Rate Of Delayed Gastric Emptying Research Articles

Impact of marmara-yegen cuttıng gastrojejunostomy on delayed gastrıc emptyıng after pancreatoduodenectomy: ınıtıal results.

Delayed gastric emptying (DGE) is one of the most common reasons for morbidity after pancreatoduodenectomy. The technical characteristics of anastomosis that could be affected by surgeon may offer a relevant chance to improve postoperative DGE rates. We investigated the effect of a technical modification of gastrojejunostomy after the classical pancreaticoduodenectomy on DGE. A total of 161 patients underwent classical pancreaticoduodenectomy (with 20-40 percent antrectomy) due to pancreatic adenocarcinoma at the Department of General Surgery, Marmara University, School of Medicine Hospital, from February 2019 to May 2023, and those who met the inclusion criteria were enrolled. One hundred twenty patients had undergone classical end-to-side gastrojejunostomy (Classical GJ group), and 41 had undergone Marmara-Yegen cutting side-to-side gastrojejunostomy (M-Yc group). DGE was defined according to the International Working Group on Pancreatic Surgery, and postoperative DGE rates of both groups were compared. In addition, multivariate analysis was performed to identify possible independent predictive factors for DGE. The total incidence of DGE was 31% in the Classical GJ group and 17% in the (M-Yc group). Although there was no significant difference between the groups regarding DGE and DGE grades (p = 0.1), DGE was distinctly lower in the M-Yc GJ group. In multi-variant analysis, Clavien-Dindo grade 3a and above postoperative complication was determined as independent predictors for DGE. We tried to explain the mechanism of DGE in terms of anatomical configuration. The incidence and severity of DGE decreased in patients who underwent M-Yc GJ.

Intra-operative pyloric BOTOX injection versus pyloric surgery for prevention of delayed gastric emptying after esophagectomy.

Delayed gastric emptying (DGE) is a common complication after esophagectomy. BOTOX injections and pyloric surgeries (PS), including pyloroplasty (PP) and pyloromyotomy (PM), are performed intraoperatively as prophylaxis against DGE. This study compares the effects of pyloric BOTOX injection and PS for preventing DGE post-esophagectomy. We retrospectively reviewed Moffitt's IRB-approved database of 1364 esophagectomies, identifying 475 patients receiving BOTOX or PS during esophageal resection. PS was further divided into PP and PM. Demographics, clinical characteristics, and postoperative outcomes were compared using Chi-Square, Fisher's exact test, Wilcoxon rank-sum, and ANOVA. Propensity-score matching was performed between BOTOX and PP cohorts. 238 patients received BOTOX, 108 received PP, and 129 received PM. Most BOTOX patients underwent fully minimally invasive robotic Ivor-Lewis esophagectomy (81.1% vs 1.7%) while most PS patients underwent hybrid open/Robotic Ivor-Lewis esophagectomy (95.7% vs 13.0%). Anastomotic leak (p = 0.57) and pneumonia (p = 0.75) were comparable between groups. However, PS experienced lower DGE rates (15.9% vs 9.3%; p = 0.04) while BOTOX patients had less postoperative weight loss (9.7 vs 11.45kg; p = 0.02). After separating PP from PM, leak (p = 0.72) and pneumonia (p = 0.07) rates remained similar. However, PP patients had the lowest DGE incidence (1.9% vs 15.7% vs 15.9%; p = < 0.001) and the highest bile reflux rates (2.8% vs 0% vs 0.4%; p = 0.04). Between matched cohorts of 91 patients, PP had lower DGE rates (18.7% vs 1.1%; p = < 0.001) and less weight loss (9.8 vs 11.4kg; p = < 0.001). Other complications were comparable (all p > 0.05). BOTOX was consistently associated with shorter LOS compared to PS (all p = < 0.001). PP demonstrates lower rates of DGE in unmatched and matched analyses. Compared to BOTOX, PS is linked to reduced DGE rates. While BOTOX is associated with more favorable LOS, this may be attributable to difference in operative approach. PP improves DGE rates after esophagectomy without improving other postoperative complications.

Early Versus Late Drainage Removal in Patients Who Underwent Pancreaticoduodenectomy: A Comprehensive Systematic Review and Meta-analysis of Randomized Controlled Trials Using Trial Sequential Analysis

BackgroundThe superiority of early drain removal (EDR) versus late (LDR) after pancreaticoduodenectomy (PD) has been demonstrated only in RCTs.MethodsA meta-analysis was conducted using a random-effects model and trial sequential analysis. The critical endpoints were morbidity, redrainage, relaparotomy, and postoperative pancreatic fistula (CR-POPF). Hemorrhage (PPH), delayed gastric emptying (DGE), length of stay (LOS), and readmission rates were also evaluated. Risk ratios (RRs) and mean differences (MDs) with a 95% confidence interval (CI) were calculated. Type I and type II errors were excluded, comparing the accrued sample size (ASS) with the required sample size (RIS). When RIS is superior to ASS, type I or II errors can be hypothesized.ResultsASS was 632 for all endpoints except DGE and PPH (557 patients). The major morbidity (RR 0.55; 95% CI 0.32–0.97) was lower in the EDR group. The CR-POPF rate was lower in the EDR than in the LDR group (RR 0.50), but this difference is not statistically significant (95% CI 0.24–1.03). The RIS to confirm or exclude these results can be reached by randomizing 5959 patients. The need for percutaneous drainage, relaparotomy, PPH, DGE, and readmission rates was similar. The related RISs were higher than ASS, and type II errors cannot be excluded. LOS was shorter in the EDR than the LDR group (MD − 2.25; 95% CI − 3.23 to − 1.28). The RIS was 567, and type I errors can be excluded.ConclusionsEDR, compared with LDR, is associated with lower major morbidity and shorter LOS.

OGC P33 Comparison of the post-operative outcomes of surgical and chemical interventions on the gastric pylorus during oesophagectomy: A systematic review and meta-analysis

Abstract Background Oesophagectomy can lead to gastric dysmotility and pyloric dysfunction, causing delayed gastric emptying (DGE). DGE is associated with significant postoperative morbidity, namely aspiration pneumonia and anastomotic leak. Surgical drainage and botox injections (BI) on pylorus were described to combat DGE. Pyloric interventions however can increase risk of bile reflux, oesophagitis, dumping syndrome and pyloric leaks. Current literature showed equivocal short- and long-term outcomes of pyloric drainage procedures, with no consensus on the necessity of such procedures. We aim to evaluate the latest literature, comparing effects of different pylorus surgical drainage methods, BI and watch-and-wait approach on the pylorus during oesophagectomy Methods The OVID database was searched systematically. Articles were screened with the Rayyan software. Inclusion Criteria of articles are as follows: • RCT and comparative cohort studies (retrospective and prospective) which included any drainage methods, performed at the same time as oesophagectomy • Oesophagectomy for benign or malignant conditions • Studies of adult human subjects ≥ age of 18 years old • Studies published in English language • Studies published within the last 25 years Primary outcomes evaluated were DGE and pulmonary complication rates. A traditional pairwise meta-analysis was performed with Revman 5.4, utilizing a random effects model for analysis of the pooled outcome measures. Results Data of 3925 patients from 27 publications evaluating up to ten pyloric interventions were analyzed. Most studies were retrospective in nature (24 studies). Due to heterogeneity of reported outcomes, pooled meta-analyses were only performed on limited studies. Pooled analyses showed pyloric interventions reduced DGE rates in 19 studies and pulmonary complications in 11 studies. Relative risks (95% CI; p value) were 0.95 (0.7,1.29; p=0.74) and 0.88 (0.72,1.08; p=0.22), respectively.Figure 1:Forrest plot comparing DGE rates of Pyloric Interventions vs No Intervention Figure 2:Forrest plot comparing rates of Pulmonary Morbidity of Pyloric Interventions vs No Intervention Conclusions Our systematic review and meta-analysis did not observe statistically significant and conclusive evidence favouring pyloric drainage procedures to none. High quality comparative studies and inconsistent scrutinization of post operative outcomes were lacking. Prospectively designed RCT or propensity matched cohort studies comparing surgical pyloric drainage, BI and no intervention should be conducted to produce standardized comparison. We suggest analyzing post operative outcomes by measuring data which could be objectively recorded (DGE utilizing the latest definition, pulmonary morbidity, anastomotic leak, biliary reflux rates, radiographic or endoscopic findings etc.) combined with subjective measurement of patient symptoms, where a patient-centred questionnaire could be performed.

Stomach-partitioning versus conventional gastrojejunostomy for unresectable gastric cancer with gastric outlet obstruction: A propensity score matched cohort study

BackgroundStomach partitioning gastrojejunostomy (SPGJ) was introduced to deal with delayed gastric emptying (DGE). This study aimed to compare the short- and long-term outcomes of SPGJ versus conventional gastrojejunostomy (CGJ). MethodThis cohort study analyzed 108 patients who underwent gastrojejunostomy for unresectable gastric cancer: 70 patients underwent SPGJ, and 38 patients underwent CGJ between 2018 and 2022. Propensity score-matched (PSM) analysis was used to balance the baseline characteristics. ResultsAfter PSM, there were 26 patients in each group. SPGJ group had significantly lower incidence of DGE (3.8% vs. 34.6%), vomiting (3.8% vs. 42.3%), and prokinetics requirement (11.5% vs. 46.2%). SPGJ group had significantly shorter time to solid diet tolerance (4.1 days vs. 5.7 days) and postoperative hospital stay (7.7 days vs. 9.3 days). There was no significant difference in relapse reinterventions, gastric outlet obstruction (GOO) recurrence, conversion surgery, and survival outcomes. ConclusionsSGPJ was associated with lower rate of DGE, prokinetics requirement, and shorter time of solid diet tolerance compared to CGJ in the treatment of unresectable gastric cancer patients with GOO.

Early oral feeding versus nasojejunal early enteral nutrition in patients following pancreaticoduodenectomy: a propensity score-weighted analysis of 428 consecutive patients.

Notwithstanding that significant medical progress has been achieved in recent years, the optimal nutritional support method following pancreaticoduodenectomy (PD) remains uncertain. This study compared the safety and feasibility of early oral feeding (EOF) with nasojejunal early enteral nutrition (NJEEN) after PD. A retrospective cohort study was conducted on 428 consecutive patients who underwent PD between August 2018 and December 2020. During the first study phase, the routine postoperative feeding strategy was NJEEN, later replaced by EOF during the second study phase. The primary outcome was the incidence of delayed gastric emptying (DGE) following PD. Propensity score weighting (PSW) was used to control for confounding factors. 440 patients underwent PD during the overall study period, with 438 patients aged 18 years and older. Ten patients experienced accidental tube dislodgement or migration and were excluded from the study based on the exclusion criteria. Finally, 211 patients and 217 patients underwent EOF and NJEEN, respectively. After PSW, it was observed that patients who underwent postoperative EOF experienced a significantly lower DGE (B/C) rate compared to those who underwent postoperative NJEEN (7.38% (31/424) vs. 14.97% (62/413), P=0.0005). Subgroup analyses according to the presence of soft pancreatic texture yielded consistent results. The EOF group exhibited lower DGE grade, DGE (B/C) rate (5.90% (11/194) vs. 22.07% (43/193), P<0.0001), postoperative gastrointestinal endoscopic intervention rate, and Clavien-Dindo Grade III or higher rate. EOF is superior to NJEEN in reducing the incidence of grade B/C DGE after PD. The EOF procedure is safe and feasible and should be recommended as the optimal postoperative feeding method following PD.

Impact of route of reconstruction of gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A prospective randomized study.

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. 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. 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). 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.

Lengthened Efferent Limb in Braun Enteroenterostomy Reduces Delayed Gastric Emptying After Pancreaticoduodenectomy.

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD), but a method to prevent DGE has not been established. This study aims to demonstrate a novel technique utilizing a lengthened efferent limb in Billroth-II (B-II) reconstruction during PD and to evaluate the impact of the longer efferent limb on DGE occurrence. Patients who underwent PD with B-II reconstruction were divided into two groups: PDs with lengthened (50-60cm) efferent limb (L group) and standard length (0-30cm) efferent limb (S group). Postoperative outcomes were compared. DGE was defined and graded according to the International Study Group of Pancreatic Surgery criteria. Among 283 consecutive patients who underwent PD from 2002 to 2021, 206 patients were included in this study. Patients who underwent Roux-en-Y reconstruction (n = 77) were excluded. Compared with the S group, the L group included older patients and those who underwent PD after 2016 (p = 0.025, < 0.001, respectively). D2 lymphadenectomy, antecolic route reconstruction, and Braun enteroenterostomy were performed more frequently in the L group (p = 0.040, < 0.001, < 0.001, respectively). The rate of DGE was significantly decreased to 6% in the L group, compared with 16% in the S group (p = 0.027), which might lead to a shorter hospital stay in the L group (p < 0.001). Multivariable analysis identified two factors as independent predictors for DGE: intraabdominal abscess [odds ratio (OR) 5.530, p = 0.008] and standard efferent limb length (OR 2.969, p = 0.047). A lengthened efferent limb in Braun enteroenterostomy could reduce DGE after PD.

Retrocolic gastrojejunostomy in pancreaticoduodenectomy reduces rates of delayed gastric emptying

Background: Delayed gastric emptying (DGE) is one of the most common postoperative complications in patients following pancreaticoduodenectomy (PD). This complication has been shown to effect 14-30% of patients postoperatively. Many randomized studies have shown no statistical difference between pylorus-sparing PD vs. classic PD. Additionally, the position of the anastomosis in classic PD, antecolic versus retrocolic, has also undergone randomized trials which have shown no difference in rates of DGE. The aim of this study was to report our incidence of DGE after a departmental change to a stapled retrocolic loop gastrojejunostomy as a result of high DGE with antecolic approach. The secondary aim was to identify risk factors for developing DGE on multivariate analysis.

Impact of Early Enteral Nutrition on Delayed Gastric Emptying and Nutritional Status After Pancreaticoduodenectomy.

Although early enteral nutrition (EEN) is an accepted practice after pancreaticoduodenectomy (PD), the impact of EEN on postoperative complications or nutritional status remains unclear. We aimed to investigate the impact of EEN on delayed gastric emptying (DGE) and nutritional status after PD. A total of 143 patients underwent PD between January 2012 and September 2020. We excluded patients who underwent a two-stage pancreatojejunostomy, in whom the enteral tube was accidentally pulled out, or with insufficient information in their medical records. The incidence of postoperative complications was compared between patients who received EEN (EEN group, n = 21) and those who did not (control group, n = 21) after propensity score matching. Univariate and multivariate analyses were performed to identify the risk factors affecting the incidence of these complications. Nutritional status was assessed at postoperative months 1, 3, and 6. The incidence of grade B/C DGE in the EEN group was significantly lower than that in the control group (4.8% vs. 28.6%, p = 0.03). There was no significant difference in overall morbidity, incidence of any other postoperative complications, or all-grade DGE. In multivariate analysis, EEN was associated with a reduction in the incidence of grade B/C DGE (p < 0.01). In the analysis of nutritional status, EEN was significantly associated with better nutritional status at postoperative month 1. EEN can lead to a lower clinically relevant DGE rate and better nutritional status in the early postoperative period in patients undergoing PD.

Prospective multicentre randomised controlled trial of the effect of Braun Enteroenterostomy in the Reconstruction after Pancreaticoduodenectomy on delayed gastric emptying (DGE): protocol for the BERP study

IntroductionDespite advances in achieving low mortality rates with pancreaticoduodenectomy (PD), morbidity remains high. A key contributor to this morbidity is delayed gastric emptying (DGE) occurring with an incidence of up...

Delayed gastric emptying is associated with increased risk of mortality in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma

Delayed 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.

Stent-Associated Infectious Complications After Pancreatoduodenectomies Can Be Prevented by Perioperative Antibiotic Therapy: An Analysis of Single-Center Standards.

Perioperative morbidity after pancreatoduodenectomies is still high. One potentially responsible factor is the insertion of bile duct stents before surgery. In our single-center study, we evaluated the influence of preoperative bile duct stenting combined with perioperative antibiotic therapy versus primary surgery in carcinoma patients. Clinical data of 973 patients undergoing pancreatoduodenectomy at the University Hospital Freiburg from 2002 to 2018 were explored retrospectively. Postoperative pancreatic fistula, delayed gastric emptying (DGE), and postpancreatectomy hemorrhage (PPH) were graded by current international definitions. Patients with pancreatic ductal adenocarcinoma or periampullary carcinoma were included. We included 634 patients of whom 372 (58.7%) were treated with preoperative bile duct stenting. No difference concerning postoperative pancreatic fistula was observed (P = 0.479). We found more wound infections (stent 18.4%, no stent 11.1%, P = 0.008) but a significantly lower rate of PPH and DGE in stented patients (PPH 7.5% vs 11.9%, P = 0.044; DGE 16.5% vs 22.5%, P = 0.039). Surprisingly, intra-abdominal abscesses were reduced in stented patients (9.4% vs 15.0%, P = 0.022), just as insufficiencies of the biliodigestive anastomosis (P = 0.021). Perioperative antibiotic therapy seems to reduce the risk for severe intra-abdominal infectious complications in stent-bearing patients.

Early oral feeding after pancreatoduodenectomy: a systematic review and meta-analysis.

The effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic review and meta-analysis was to investigate the effect of EOF on clinical outcomes after PD, such as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and length of stay (LOS). A systematic review and meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and assimilated evidence from studies reporting outcomes for patients who received EOF after PD compared to enteral tube feeding (EN) or parenteral nutrition (PN). Four studies reported outcomes after EOF compared to EN/PN after PD and included 553 patients. Meta-analyses showed no difference in rates of CR-POPF (OR 0.74; 95%CI 0.44-1.24; p=0.25) or DGE (Grade B/C) (OR 0.83; 95%CI 0.31-2.21; p=0.70). LOS was significantly shorter in the EOF group compared to the EN/PN group (Mean Difference-3.40 days; 95%-6.11-0.70 days; p=0.01). Current available evidence suggests that EOF after PD is not associated with increased risk of DGE, does not exacerbate POPF and appears to reduce length of stay.

368. EARLY DELAYED GASTRIC EMPTYING AFTER ESOPHAGECTOMY: VALIDATION OF THE INTERNATIONAL EXPERT CONSENSUS DEFINITION (MIE GROUP)

Abstract Early delayed gastric emptying (DGE) affects up to 37% of patients after esophagectomy. An international expert consensus (IEC) agreed on a diagnostic criteria in 2020. The degree of adoption of this definition worldwide is unknown and how it compares to well established definitions locally with subtle yet significant differences. The aim of this study was to compare the IEC definition of early DGE to the definition at the University. All patients who underwent esophagectomy for cancer at UHP between April 2019–August 2020 were analysed. The IEC definition was applied retrospectively and the rates of DGE were compared between the two criteria. One hundred consecutive patients [74 Male (74%), median age (range) 68 (45–83 years)] were analysed. The rates of early DGE according to the IEC and UHP definitions were 20% and 28% respectively (p = 0.246). Eight patients had anastomotic leak, 6 of whom had DGE. Pneumonia was diagnosed in 28 patients (8 and 6 in the IEC and UHP groups respectively). Twenty-nine patients (29%) had pyloric balloon dilatation (PBD). Seventeen patients in the index admission and twelve at later date. Of the 17 patients 9 were in the IEC group and 11 in the UHP group. The UHP definition does seem to match the MIE consensus definition and is not inferior. The dynamic process of DGE does support the policy our unit has to continue monitoring patients with chest radiographs. This not only identifies DGE early and modify management but also allows assessment of conduit after the patient starts eating. Definition of Early Delayed Gastric Emptying post Esophagectomy.pdf (could not be inserted).

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.

Outcomes Following Pancreatoduodenectomy in Octogenarians in Scotland

Background: The benefit of pancreatoduodenectomy (PD) in patients over 80 is not well established. The outcomes of patients undergoing PD in Scotland over a ten year period were evaluated to determine efficacy of this procedure in elderly patients. Methods: Data from all patients who had undergone PD in Scotland from 2007-2017 were collated. Primary outcome was overall survival and secondary outcomes included post-operative morbidity, mortality rates and rates of procedure specific morbidity – post-operative pancreatic fistula (POPF), delayed gastric emptying (DGE) and post-procedure haemorrhage (PPH). Outcomes for those over 80 years were compared with patients under 80. Results: 1102 patients underwent PD during the study period of which 30 (2.7%) were over 80. Overall survival for over 80s was 18.7 months compared with 33 months for under 80s (p=0.002). For patients over 80 with pancreatic adenocarcinoma, median survival was 12.5 months compared with 21 months for those under 80 (p=0.06). There was no significant difference in length of stay - 15 days (over 80s) versus 14 days (under 80s) p=0.85; major morbidity - 10% (over 80s) versus 16.4% (under 80s) p=0.2; and 90 day mortality - 10% (over 80s) versus 6.4% (under 80s) p=0.44. No significant difference was observed in rates of POPF, PPH or DGE. Conclusions: Low numbers of patients over 80 in Scotland undergo PD and overall survival is reduced in this group. Short term outcomes in patients over 80 are comparable to younger patients however, and access to surgery in this group could potentially be improved by prehabilitation.

A Network Meta-Analysis Comparing Gastric Resection Approaches and Enteric Anastomotic Configurations on Delayed Gastric Emptying Following Pancreaticoduodenectomy

Introduction: Delayed gastric emptying (DGE) is frequent following pancreaticoduodenectomy (PD). Several randomized controlled trials (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. Method: 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 Braun enteroenterostomy. 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: A total of 24 RCTs, including 2526 patients and 14 approaches to PD were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6%. Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy (Figure 1) was associated with the lowest rates of DGE, and ranked the best in 35% of comparisons. Classic Whipple, retrocolic, Billroth II with Braun enteroenterostomy ranked the worst for DGE, in 32% of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (OR 2.10, 95% CrI: 0.92-4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when a Braun enteroenterostomy was used (OR 1.90, 95% CrI: 0.92-3.90). Conclusions: Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE.

The PrEDICT-DGE score as a simple preoperative screening tool identifies patients at increased risk for delayed gastric emptying after pancreaticoduodenectomy.

Morbidity after Pancreaticoduodenectomy (PD) has remained unchanged over the past decade. Delayed Gastric Emptying (DGE) is a major contributor with significant impact on healthcare-costs, quality of life and, for malignancies, even survival. We sought to develop a scoring system to aid in easy preoperative identification of patients at risk for DGE. The ACS-NSQIP dataset from 2014 to 2018 was queried for patients undergoing PD with Whipple or pylorus preserving reconstruction. 15,154 patients were analyzed using multivariable logistic regression to identify risk factors for DGE, which were incorporated into a prediction model. Subgroup analysis of patients without SSI or fistula (primary DGE) was performed. We identified 9 factors independently associated with DGE to compile the PrEDICT-DGE score: Procedures (Concurrent adhesiolysis, feeding jejunostomy, vascular reconstruction with vein graft), Elderly (Age>70), Ductal stent (Lack of biliary stent), Invagination (Pancreatic reconstruction technique), COPD, Tobacco use, Disease, systemic (ASA>2), Gender (Male) and Erythrocytes (preoperative RBC-transfusion). PrEDICT-DGE scoring strongly correlated with actual DGE rates (R2=0.95) and predicted patients at low, intermediate, and high risk. Subgroup analysis of patients with primary DGE, retained all predictive factors, except for age>70 (p=0.07) and ASA(p=0.30). PrEDICT-DGE scoring accurately identifies patients at high risk for DGE and can help guide perioperative management.