Postoperative Delayed Gastric Emptying Research Articles

The influence of delayed gastric emptying on quality of life after partial duodenopancreatectomy.

Quality of life (QoL) is temporarily compromised after pancreatic surgery, but no evidence for a negative impact of postoperative complications on QoL has been provided thus far. Delayed gastric emptying (DGE) is one of the most common complications after pancreatic surgery and is associated with a high level of distress. Therefore, the aim of this study was to analyse the influence of DGE on QoL. This single-centre retrospective study analysed QoL after partial duodenopancreatectomy (PD) via the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30). The QoL of patients with and without postoperative DGE was compared. Between 2010 and 2022, 251 patients were included, 85 of whom developed DGE (34%). Within the first postoperative year, compared to patients without DGE, those with DGE had a significantly reduced QoL, by 9.0 points (95% CI: -13.0 to -5.1, p < 0.001). Specifically, physical and psychosocial functioning (p = 0.020) decreased significantly, and patients with DGE suffered significantly more from fatigue (p = 0.010) and appetite loss (p = 0.017) than patients without DGE. After the first postoperative year, there were no significant differences in QoL or symptom scores between patients with DGE and those without DGE. Patients who developed DGE reported a significantly reduced QoL and reduced physical and psychosocial functioning within the first year after partial pancreatoduodenectomy compared to patients without DGE.

Preoperative and postoperative complications as risk factors for delayed gastric emptying following pancreaticoduodenectomy: A single-center retrospective study.

Mortality rates after pancreaticoduodenectomy (PD) have significantly decreased in specialized centers. However, postoperative morbidity, particularly delayed gastric emptying (DGE), remains the most frequent complication following PD. To identify risk factors associated with DGE after the PD procedure. In this retrospective, cross-sectional study, clinical data were collected from 114 patients who underwent PD between January 2015 and June 2018. Demographic factors, pre- and perioperative characteristics, and surgical complications were assessed. Univariate and multivariate analyses were performed to identify risk factors for post-PD DGE. The study included 66 males (57.9%) and 48 females (42.1%), aged 33-83 years (mean: 62.5), with a male-to-female ratio of approximately 1.4:1. There were 63 cases (55.3%) of PD and 51 cases (44.7%) of pylorus-preserving pancreatoduodenectomy. Among the 114 patients who underwent PD, 33 (28.9%) developed postoperative DGE. Univariate analysis revealed significant differences in four of the 14 clinical indexes observed: pylorus preservation, retrocolonic anastomosis, postoperative abdominal complications, and early postoperative albumin (ALB). Logistic regression analysis further identified postoperative abdominal complications [odds ratio (OR) = 4.768, P = 0.002], preoperative systemic diseases (OR = 2.516, P = 0.049), and early postoperative ALB (OR = 1.195, P = 0.003) as significant risk factors. Postoperative severe abdominal complications, preoperative systemic diseases, and early postoperative ALB are identified as risk factors for post-PD DGE.

Efficacy and safety of adhesion barrier in living-donor liver transplantation with right liver graft to prevent delayed gastric emptying.

Delayed gastric emptying (DGE) is a common complication of liver transplantation. This study aimed to clarify the efficacy and safety of the application of an adhesion barrier for preventing DGE in living-donor liver transplantation. This retrospective study included 453 patients who underwent living-donor liver transplantation using a right lobe graft between January 2018 and August 2019, and the incidence of postoperative DGE and complications was compared between patients in whom adhesion barrier was used (n=179 patients) and those in whom adhesion barrier was not used (n=274 patients). We performed 1:1 propensity score matching between the 2 groups, and 179 patients were included in each group. DGE was defined according to the International Study Group for Pancreatic Surgery classification. The use of adhesion barrier was significantly associated with a lower overall incidence of postoperative DGE in liver transplantation (30.7 vs. 17.9%; p =0.002), including grades A (16.8 vs. 9.5%; p =0.03), B (7.3 vs. 3.4%; p =0.08), and C (6.6 vs. 5.5%; p =0.50). After propensity score matching, similar results were observed for the overall incidence of DGE (29.6 vs. 17.9%; p =0.009), including grades A (16.8 vs. 9.5%; p =0.04), B (6.7 vs. 3.4%; p =0.15), and C (6.1 vs. 5.0%; p =0.65). Univariate and multivariate analyses showed a significant correlation between the use of adhesion barrier and a low incidence of DGE. There were no statistically significant differences in postoperative complications between the 2 groups. The application of an adhesion barrier could be a safe and feasible method to reduce the incidence of postoperative DGE in living-donor liver transplantation.

Association between perineural infiltrations and delayed gastric emptying after Whipple procedure for periampullary tumours, and the relationship with other clinicopathological factors and overall survival.

Pancreaticoduodenectomy is a major procedure. Delayed gastric emptying (DGE) is a frequent postoperative complication that is attributed to several factors. To investigate the probable association between perineural infiltrations and DGE, and the effects on overall survival. A total of 123 patients who underwent pancreaticoduodenectomy were enrolled in the study. Factors like the presence of perineural infiltrations and post-operative DGE along with age, gender, presence of postoperative fistula, and grade of fistula and postoperative haemorrhage were analysed, and survival analyses were conducted. The presence of perineural infiltrations is statistically associated with DGE occurrence (p = 0.01). Moreover, the occurrence of DGE is statistically associated with male gender (p = 0.001), worse grade of postoperative fistula (p < 0.01), and the presence of postoperative haemorrhage (p = 0.03). There was no statistical association between the presence of perineural infiltrations and the other factors. Cox regression and Kaplan-Meier survival analyses showed that increased overall survival is associated with low age (p = 0.018 and p = 0.028, respectively), absence of perineural infiltrations (p = 0.005 and p = 0.003, respectively), better grade of postoperative fistula (p < 0.001), and absence of postoperative haemorrhage (p < 0.001). Multivariate analysis showed that independent prognostic factors for survival prognosis are perineural infiltrations, age, the presence of postoperative pancreatic fistula, and the presence of postoperative haemorrhage. This is the first study that proves a statistically significant association between the presence of perineural infiltrations and the occurrence of DGE. Moreover, perineural infiltrations are an important independent prognostic factor for overall survival, along with other clinical factors.

The impact of gastrojejunostomy orientation on delayed gastric emptying after pancreaticoduodenectomy: a single center comparative analysis.

Delayed gastric emptying (DGE) represents the most frequent complication after pancreaticoduodenectomy (PD). Aim of this study was to evaluate the impact of gastrojejunostomy (GJ)orientation on DGE incidence after PD. One-hundred and twenty-one consecutive PDs were included in the analysis and divided in the horizontal (H-GJ group) and vertical GJ anastomosis groups (V-GJ group). Postoperative data and the value of the flow angle between the efferent jejunal limb and the stomach of the GJ anastomosis at the upper gastrointestinal series were registered. Seventy-five patients (62%)underwent H-GJ, while 46 patients (38%)underwent V-GJ. The incidence of DGE was significantly lower in the V-GJ group as compared to the H-GJ group (23.9%vs45.3%; p=0.02). V-GJ was also associated to a less severe DGE manifestation (p=0.006). The flow angle was significantly lower in case of V-GJ as compared to H-GJ (24.5°vs37°; p=0.002). At the multivariate analysis, ASA score≥3 (p=0.02), H-GJ (p=0.03), flow angle>30°(p=0.004) and Clavien-Dindo≥3 (p=0.03) were recognized as independent prognostic factors for DGE. These same factors were independent prognostic features also for a more severe DGE manifestation. VGJ and the more acute flow angle appear to be associated to a lower incidence rate and severity of DGE. This modified technique should be considered by surgeons in order to reduce postoperative DGE occurrence.

Intraoperative endoluminal pyloromyotomy for reduction of delayed gastric emptying after pylorus preserving partial pancreaticoduodenectomy (PORRIDGE trial): study protocol for a randomised controlled trial

BackgroundPylorus-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.MethodsThis 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.DiscussionDGE 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 registrationGerman Clinical Trials RegisterDRKS00013503. Registered on 27 December 2017.

Treatment Modalities and the Role of Endoscopy for Delayed Gastric Emptying After Whipple Operation: Analysis of 53 Patients.

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.

Effect of Billroth-II versus Roux-en-Y reconstruction for gastrojejunostomy after pancreaticoduodenectomy on delayed gastric emptying: A meta-analysis of randomized controlled trials.

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 Post-Esophagectomy: A Single-Institution Experience.

Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy in patients with esophageal carcinoma. Management of DGE varies widely and it is unclear how comorbidities influence the postoperative course. This study sought to determine factors that influence postoperative DGE. This retrospective study evaluates patients who underwent esophagectomy with gastric pull-up between 2007 and 2019. The cohort was stratified in various ways to determine if postoperative care and outcomes differed, including patient demographics, comorbidities, intraoperative and postoperative procedures. During the study period, 149 patients underwent esophagectomy and 37 had diabetes. Overall incidence of DGE, as defined in this study, was 76.5%. Surgery type was significantly different between DGE and normal emptying cohorts (P = 0.005). Comparing diabetic and nondiabetic patients, there was no significant difference noted in DGE (P = 0.25). Additionally, there was no difference in presence of DGE for patients who underwent any intraoperative pyloric procedure compared to those who did not (P = 0.36). Of significance, all 16 patients with chronic obstructive pulmonary disease had a delay in gastric emptying (P = 0.01). A higher proportion of patients with DGE post-esophagectomy were identified compared to the literature. There is little consensus on a true definition of DGE, but we believe this definition identifies patients suffering in the immediate postoperative period and in follow-up. There is no evidence to support a different postoperative course for patients with diabetes, but the link between chronic obstructive pulmonary disease and DGE warrants further investigation.

Influencing factors of postoperative early delayed gastric emptying after minimally invasive Ivor-Lewis esophagectomy.

BACKGROUNDThe main clinical treatment for esophageal cancer is surgery. Since traditional open esophageal cancer resection has the disadvantages of large trauma, long recovery period, and high postoperative complication rate, its clinical application is gradually reduced. The current report of minimally invasive Ivor-Lewis esophagectomy (MIILE) is increasing. However, researchers found that patients with MIILE had a higher incidence of early delayed gastric emptying (DGE).AIMTo investigate the influencing factors of postoperative early DGE after MIILE.METHODSA total of 156 patients diagnosed with esophageal cancer at Deyang People's Hospital were enrolled. According to the criteria of DGE, patients were assigned to a DGE group (n = 49) and a control group (n = 107). The differences between the DGE group and the control group were compared. Multivariate logistic regression analysis was used to further determine the influencing factors of postoperative early DGE. The receiver operating characteristic (ROC) curve was used to assess potential factors in predicting postoperative early DGE.RESULTSAge, intraoperative blood loss, chest drainage time, portion of anxiety score ≥ 45 points, analgesia pump use, postoperative to enteral nutrition interval, and postoperative fluid volume in the DGE group were higher than those in the control group. Perioperative albumin level in the DGE group was lower than that in the control group (P < 0.05). Age, anxiety score, perioperative albumin level, and postoperative fluid volume were independent factors influencing postoperative early DGE, and the differences were statistically significant (P < 0.05). The ROC curve analysis revealed that the area under the curve (AUC) for anxiety score was 0.720. The optimum cut-off value was 39, and the sensitivity and specificity were 80.37% and 65.31%, respectively. The AUC for postoperative fluid volume were 0.774. The optimal cut-off value was 1191.86 mL, and the sensitivity and specificity were 65.3% and 77.6%, respectively. The AUC for perioperative albumin level was 0.758. The optimum cut-off value was 26.75 g/L, and the sensitivity and specificity were 97.2% and 46.9%, respectively.CONCLUSIONAdvanced age, postoperative anxiety, perioperative albumin level, and postoperative fluid volume can increase the incidence of postoperative early DGE.

Preoperative endoscopic pyloric balloon dilatation decreases the rate of delayed gastric emptying after Ivor-Lewis esophagectomy.

Delayed gastric emptying (DGE) after Ivor-Lewis esophagectomy occurs postoperatively in up to 50% of the patients. This pyloric dysfunction can lead to severe secondary complications postoperatively such as early aspiration, pneumonia or may even have an impact on anastomotic healing and therefore leakage. Early detection of DGE is essential to prevent further complications. The common treatment postoperatively is endoscopic pyloric balloon dilatation (EPBD) after symptoms already occurred. In our work, we analyzed patients who received a preoperative EPBD during the routine restaging endoscopy and compared those patients to a control group to analyze if preoperative EPBD may prevent postoperative DGE and secondary additional complications. We performed a single-center retrospective analysis of 115 patients who received an Ivor-Lewis esophagectomy by the same surgeon between June 2015 and October 2017. Out of these 115 patients, 91 (79.1%) patients received EPBD preoperatively during the staging/restaging endoscopy (PDG, pyloric dilatation group). In 24 (20.9%) patients, preoperative EPBD was not performed due to stenotic esophageal tumors or logistic reasons (NDG, non-pyloric dilatation group). Data of the PDG and NDG group were compared regarding the rate of postoperative DGE as well as DGE and EPBD related complications. In total, 21 (18.3%) patients developed pyloric dysfunction requiring a total of 27 EPBD during follow-up. There were 12 (13.2%) patients in the PDG and 9 (37.5%) patients in the NDG (p=0.014), respectively. DGE-related complications such as anastomotic leaks (p=0.466), pulmonary complications (p=0.466) and longer median hospital stay (p=0.685) were more frequent in the NDG group; however this difference did not reach statistical significance. The success rate for postoperative EPBD with 20-mm balloons was lower (58.5%) compared to the usage of 30-mm balloons (93.3%). All pre- and postoperative EPBD were performed without any complications. Preoperative EPBD is feasible, safe and can be combined with restating endoscopy. It seems that preoperative EPBD reduces the incidence of DGE and can prevent the need for early postoperative endoscopic interventions. Our recommendation is therefore to perform an EPBD preoperatively when possible to reduce postoperative complications to a minimum. For postoperative EPBD, we recommend the use of the 30-mm balloon due to lower redilatation rates.

Pancreaticoduodenectomy with right gastric vessels preservation: impact on intraoperative and postoperative outcomes.

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. 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. 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. 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.

Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy.

AIMTo investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy.METHODSIn this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying (DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed.RESULTSTechnical success was achieved in all patients (100%). Early symptom improvement was observed in 15 of 20 patients (75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d (range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients (70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients (95%).CONCLUSIONEndoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

Prucalopride for the treatment of delayed gastric emptying after pancreaticoduodenectomy: a pilot study

Introduction: Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD) reported in 19–57% of patients. Prucalopride, a 5-hydroxytryptamine, 5HT-4 receptor agonist has been shown to be an excellent drug to treat post-operative ileus. In this pilot study we wanted to test Prucalopride in the treatment of DEG after PD. Methods: We conducted a monocentric study on a consecutive series of PD performed in patients affected by pancreatic adenocarcinomas from January 2013 to December 2017 at IRCCS-ISMETT-UPMC. Patient's demographics, oncologic staging, operative times, intraoperative vitals, and all early surgey-related complications using Clavien grading system were collected and analyzed. Post-operative DGE was determined by the inability to return to a standard diet by the end of the first post-operative week and includes prolonged nasogastric intubation on the patient. Results: There were 96 consecutive patients who underwent PD in our department between January 2013 and December 2017. Multivariate analyses were performed to investigate the effectiveness of the Prucalopride in the treatment of DGE. The overall incidence of DGE was 26,04 % (patients underwent PD: 96, patient with DGE post PD: 25) Of these, 7 patients (6 F, 1 M) were treated with Prucalopride after the failure of medical therapy with common prokinetic (metoclopramide, domperidone). Each of these had a resolution of the DGE with improvement of the outcome and with early discharge. Conclusion: Prucalopride may serve as a post-operative tool for DGE after PD, further studies are needed to validate this proof of concept.

Risk factors for post-pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or deep surgical site infection

Introduction: Delayed gastric emptying (DGE) is a common complication following pancreaticoduodenectomy. Pancreatic fistula or deep surgical site infection (SSI) may contribute to development of DGE, but less is known about risk factors for DGE in the absence of these other complications. Our objective was to explore risk factors for postoperative DGE in patients without pancreatic fistula or deep SSI. Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) pancreatectomy variables were used to identify patients with DGE following pancreaticoduodenectomy. Multivariable models were developed to assess preoperative, intraoperative, and technical factors associated with DGE. Results: A total of 10,614 pancreaticoduodenectomies were identified with an overall DGE rate of 17.1%. DGE was not associated with pancreatic fistula or deep SSI in 56% of cases. The rate of DGE was 11.9% in patients without pancreatic fistula or deep SSI. These patients were more likely to develop DGE if age ≥75 (OR 1.29 [95%CI 1.09-1.52]), male (OR 1.44 [95% CI 1.26–1.65]), black race (OR 1.25 [95% CI 1.01–1.55]), or underwent pylorus-sparing pancreaticoduodenectomy (OR 1.31 [95% CI 1.08–1.58]). Factors not associated with DGE included diabetes, BMI, malignancy, open/laparoscopic approach, and antecolic/retrocolic gastric reconstruction. Conclusion: The incidence of DGE after pancreaticodudenectomy is notable even in patients without other abdominal complications. Identification of patients at increased risk for DGE can be used to make more informed decisions regarding selective use of pylorus-sparing pancreaticoduodenectomy, enteral feeding access, nasogastric tubes, and adjustment of enhanced recovery pathways.

Is systematic nasogastric decompression after pancreaticoduodenectomy really necessary?

Since the spread of enhanced recovery programs, early withdrawal of the nasogastric tube (NGT) is recommended after pancreaticoduodenectomy (PD), although few data on the safety of this practice are available. The aim of the present study was to evaluate the absence of nasogastric decompression after PD on postoperative outcome. All consecutive patients undergoing PD between January 2014 and December 2015 at a single center were retrospectively analyzed. Since May 2015, all operated patients had the NGT removed immediately after the procedure (NGT- group) and were compared to patients operated before this practice (NGT+ group), who had the NGT maintained until at least postoperative day 3. During the study period, 139 patients underwent PD, of whom 40 (29%) were in the NGT- group and 99 (71%) were in the NGT+ group. The length of hospital stay (LOS) and rate of postoperative complications of grade 2 or higher according to the Clavien-Dindo grading system were significantly higher in the NGT+ group [14 (11-25) vs. 10 (8-14.2), P = 0.005 and 82.8 vs. 40%, P < 0.001, respectively]. Incidence and severity of delayed gastric emptying (DGE) grade B-C were also higher in the NGT+ group (45.5 vs. 7.5%, P < 0.001). There was no difference between the two groups concerning the 90-day postoperative mortality (P = 0.18). The absence of systematic nasogastric decompression after PD might reduce postoperative complications, DGE, and LOS. These encouraging results deserve to be confirmed by a prospective randomized study (NCT: 02594956).

Study on the association of gastric conduit width and postoperative early delayed gastric emptying in middle-lower esophageal cancer patients undergoing Ivor-Lewis procedure

To examine the relationship between gastric conduit width and postoperative early delayed gastric emptying (DGE) in patients with middle-lower esophageal carcinoma who underwent Ivor-Lewis operation. Clinical data of 282 consecutive patients with middle-lower esophageal cancer who underwent the Ivor-Lewis operation by same surgical team in our department from January 2013 to June 2015 were retrospectively analyzed. Patients were divided into three groups according to the width of gastric conduit: width > 5.0 cm as broad group (n=93); width 3.0-5.0 cm as moderate group (n=70); width < 3.0 cm as narrow group (n=119). The gastric conduits of patients in narrow group were completely positioned the esophageal bed and fixed to the pericardium posterior wall. None of patients received pyloroplasty or pylorotomy. Perioperative data, operation-associated complications, and postoperative upper gastrointestinal radiographic results(1 week and 4 weeks after operation) were compared among groups. The baseline data among these groups were comparable in terms of age, gender, tumor TNM staging, pathological types, serum albumin level, and the rate of receiving neoadjuvant therapy(all P>0.05). There were no significant differences in operative time, blood loss, and postoperative hospital stay among groups(all P>0.05). No patients died during perioperative peried. Anastomotic leakage occurred in 2 cases, one from broad group and another from narrow group. The incidences of arrhythmia and postoperative pulmonary complications, including infection, atelectasis, pneumothorax, and pleural effusion were similar among groups (all P>0.05). The average amount of gastric juice drainage in narrow group was (98±57) ml/day, which was markedly lower than that in broad group [(157±62) ml/day, P=0.000] and in moderate group [(123±68) ml/day, P=0.008]. One week after operation, the overall incidence of DGE was 10.6%(30/282), the incidence of DGE in broad, moderate, narrow groups was 17.2%(16/93), 14.3%(10/70), and 3.4%(4/119) respectively, and broad and moderate groups had higher incidence as compared to narrow group (P=0.001 and P=0.006). During the Ivor-Lewis operation, application of a narrow gastric conduit (width < 3.0 cm), which completely position the esophageal bed with fixation to the pericardium posterior wall, can significantly reduce the incidence of postoperative early DGE.

Efficacy comparison between pylorus-preserving pancreaticoduodenectomy and standard pancreaticoduodenectomy for periampullary carcinoma

Objective To compare the short-term efficacy of pylorus-preserving pancreaticoduodenectomy (PPPD) and standard pancreaticoduodenectomy (SPD) for the treatment of periampullary carcinoma. Methods The clinical data of 85 patients with periampullary carcinoma who were admitted to the Zhongshan Hospital of Fudan University from October 2010 to October 2012 were retrospectively analyzed. Forty-four patients who underwent PPPD were divided into the PPPD group and 41 patients who underwent SPD were divided into the SPD group. The pancreatic fistula(Grade B and above), biliary fistula, blood loss, intra-abdominal infection, delayed gastric emptying (DGE) and prognosis were analyzed. Patients were followed up by telephone interview and outpatient examination once every 3 months within postoperative 1 year and once every 6 months within postoperative 2-3 years till October 2014. Count data were analyzed using the chi-square test, measurement data with normal distribution were presented as M(Qn) and comparison was analyzed using the Mann-Whitney U test. The survival curve was drawn by the Kaplan-Meier method, and survival rate was analyzed using the Log rank test. Results The operation time was 195 minutes (180 minutes, 240 minutes) in the PPPD group and 210 minutes (180 minutes, 300 minutes) in the SPD group, with a significant difference (Z=-2.090, P 0.05). There was no perioperative death and incidence of overall complication was 42.4%(36/85) with pancreatic fistula, intra-abdominal infection and DGE as the top 3 common postoperative complications. The incidence of DGE was 20.5%(9/44) in the PPPD group, which was significantly different from 4.9%(2/41) in the SPD group (χ2=4.571, P 0.05). Eighty-five patients were followed up for 6-47 months with a median time of 31 months, and postoperative overall 1- and 3-year survival rates were 95.3% and 75.5%, respectively. The 1- and 3-year survival rates were 97.7% and 78.9% in the PPPD group, and 92.7% and 71.7% in the SPD group, respectively, with no significant difference in 3-year survival rate (χ2=0.690, P>0.05). The 3-year overall survival rate was 80.5% in patients without lymph node involvement (LNI) compared with 54.9% in patients with LNI, showing a significant difference (χ2=4.290, P<0.05). Conclusions Both PPPD and SPD have good short-term efficacy for periampullary carcinoma. There is no significant difference between PPPD and SPD concerning short-term survival rate of periampullary carcinoma. PPPD has shorter operation time, but has a higher postoperative DGE incidence. LNI is a significant prognostic factor for short-term survival of periampullary carcinoma. PPPD is not recommended while the lymph nodes are involved. Key words: Periampullary neoplasms; Pancreaticoduodenectomy; Delayed gastric emptying; Pancreatic fistula

Effect of Preoperative Biliary Drainage on Complications Following Pancreatoduodenectomy: A Meta-Analysis.

Preoperative biliary drainage (PBD) prior to pancreatoduodenectomy (PD) is still controversial; therefore, the aim of this study was to examine the impact of PBD on complications following PD. A meta-analysis was carried out for all relevant randomized controlled trials (RCTs), prospective and retrospective studies published from inception to March 2015 that compared PBD and non-PBD (immediate surgery) for the development of postoperative complications in PD patients. Pooled odds ratio (OR) and 95% confidence interval (CI) were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0.05). Eight RCTs, 13 prospective studies, 20 retrospective studies, and 3 Chinese local retrospective studies with 6286 patients were included in this study. In a pooled analysis, there were no significant differences between PBD and non-PBD group in the risks of mortality, morbidity, intra-abdominal abscess, sepsis, hemorrhage, pancreatic leakage, and biliary leakage. However, subgroup analysis of RCTs yielded a trend toward reduced risk of morbidity in PBD group (OR 0.48, CI 0.24 to 0.97; P = 0.04). Compared with non-PBD, PBD was associated with significant increase in the risk of infectious complication (OR 1.52, CI 1.07 to 2.17; P = 0.02), wound infection (OR 2.09, CI 1.39 to 3.13; P = 0.0004), and delayed gastric emptying (DGE) (OR 1.37, CI 1.08 to 1.73; P = 0.009). This meta-analysis suggests that biliary drainage before PD increased postoperative infectious complication, wound infection, and DGE. In light of the results of the study, PBD probably should not be routinely carried out in PD patients.

A case-matched comparison and meta-analysis comparing pylorus-resecting pancreaticoduodenectomy with pylorus-preserving pancreaticoduodenectomy for the incidence of postoperative delayed gastric emptying

ObjectivesThis study was conducted to compare the incidences of delayed gastric emptying (DGE) following pylorus-resecting pancreaticoduodenectomy (PrPD) and pylorus-preserving pancreaticoduodenectomy (PpPD), respectively. MethodsData for 37 patients submitted to PrPD were compared with data for a matched number of patients submitted to PpPD during the same period. A meta-analysis of comparative studies of the two techniques was also carried out. The primary endpoint was the rate of DGE (grades A–C) defined according to the International Study Group of Pancreatic Surgery criteria. ResultsIn the case-matched comparison, both overall DGE (six PrPD patients and 17 PpPD patients; P = 0.006) and clinically relevant DGE (one PrPD and eight PpPD patients; P = 0.013) occurred significantly less often in the PrPD group than in the PpPD group. Based on eight non-randomized clinical trials and two randomized clinical trials involving 804 subjects, the meta-analysis further confirmed a significant reduction in DGE with pooled odds ratios of 0.33 [95% confidence interval (CI) 0.17–0.63; P < 0.001] and 0.13 (95% CI 0.05–0.40; P < 0.001) for overall DGE and clinically relevant DGE, respectively. Other complications and mortality were similar in both groups. ConclusionsPylorus-resecting pancreaticoduodenectomy is a safe procedure associated with less severe and less frequent postoperative DGE than PpPD.