal distribution between those being scored as primary and secondary. Duodenal preservation, as well as keeping the pancreas intact following duodenectomy, was not followed by primary DGE. Multivariate risk factor analyses for the development of primary GE revealed no specific risk profile except for high age. DGE is frequently seen after different surgical procedures directed toward the pancreatic gland. DGE is most commonly seen after PD, and half of these cases are scored as primary DGE. Primary and secondary DGE are seen in one-quarter of the cases even after pancreatic tail resection emphasizing the complex nature of the pathogenesis. Resection of the duodenum as an important mechanism behind DGE is not supported by the present results.

Hemorrhage after major pancreatic resection: incidence, risk factors, management, and outcome

Introduction: Hemorrhage is a rare, but dreaded complication after pancreatic surgery. The aim of this study was to examine the incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage (PPH) in a tertiary care center. Methods: A total of 414 patients underwent major pancreatic resections at our institution. PPH was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. Results: Some 47 patients (11.4%) developed PPH. Operative duration and postoperative pancreatic fistula (POPF) Grades B and C were significantly associated with severe PPH on multivariable logistic regression. Most patients with PPH Grade C (14 of 15 patients; 93.3%) presented with late hemorrhage (>24 hours). Nine patients (60%) had sentinel bleeds. Angiographic coiling/stenting was performed in 7 patients. Relaparotomy was undertaken in 6 patients. The mortality rate among patients with PPH Grade C was 2/15 (13.3%), and both fatalities occurred late as a consequence of eroded vessels in association with the pancreaticogastrostomy. Conclusion: Severe hemorrhagic complications after major pancreatic surgery usually occur late in the postoperative course. Sentinel bleed is an early warning sign. POPF is the most important risk factor for severe PPH and future strategies to reduce the incidence of POPF might also affect the incidence of bleeding episodes.

Safety of extended pancreatectomy compared to standard pancreatic resection based on International Study Group for Pancreatic Surgery (ISGPS) definitions

Safety of extended pancreatectomy compared to standard pancreatic resection based on International Study Group for Pancreatic Surgery (ISGPS) definitions

Borderline resectable pancreatic cancer

Surgery followed by adjuvant chemotherapy remains the only treatment option for pancreatic ductal adenocarcinoma (PDAC) with the chance of long-term survival. If a radical tumor resection is possible, 5-year survival rates of 20–25% can be achieved. Pancreatic surgery has significantly changed during the past years and resection approaches have been extended beyond standard procedures, including vascular and multivisceral resections. Consequently, borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC), which has recently been defined by the International Study Group for Pancreatic Surgery (ISGPS), has become a controversial issue with regard to its management in terms of upfront resection vs. neoadjuvant treatment and sequential resection. Preoperative diagnostic accuracy to define resectability of PDAC is a keypoint in this context as well as the surgical and interdisciplinary expertise to perform advanced pancreatic surgery and manage complications.The present mini-review summarizes the current state of definition, management and outcome of BR-PDAC. Furthermore, the topic of ongoing and future studies on neoadjuvant treatment which is closely related to borderline resectability in PDAC is discussed.

Can round ligament of the liver patch decrease the rate and the grade of postoperative pancreatic fistula?

The most serious complication after pancreatic surgical procedures is still a postoperative pancreatic fistula. In clinical practice there are various methods to prevent the formation of pancreatic fistula, but none of them is fully efficient. Recently, the role of grafting the round ligament of the liver on the pancreas is emphasized as a promising procedure which reduces the severity and shortens the healing time of postoperative pancreatic fistula. The aim of the study was to assess the impact of grafting a round ligament patch on the pancreatic stump or the area of the pancreatic anastomosis on the severity and healing of pancreatic fistula after surgical treatment of the pancreas (alternatively on prevention of pancreatic fistula formation). The retrospective study covered patients operated due to pancreatic tumors in the Department of General, Gastrointestinal and Oncologic Surgery of the WUM. Pancreatic fistula was diagnosed according to the definition developed by the ISGPS (International Study Group of Pancreatic Surgery). 10 patients with pancreatic tumors of different location were operated. The round ligament was grafted on the pancreatic stump, the area of the pancreatic anastomosis or on the site of the local tumor removal. Pancreatic fistula developed in 9 patients, including grade A pancreatic fistula in 5 patients, grade B fistula in 3 patients, and grade C fistula in 1 patient. Distant complications occurred in one patient. None of the patients required a reoperation and no deaths were reported. The average hospital stay was 22.4 days. The hospital stay of patients with grade A fistula was shorter than in case of patients with grade B and C fistula. Grafting of the round ligament of the liver on the pancreatic stump did not prevent the development pancreatic fistula. Grade A pancreatic fistula developed most often. Grade C fistula developed in 1 patient and was complicated by intraabdominal abscesses and sepsis. Although the patient did not require a repeated surgery, but only a continuation of conservative treatment on an outpatient basis. Patients with grade B fistula required prolonged drainage and in the end were supervised by the surgical polyclinic.

Evolving Techniques in Pancreatic Surgery.

Evolving Techniques in Pancreatic Surgery.

Isolated pancreatic injuries: An analysis of 49 consecutive patients treated at a Level 1 Trauma Centre

This study interrogated a large prospectively documented institutional database to determine morbidity and mortality after an isolated pancreatic injury (IPI). Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. The degree of the pancreatic duct injury was graded using a modified Takishima duct injury classification. Primary endpoints were general and pancreas-specific morbidity and mortality. Four hundred and forty-eight consecutive patients were treated between 1990 and 2014 for pancreatic injuries of whom 49 (median age: 30, range: 13-68 years, 41 men, blunt injuries: n=43) had an IPI. Thirty-four (70%) patients underwent urgent surgery, 20 of whom had a distal pancreatectomy and 14 had external drainage of the pancreatic injury. Fifteen (30%) patients presented with a non-resolving pancreatic pseudocyst or fistula; five had grade 4A or 4B ductal injuries and underwent surgery, 10 with 3A and 3B ductal injuries were successfully managed endoscopically. Fifty-five percent had postoperative morbidity. Two patients (4%) died of non-pancreatic-related causes. While overall mortality is low after an IPI, morbidity is high. Two thirds of patients required operative intervention and one third were treated endoscopically. The degree of pancreatic ductal injury determined whether endoscopic intervention was effective.

Postoperative pancreatic fistula: We need to redefine grades B and C

Postoperative pancreatic fistula (POPF) is the most important complication after pancreatic surgery. In 2005, the International Study Group of Pancreatic Surgery (ISGPS) introduced a standardized POPF definition with severity grading from A to C. In recent years, interventional drainage (ID) has become the standard of care for symptomatic postoperative fluid collections or undrained POPF. From the original definition, it is unclear whether ID is categorized as POPF grade B or C. Therefore, international authors shift ID between grades B and C. The aim of the study was to analyze patients with ID (proposed new grade B) versus patients who underwent reoperation (grade C) for POPF. Between 2005 and 2013, all patients undergoing pancreatic resection were analyzed regarding POPF grade A-C. Demographic data, type of operation, postoperative complications, therapies and outcome were examined with focus on ID versus reoperation. Of the 2,955 patients included, 403 developed POPF (13.6%). Among all POPF, 11% were grade A, 17% grade B (clinically symptomatic without ID), and 72% grade C. These patients underwent either ID (n = 165) or reoperation (n = 123). Patients with ID had an average hospital stay of 33 days and POPF-associated mortality of 0%. This was strikingly different from patients undergoing reoperation with a hospital stay of 47 days and POPF-associated mortality of 37% (P < .0001). After 10 years of the ISGPS classification, there is a clear-cut outcome difference between patients undergoing POPF-associated ID or reoperation. We propose assigning all patients undergoing ID as POPF grade B. Patients undergoing reoperation should definitely remain within category C.

Evolution in the Treatment of Delayed Postpancreatectomy Hemorrhage: Surgery to Interventional Radiology.

We summarized a single center's evolution in the management of postpancreatectomy hemorrhage (PPH) from surgical toward endovascular management. Between 2003 and 2013, 337 patients underwent Whipple procedures. Using the International Study Group of Pancreatic Surgery (ISGPS) consensus definition, patients with PPH were identified and retrospectively analyzed for the presentation of hemorrhage, type of intervention, and 90-day mortality outcome measures. Management evolved from operative intervention alone, to combined operative and on-table angiographic intervention, to endovascular intervention alone. The prevalence of PPH was 3.0%. Delayed PPH occurred with a mean of 13.8 days. On angiography, visceral arteries affected were the gastroduodenal artery, hepatic artery, jejunal branches of the superior mesenteric artery, pancreaticoduodenal artery, and inferior phrenic artery. Ninety-day mortality for PPH was 20%. From early to recent experience, the mortality rate was 100% for operative intervention alone, 25% for combined operative and on-table angiographic intervention, and 0% for endovascular intervention alone. Our 10-year experience supports current algorithms in the management of PPH. Key considerations include the recognition of the sentinel bleed, the presence of a pancreatic fistula, and the initial operative role of a long gastroduodenal artery stump with radiopaque marker for safe and effective embolization should PPH occur.

Delayed Gastric Emptying After Pancreaticoduodenectomy: an Analysis of Risk Factors and Cost

IntroductionDelayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD), yet it remains incompletely understood. The International Study Group of Pancreatic Surgery (ISGPS) in 2007 defined a three-tiered grading system to standardize studies of DGE. MethodsIn this study, 721 patients undergoing PD between 2006 and 2012 were retrospectively categorized by the ISGPS DGE criteria, as well as a modified grading system (termed primary DGE) if, on retrospective review, DGE was not believed to be a sequela of a separate complication. Predictive factors and associated outcomes were determined. ResultsISGPS-defined DGE occurred in 140 (19.4 %) patients. In a multivariate analysis, predictors of ISGPS-defined DGE included abdominal infection (odds ratio (OR) 5.5, p < 0.001), male gender (OR 1.92, p = 0.007), smoking history (OR 1.75 p = 0.033), and periampullary adenocarcinoma (OR 1.66, p = 0.041). Primary DGE occurred in 12.2 % of patients. Predictors included abdominal infection (OR 3.15, p < 0.001) and smoking history (OR 2.04, p = 0.008). Median hospital charges increased over $10,000 with each severity grade of DGE (p < 0.001). ConclusionDGE is common after PD and contributes substantially to cost. DGE is frequently a secondary complication of abdominal infection, and interventions that limit such complications may be the most effective strategy toward preventing DGE.

Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy

BackgroundOne of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5–20 %. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal end-to-side anastomosis in SSPPD. MethodsBetween October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007–March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010–September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively. ResultsThe incidence of DGE was 21.3 % in the SSPPD-ETS group and 2.5 % in the SSPPD-STS group (P = 0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different. ConclusionsThe greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD.

Delayed Gastric Emptying (DGE) Following Total Pancreatectomy with Islet Auto Transplantation in Patients with Chronic Pancreatitis

BackgroundThe prevalence and factors associated with delayed gastric emptying (DGE) in patients undergoing total pancreatectomy with islet auto transplantation (TP-IAT) for chronic pancreatitis are unknown. MethodsA retrospective study of all patients who underwent TP-IAT at Johns Hopkins Hospital (JHH) from August 2011 to November 2014 was performed. The International Study Group of Pancreatic Surgery (ISGPS) clinical grading of DGE was used in this study. Key ResultsA total of 39 patients with chronic pancreatitis underwent TP-IAT during the study period. The prevalence of DGE following TP-IAT was 35.9 %. Twenty-five patients (64.1 %) had no DGE, 10 (25.6 %) had grade A, 2 (5.1 %) had grade B, and 2 patients (5.1 %) had grade C DGE. Patients with DGE had 5.7-fold higher odds of having a hospital length of stay (LOS) greater than 14 days (OR 5.70, 95 % CI 1.37–23.76, p = 0.02). Patients undergoing laparoscopic TP-IAT had significantly shorter LOS (10.5 vs. 14 days, p = 0.02) and lower need for prokinetics (0.01) during the postoperative course. Conclusions and InferencesDGE is common after TP-IAT and can prolong LOS. Laparoscopic TP-IAT lowers LOS and need for prokinetics postoperatively. Further studies are needed to determine if laparoscopic approaches will improve long-term dysmotility.

Management of postoperative pancreatic fistula

The occurrence of a postoperative pancreatic fistula is one of the most important complications following pancreatic resections. The frequency of this complication varies between 3 % after pancreatic head resection and up to 35 % following distal pancreatectomy. In 2005, the international definition of postoperative pancreatic fistula was standardized according to the approach of the International Study Group of Pancreatic Surgery (ISGPS) including an A-C grading system of the severity. Consequently, results from different studies have become comparable and the historically reported fistula rates can be evaluated more critically. The present review summarises the currently available data on incidence, risk factors, fistula-associated complications and management of postoperative pancreatic fistula.

Primary versus secondary delayed gastric emptying (DGE) grades B and C of the International Study Group of Pancreatic Surgery after pancreatoduodenectomy: a retrospective analysis on a group of 132 patients.

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PDD) significantly contributing to post-operative morbidity. Clinical risk factors for DGE occurrence after PDD remain controversial. From January 2004 to December 2011, a total of 132 patients underwent PDD for either malignancies (73.5%) or benign diseases (26.5%) in one single universitary center. Post-operative mortality and morbidity were, respectively, 3 and 44.7%. DGE has been defined in accordance with the International Study Group of Pancreatic Surgery (ISGPS) classification. DGE was distinguished in primary or secondary. Factors associated with grades B and C of DGE, based on severity and clinical impact, were assessed by means of univariate and multivariate analysis. Thirty-eight patients (28.8%) had clinical DGE grade B or C. Post-operative complications (pancreatic fistula and/or hemorrhage or anastomotic leak) were reported in 25 out of the 38 patients (65.8%, secondary DGE), while in 13 patients it was not associated to any other complication (34.2%, primary DGE). Post-operative complications (pancreatic fistula and hemorrhage) appeared to be the most important predictive factor for Grade B or C DGE.

Borderline resectable pancreatic cancer.

Borderline resectable pancreatic cancer (BRPC) is an evolving diagnostic entity that blurs the distinction between resectable and locally advanced pancreatic cancer (Varadhachary et al. Ann Surg Oncol 13:1035-1046, 2006). Until recently the management of this disease has been poorly defined; however, consensus guidelines have been developed regarding the proper management of this diagnostic entity. Recent studies have shown that if appropriately identified and treated, this subset of disease can have outcomes similar to pancreatic cancer that is defined as resectable (Laurence et al. J Gastrointest Surg 15:2059-2069, 2011). The aim of this review is to outline the current consensus on definitions, workup and management of BRPC, and also provide a summary of issues that require progress as defined by the International Study Group of Pancreatic Surgery (ISGPS).

Pancreatic fistulae after pancreatic resections for neuroendocrine tumours compared with resections for other lesions

BackgroundResection for pancreatic neuroendocrine tumours (PNET) is suggested to be associated with an increased risk of a post-operative pancreatic fistula (POPF). The aim of this study was to describe morbidity after resections for PNET, focusing on POPF. Outcomes were compared with resections for other lesions. MethodsPatients undergoing an elective pancreatic resection during a 12-year period were retrospectively analysed. Morbidity was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definitions. ResultsEighty-eight out of 832 patients (10.6%) underwent a resection for PNET. Atypical pancreatic resections (enucleation and central pancreatectomy) and distal pancreatectomies were more frequently performed for PNET. The POPF rate was 22.7% in patients operated for PNET compared with 17.2% in other patients (P = 0.200). In univariate analysis, body mass index (BMI), pancreatic duct diameter, somatostatin analogue administration, type of resection and type of pathology were associated with a POPF. In multivariate analysis, BMI, a pancreatic duct diameter <3 mm and central pancreatectomy remained independent risk factors [odds ratio (OR) 1.93, 95% confidence interval (CI) 1.22–3.07 and OR 3.04, 95% CI 1.05–8.82, respectively]. ConclusionsHigh rates of POPF were found in patients operated for PNET. However, this was mainly owing to the fact that atypical resections, known to be associated with a higher fistula rate, were performed more frequently in these patients.

Proposal and Critical Appraisal of Exclusion Criteria to the International Study Group for Pancreatic Surgery Definition of Delayed Gastric Emptying

The International Study Group for Pancreatic Surgery (ISGPS) defined criteria to objectively standardize delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD). These criteria are inclusive by design, and may overestimate actual DGE incidence. This study critically examined individual DGE cases after PD to determine which patients are misclassified by these criteria, and for what reasons. Exclusion criteria designed to optimize the accepted DGE definition are proposed and evaluated. We performed a retrospective review of prospectively collected data. We reviewed 357 consecutive patients undergoing PD by a single surgeon; included were 52 cases of ISGPS-defined DGE (14.6%). A detailed evaluation was conducted of cases using accepted and novel diagnostic criteria. Of 52 ISGPS-defined DGE cases, 12 (23%) appeared not to represent genuine DGE on clinical review. Six required nasogastric tube placement for reoperation or management of emesis secondary to non-DGE conditions, 4 for reintubation without other evidence of DGE, and 2 remained NPO to treat non-DGE conditions. The proposed exclusion criteria use absence of gastric distention, passage of oral contrast, and presence of documented non-DGE conditions to determine genuine DGE. The incidence of true DGE was 11.2% in this cohort. The overall positive predictive value of the ISGPS criteria was 76.9%. Preoperative variables, DGE class, and incidence of disease-specific outcomes were similar with both definitions. The ISGPS consensus guidelines promote a standardized, sensitive, and easily applicable definition of DGE, but may falsely classify DGE in approximately 23.1%. Introduction of the proposed exclusion criteria, which establish objective radiologic data as a component of the definition, could substantially limit this overestimation.