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Schrempf MC, Anthuber M, Spatz J, Sommer F, Vlasenko D, Geissler B, Wolf S, Schiele S, Pinto DRM, Hoffmann M. Intraoperative Endoluminal Pyloromyotomy Versus Stretching of the Pylorus for the Reduction of Delayed Gastric Emptying After Pylorus-Preserving Partial Pancreatoduodenectomy: A Blinded Randomized Controlled Trial (PORRIDGE Study; DRKS00013503). Ann Surg Oncol 2025; 32:4076-4084. [PMID: 39904851 PMCID: PMC12049319 DOI: 10.1245/s10434-025-16950-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 01/15/2025] [Indexed: 02/06/2025]
Abstract
BACKGROUND Pylorus-preserving partial pancreatoduodenectomy (ppPD) is a treatment for tumors of the pancreatic head. Delayed gastric emptying (DGE) is one of the most common complications following ppPD. In a retrospective analysis, intraoperative endoluminal pyloromyotomy (PM) was shown to be associated with a reduction in DGE rates. OBJECTIVE The aim of this randomized controlled trial was to investigate the effect of intraoperative endoluminal PM on DGE after ppPD. METHODS Patients undergoing ppPD were randomized intraoperatively to receive either PM or atraumatic stretching of the pylorus prior to creation of the duodenojejunostomy. The primary endpoint was the rate of DGE within 30 days after surgery. RESULTS Sixty-four patients were randomly assigned to the PM group and 64 patients were assigned to the control group. There were no differences between the two groups regarding baseline characteristics. The DGE rate was 59.4% (76/126). In two patients (1.6%) DGE was not assessable. The most common DGE grade was A (51/126, 40.5%), followed by B (20/126, 15.9%) and C (5/126, 4.0%). The rate of DGE was 62.5% in the PM group versus 56.3% in the control group (odds ratio 1.41, 95% confidence interval 0.69-2.90; p = 0.34). The complication rate did not differ between both groups (p = 0.79) and there were no differences in quality of life on postoperative day 30. CONCLUSIONS Intraoperative endoluminal PM did not reduce the rate or severity of DGE after ppPD compared with atraumatic stretching of the pylorus.
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Affiliation(s)
- Matthias C Schrempf
- Department of General, Visceral and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany.
| | - Matthias Anthuber
- Department of General, Visceral and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Johann Spatz
- Department of General and Visceral Surgery, Barmherzige Brueder Krankenhaus Munich, Munich, Germany
| | - Florian Sommer
- Department of General, Visceral and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Dmytro Vlasenko
- Department of General, Visceral and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Bernd Geissler
- Department of General, Visceral and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Sebastian Wolf
- Department of General, Visceral and Thoracic Surgery, Asklepios Stadtklinik Bad Tölz, Bad Tölz, Germany
| | - Stefan Schiele
- Department of Computational Statistics and Data Analysis, Institute of Mathematics, University of Augsburg, Augsburg, Germany
| | - David R M Pinto
- Department of General, Visceral and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Michael Hoffmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Augsburg, Augsburg, Germany
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Gurria JP, Mullapudi B, Lowe CMO, Jenkins T, Ogg MS, Bondoc A, Tiao G, Vitale D, Abu-El-Haija M. Intraoperative Pyloric Botulinum Toxin Injection for Post Total Pancreatectomy With Islet Autotransplantation Gastroparesis Improvement in Children. J Pediatr Surg 2025; 60:162341. [PMID: 40280295 DOI: 10.1016/j.jpedsurg.2025.162341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Revised: 04/06/2025] [Accepted: 04/17/2025] [Indexed: 04/29/2025]
Abstract
BACKGROUND Acute Recurrent Pancreatitis (ARP) and Chronic Pancreatitis (CP) may cause abdominal pain, malnutrition, opioid dependency, and impairment in quality of life. Total Pancreatectomy with Islet Autotransplantation (TPIAT) is an option when other measures fail. Pancreatitis gastroparesis can be potentiated by surgery. Botulinum toxin (BT) injections into the pylorus have been used in children for gastroparesis. We evaluated outcomes of pyloric injection of BT for TPIAT in children. METHODS Retrospective cohort of children who underwent TPIAT (2021-2023). Twenty with-BT and 20 without-BT were evaluated for time to achieve full oral nutrition, percent weight change at discharge, days with emesis through post op day 14 (POD14), days when gastrostomy tube (G) required drainage for vomiting through POD14, length of stay (LOS). We hypothesized that pyloric BT during TPIAT would decrease post-operative gastroparesis symptoms. RESULTS CP diagnosis present in 80 % of with-BT & 65 % of the without-BT patients. The groups were similar by sex (with-BT, 45 % male vs 50 % in without-BT). With-BT patients had fewer days to full PO (29.4 (18.3) vs. 40.9 (15.9), p < 0.01), and fewer G tube days (mean 7.2 SD (2.6) vs 10.1(3.4)) (p < 0.01) but no significant difference in emesis days (2.7 (2.8) vs 4.2 (2.9)) (p = 0.21), percent weight change at discharge (-2.9 % (2.7) vs. -4.6 % (2.7)) (p = 0.07) and LOS (median 15.5 IQR(14-16.5) vs. 16 (13.5-19)) (p = 0.46). CONCLUSION Pyloric BT may improve postoperative gastroparesis symptoms among pediatric patients undergoing TPIAT. To our knowledge, this is the first pediatric study evaluating morbidity associated with gastroparesis after TPIAT in an already high-risk population due to ARP or CP. TYPE OF STUDY Retrospective Cohort Study LEVEL OF EVIDENCE: III.
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Affiliation(s)
- Juan P Gurria
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA.
| | - Bhargava Mullapudi
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Colleen M O Lowe
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Todd Jenkins
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark S Ogg
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Alex Bondoc
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Greg Tiao
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - David Vitale
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Medical Hospital Center, Cincinnati, OH, USA
| | - Maisam Abu-El-Haija
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Medical Hospital Center, Cincinnati, OH, USA
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Hofmann FO, Engelstädter VS, Aghamaliyev U, Knoblauch MM, Pretzsch E, Weniger M, D'Haese JG, Renz BW, Werner J, Ilmer M. Primary delayed gastric emptying after pylorus-resecting pancreatoduodenectomy: A matched-pair comparison of Roux-en-Y vs. Billroth-II reconstruction. Surg Open Sci 2024; 22:46-52. [PMID: 39584027 PMCID: PMC11582468 DOI: 10.1016/j.sopen.2024.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Revised: 10/13/2024] [Accepted: 10/17/2024] [Indexed: 11/26/2024] Open
Abstract
Background After pylorus-resecting pancreatoduodenectomy (PrPD), delayed gastric emptying (DGE) might partially be attributed to biliary reflux. We investigated whether the incidence of primary DGE is reduced after Roux-en-Y instead of Billroth-II reconstruction. Methods Patients undergoing PrPD from 2016 to 2019 at a high-volume center were identified. Excluding causes of secondary DGE, we matched patients with Roux-en-Y and Billroth-II reconstruction in a 1:2 ratio and compared primary DGE. Results In 24 vs. 48 (Roux-en-Y vs. Billroth-II) patients, DGE (grade B/C) incidence (20.8 % vs. 18.8 %; P = 1.000), nasogastric tube requirement (median 2 vs. 2 days; P = 0.844) and time to solid food intake (7 vs. 7 days; P = 0.933) were comparable. Univariable logistic regression showed no association between DGE and Roux-en-Y reconstruction (OR 1.47; P = 0.524), in contrast to age (1.08; P = 0.030) and pancreatic biochemical leak (4.98; P = 0.007). Conclusions Primary DGE did not differ between Roux-en-Y and Billroth-II reconstruction after PrPD. Instead, age and postoperative pancreatic biochemical leak were associated with higher DGE risk.
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Affiliation(s)
- Felix O. Hofmann
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Victoria S. Engelstädter
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Ughur Aghamaliyev
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Mathilda M. Knoblauch
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Elise Pretzsch
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Maximilian Weniger
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jan G. D'Haese
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
- Department of General, Visceral and Vascular Surgery, Agatharied Hospital, Hausham, Germany
| | - Bernhard W. Renz
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jens Werner
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Matthias Ilmer
- Department of General, Visceral and Transplantation Surgery, Ludwig-Maximilians-University Hospital Munich, Marchioninistrasse 15, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Duan P, Sun L, Kou K, Li XR, Zhang P. Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2024; 23:449-457. [PMID: 37980179 DOI: 10.1016/j.hbpd.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 10/31/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE. DATA SOURCES Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: "pancreaticoduodenectomy", "pancreaticojejunostomy", "pancreaticogastrostomy", "gastric emptying", "gastroparesis" and "postoperative complications". The search was limited to English publications. Additional articles were identified by a manual search of references from key articles. RESULTS In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE. CONCLUSIONS Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.
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Affiliation(s)
- Peng Duan
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Lu Sun
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Kai Kou
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China
| | - Xin-Rui Li
- Department of Dental Implantology, Hospital of Stomatology, Jilin University, Changchun 130021, China
| | - Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, General Surgery Center, the First Hospital of Jilin University, Changchun 130021, China.
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Yamane K, Nagai K, Anazawa T, Kasai Y, Yoh T, Ogiso S, Uchida Y, Ito T, Ishii T, Hatano E. Optimizing terminology for pancreatectomy: Introducing a new notation system. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:691-696. [PMID: 39128875 PMCID: PMC11503452 DOI: 10.1002/jhbp.12065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
We introduce a novel notation system for pancreatectomy designed to provide a clear and concise representation of surgical procedures. As surgical techniques and the scope of pancreatic surgeries continue to diversify, existing communication methods among medical professionals regarding the specifics of the surgeries have proven inadequate. Our proposed notation system clearly indicates the approach (open, laparoscopic, or robot-assisted), type of surgery (e.g., pancreatoduodenectomy, distal pancreatectomy), and extent of resection and accompanying resected organs or vasculature. These elements are all recorded in this order by using abbreviations. For example, a pancreatoduodenectomy with pancreatic transection just above the SMA and combined resection of the SMV would be noted as "OPD(hb')-SMV". This new notation system allows for concise expression of the essential information on performed procedures of pancreatic resection, leading to smooth information sharing. This initiative is an essential step towards standardizing pancreatic surgery documentation on a global scale. Here, we present the development and application of this system, highlighting its potential to transform surgical communication and documentation.
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Affiliation(s)
- Kei Yamane
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Kazuyuki Nagai
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Takayuki Anazawa
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Yosuke Kasai
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Tomoaki Yoh
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Satoshi Ogiso
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Yoichiro Uchida
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Takashi Ito
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Takamichi Ishii
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Etsuro Hatano
- Division of Hepato‐Biliary‐Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
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Rebelo A, Kresse R, Sunami Y, Ronellenfitsch U, Kleeff J, Klose J. How to Reduce Delayed Gastric Emptying After Pancreatoduodenectomy: A Systematic Literature Review and Meta-Analysis. ANNALS OF SURGERY OPEN 2024; 5:e458. [PMID: 39310336 PMCID: PMC11415098 DOI: 10.1097/as9.0000000000000458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 06/02/2024] [Indexed: 09/25/2024] Open
Abstract
Introduction The occurrence of delayed gastric emptying (DGE) following pancreatoduodenectomy is of high clinical relevance. Despite the pivotal nature of this topic, the existing evidence is limited and often conflicting. This meta-analysis aims to assess the impact of various interventions, such as the type of surgical reconstruction (specifically pylorus resection or preservation), enhanced recovery after surgery (ERAS), epidural anesthesia (EA), as well as strategies involving nasogastric decompression on DGE. Methods Following the PRISMA guidelines, a systematic search was conducted. Studies that compared patients undergoing pancreatoduodenectomy regarding one of the following interventions were included: pylorus-preserving pancreaticoduodenectomy (ppPD) versus pylorus-resecting pancreaticoduodenectomy (prPD), ERAS versus no ERAS, epidural anesthesia EA versus no EA, nasogastric decompression versus no nasogastric decompression and jejunostomy/nasojejunal feeding tube placement (J/NJF) versus no J/NJF. Results The analysis included 5930 patients from 29 studies. Patients undergoing ppPD exhibited a higher incidence of DGE compared with those undergoing prPD (logOR, -0.95; 95% CI = -1.57 to -0.34; P = 0.002). Additionally, patients in the ERAS group showed reduced rates of DGE (logOR, -0.712; 95% CI = -1.242 to -0.183; P = 0.008). Lower rates of DGE were observed in patients without a J/NJF (logOR, -0.618; 95% CI, 0.39-0.84; P < 0.001). Conclusion In summary, our meta-analysis reveals that pylorus resection, adherence to ERAS protocols, and the absence of a J/NJF are associated with lower rates of DGE after pancreatoduodenectomy. Although these results are partially based on observational studies, they contribute valuable insights to the current understanding of interventions impacting DGE in these complex procedures.
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Affiliation(s)
- Artur Rebelo
- From the Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Randi Kresse
- From the Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Yoshiaki Sunami
- From the Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Ulrich Ronellenfitsch
- From the Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Jörg Kleeff
- From the Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Johannes Klose
- From the Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Klein M, Warschkow R, Ukegjini K, Krstic D, Burri P, Chatziisaak D, Steffen T, Schmied B, Probst P, Tarantino I. The influence of delayed gastric emptying on quality of life after partial duodenopancreatectomy. Langenbecks Arch Surg 2024; 409:155. [PMID: 38727871 DOI: 10.1007/s00423-024-03345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/05/2024] [Indexed: 05/15/2024]
Abstract
PURPOSE 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Marie Klein
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland.
| | - Rene Warschkow
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland
| | - Kristjan Ukegjini
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland
| | - Daniel Krstic
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland
| | - Pascal Burri
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland
| | - Dimitrios Chatziisaak
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland
| | - Thomas Steffen
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland
| | - Bruno Schmied
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland
| | - Pascal Probst
- Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland
| | - Ignazio Tarantino
- Department of General, Visceral, Endocrine, and Transplant Surgery, Cantonal Hospital of St. Gallen, Rorschacherstrasse 95, St. Gallen, CH-9007, Switzerland
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Xie FL, Ren LJ, Xu WD, Xu TL, Ge XQ, Li W, Ge XM, Zhou WK, Li K, Zhang YH, Wang Z. Preoperative and postoperative complications as risk factors for delayed gastric emptying following pancreaticoduodenectomy: A single-center retrospective study. World J Gastrointest Surg 2023; 15:1941-1949. [PMID: 37901734 PMCID: PMC10600768 DOI: 10.4240/wjgs.v15.i9.1941] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND 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. AIM To identify risk factors associated with DGE after the PD procedure. METHODS 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. RESULTS 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. CONCLUSION Postoperative severe abdominal complications, preoperative systemic diseases, and early postoperative ALB are identified as risk factors for post-PD DGE.
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Affiliation(s)
- Fang-Liang Xie
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Li-Jun Ren
- Operating Theatre, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Wei-Dong Xu
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Tong-Lei Xu
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Xia-Qing Ge
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Wei Li
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Xu-Ming Ge
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Wen-Kai Zhou
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Kai Li
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Yun-Hai Zhang
- Department of Pain, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
| | - Zhong Wang
- Department of Hepatobiliary Surgery, Xuzhou Medical University Affiliated Hospital of Lianyungang (The First People's Hospital of Lianyungang), Lianyungang 222061, Jiangsu Province, China
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9
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Morelli L, Di Franco G, Furbetta N, Palmeri M, Guadagni S, Gianardi D, Carpenito C, Comandatore A, Giovannetti E, Di Candio G, Cuschieri A. Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy: Comparison between traditional open surgery and full-robotic approach with da Vinci Xi. Int J Med Robot 2023; 20:e2571. [PMID: 37655499 DOI: 10.1002/rcs.2571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/22/2023] [Accepted: 08/20/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy, especially after pylorus preservation (Pp). We evaluated the effect of a fully robotic approach with da Vinci Xi on DGE after PpPD. METHODS Open and robotic PDs were performed in 353 and 50 cases, respectively, from January 2009 to March 2022. We compared the clinical outcomes and incidence of clinically relevant DGE between robotic PpPD (R-PpPD) and open PpPD after one-to-one case-control matching. RESULTS Each group consisted of 30 patients. Clinically relevant DGE was less common after R-PpPD (3/30 [10%] vs. 10/30 cases [33.3%], p = 0.028). The median length of hospital stay (LoS) was significantly lower in the R-PpPD group (10 vs. 15 days, p = 0.013). CONCLUSION The reduced tissue trauma by the minimally invasive robotic approach is associated with a lower incidence of DGE, reducing the LoS and encouraging PpPD performed using the fully robotic approach.
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Affiliation(s)
- Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Cristina Carpenito
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Annalisa Comandatore
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Elisa Giovannetti
- Fondazione Pisana per la Scienza ONLUS, Pisa, Italy
- Department of Medical Oncology, Amsterdam University Medical Center, VU University, Amsterdam, the Netherlands
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alfred Cuschieri
- Institute for Medical Science and Technology, University of Dundee, Scotland, UK
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10
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Miyamoto R, Takahashi A, Ogura T, Kitamura K, Ishida H, Matsudaira S, Kihara A, Kanda H, Kawashima Y. Transduodenal ampullectomy for early ampullary cancer: Clinical management, histopathological findings and long-term outcomes at a single center. Surgery 2023; 173:912-919. [PMID: 36697354 DOI: 10.1016/j.surg.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Transduodenal ampullectomy has been attempted in ampullary tumors, including early ampullary cancer. However, the indication and extent of transduodenal ampullectomy with curative intent remain controversial. Herein, we address the perioperative and long-term outcomes of patients with early ampullary cancer who underwent transduodenal ampullectomy at a single center. METHODS We retrospectively enrolled 10 early ampullary cancer patients who underwent transduodenal ampullectomy and 11 early ampullary cancer patients who underwent subtotal stomach-preserving pancreatoduodenectomy at Saitama Cancer Center between October 2008 and May 2021. Among this cohort, we analyzed the perioperative outcomes and long-term outcomes. RESULTS In terms of the perioperative outcomes between the transduodenal ampullectomy and subtotal stomach-preserving pancreatoduodenectomy groups, the transduodenal ampullectomy group exhibited a shorter operating time (244 minutes vs 390 minutes, P = .003), less intraoperative blood loss (67.5 grams vs 774 grams, P = .006) and shorter length of postoperative hospital stay (15 days vs 33 days). With respect to the postoperative nutrition status, the transduodenal ampullectomy group exhibited less postoperative weight loss (0.67% vs 8.95%, P = .021), a better Controlling Nutritional Status score (1.0 vs 2.1, P = .011) and a better Prognostic Nutritional Index score (42.9 vs 40.9, P = .018). The 5-year survival in the adenoma with high-grade dysplasia and T1 ampullary cancer which invaded the mucosal layer groups was 100%, whereas the median survival time in the T1 ampullary cancer which invaded the sphincter of Oddi group was 20.7 months (P = .0028). CONCLUSION Transduodenal ampullectomy is assumed to be a feasible and effective surgical procedure for the treatment of selected patients with early ampullary cancer, including patients with adenoma with high-grade dysplasia or T1 ampullary cancer which invaded the mucosal layer ampullary cancer.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan.
| | - Amane Takahashi
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Toshiro Ogura
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Kei Kitamura
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Hiroyuki Ishida
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Shinichi Matsudaira
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Atsushi Kihara
- Department of Pathology, Jichi Medical University, Tochigi, Japan
| | - Hiroaki Kanda
- Department of Pathology, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Yoshiyuki Kawashima
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
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11
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Niwano F, Babaya N, Hiromine Y, Matsumoto I, Kamei K, Taketomo Y, Yoshida S, Takeyama Y, Noso S, Ikegami H. Three-Year Observation of Glucose Metabolism After Pancreaticoduodenectomy: A Single-Center Prospective Study in Japan. J Clin Endocrinol Metab 2022; 107:3362-3369. [PMID: 36074913 PMCID: PMC9693916 DOI: 10.1210/clinem/dgac529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT The glucose tolerance of patients changes considerably from before to after pancreaticoduodenectomy wherein approximately half of the pancreas is resected. OBJECTIVE The aim of this prospective study was to investigate the incidence of and risk factors for diabetes after pancreaticoduodenectomy. METHODS This study is a part of an ongoing prospective study, the Kindai Prospective Study on Metabolism and Endocrinology after Pancreatectomy (KIP-MEP) study. Of the 457 patients enrolled to date, 96 patients without diabetes who underwent pancreaticoduodenectomy were investigated in this study. Preoperatively, 1 month post-pancreaticoduodenectomy, and every 6 months thereafter, the glucose metabolism and endocrine function were evaluated using the 75 g oral glucose tolerance test. Various other metabolic, endocrine, and exocrine indices were also examined over a period of up to 36 months. RESULTS Of the 96 patients analyzed in this study, 33 were newly diagnosed with diabetes. The cumulative diabetes incidence at 36 months following pancreaticoduodenectomy was 53.8%. The preoperative insulinogenic index and ΔC-peptide in the glucagon stimulation test were significantly lower in the progressors to diabetes than in the nonprogressors. Multivariate Cox regression analysis demonstrated that the insulinogenic index was the only significant risk factor for new-onset diabetes. CONCLUSION The majority of patients developed new-onset diabetes after pancreaticoduodenectomy, and a low value of the insulinogenic index was suggested to be a risk factor for diabetes. Preoperative assessment for the prediction of the onset of diabetes serves as useful information for patients and is important for postoperative glycemic control and diabetes management in patients who require pancreaticoduodenectomy.
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Affiliation(s)
- Fumimaru Niwano
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Naru Babaya
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yoshihisa Hiromine
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Keiko Kamei
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yasunori Taketomo
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Sawa Yoshida
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka 589-8511, Japan
| | - Hiroshi Ikegami
- Correspondence: Hiroshi Ikegami, MD, PhD, Department of Endocrinology, Metabolism, and Diabetes, Kindai University Faculty of Medicine 377-2 Ohno-higashi, Osaka-sayama, Osaka 589-8511, Japan.
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12
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Jin Q, Ren Q, Chang X, Lu X, Wang G, He N. Pylorus-preserving versus Pylorus-resecting: Impact on dynamic changes of nutrition and body composition in pancreatic cancer patients before and after pancreatoduodenectomy. Cancer Med 2022; 12:2713-2721. [PMID: 36028989 PMCID: PMC9939197 DOI: 10.1002/cam4.5155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 07/05/2022] [Accepted: 08/08/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To investigate if different methods of pancreatoduodenectomy (with or without pyloric preservation) would have different impacts on postoperative nutrition and body composition changes among pancreatic cancer patients. METHODS Demographic and clinicopathological data, perioperative data were collected, body composition (e.g. skeletal muscle cross-sectional area [CSA], visceral fat area [VFA]) were evaluated with abdominal CT before and after surgery. Sarcopenia patients' proportion changes were also recorded. RESULTS The hospital stay in the PRPD group was significantly less than that in the PPPD group (p < 0.05). A significant difference was found in CSA, skeletal muscle index (SMI), VFA, VFA/CSA and albumin (ALB) in both groups between preoperative, 3, and 12 months after surgery. The loss of visceral fat in the PRPD group was more prominent than that in the PPPD group at 3 months and 12 months after surgery (p < 0.05). VFA/CSA was higher in the PPPD group than in the PRPD group (3 months: p < 0.05, 12 months: p < 0.001). The proportion of sarcopenic patients increased significantly over time in the PPPD and PRPD groups (p < 0.001). CONCLUSIONS Postoperative CSA and VFA continued to significantly decrease in both PPPD and PRPD groups, while the incidence of sarcopenia continued to increase. Compared with PRPD, PPPD has a protective effect on visceral fat. PPPD may contribute to better maintaining visceral fat mass and blood ALB levels. CT quantification can be an objective and effective method to evaluate the nutritional status of pancreatic cancer patients during the pre- and postoperative period and can provide a useful objective basis for guiding clinical treatment.
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Affiliation(s)
- Qianna Jin
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Qianqian Ren
- Department of Radiology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina,Hubei Province Key Laboratory of Molecular ImagingWuhanChina
| | - Xiaona Chang
- Department of Pathology, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiaoming Lu
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Guobin Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Nan He
- Cancer Center, Union Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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13
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Kimura K, Minagawa R, Izumi T, Otake A, Aoyagi T, Taniguchi D, Yano H, Kajiwara Y, Minami K, Nishizaki T. Ligation of left gastric vein may cause delayed gastric emptying after pancreatoduodenectomy: a retrospective study. BMC Gastroenterol 2022; 22:398. [PMID: 36008761 PMCID: PMC9414412 DOI: 10.1186/s12876-022-02478-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to determine which running pattern of the left gastric vein (LGV) is most frequently ligated in subtotal stomach-preserving pancreatoduodenectomy (SSPPD) and how LGV ligation affects delayed gastric emptying (DGE) after SSPPD. Methods We retrospectively analysed 105 patients who underwent SSPPD between January 2016 and September 2021. We classified the running pattern of LGV as follows: type 1 runs dorsal to the common hepatic artery (CHA) or splenic artery (SpA) to join the portal vein (PV), type 2 runs dorsal to the CHA or SpA and joins the splenic vein, type 3 runs ventral to the CHA or SpA and joins the PV, and type 4 runs ventral to the CHA or SpA and joins the SpV. Univariate and multivariate analyses were used to identify differences between patients with and without DGE after SSPPD. Results Type 1 LGV running pattern was observed in 47 cases (44.8%), type 2 in 23 (21.9%), type 3 in 12 (11.4%), and type 4 in 23 (21.9%). The ligation rate was significantly higher in type 3 (75.0%) LGVs (p < 0.0001). Preoperative obstructive jaundice (p = 0.0306), LGV ligation (p < 0.0001), grade B or C pancreatic fistula (p = 0.0116), and sepsis (p = 0.0123) were risk factors for DGE in the univariate analysis. Multivariate analysis showed that LGV ligation was an independent risk factor for DGE (odds ratio: 13.60, 95% confidence interval: 3.80–48.68, p < 0.0001). Conclusion Type 3 LGVs are often ligated because they impede lymph node dissection; however, LGV preservation may reduce the occurrence of DGE after SSPPD. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02478-5.
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Affiliation(s)
- Koichi Kimura
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan.
| | - Ryosuke Minagawa
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
| | - Takuma Izumi
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
| | - Akihiko Otake
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
| | - Takehiko Aoyagi
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
| | - Daisuke Taniguchi
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
| | - Hiroko Yano
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
| | - Yuichiro Kajiwara
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
| | - Kazuhito Minami
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
| | - Takashi Nishizaki
- Department of Surgery, Matsuyama Red Cross Hospital, 1, Bunkyomachi, Matsuyama City, Ehime, 790-8524, Japan
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14
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Busquets J, Martín S, Secanella L, Sorribas M, Cornellà N, Altet J, Peláez N, Bajen M, Carnaval T, Videla S, Fabregat J. Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD). Langenbecks Arch Surg 2022; 407:2247-2258. [PMID: 35786739 PMCID: PMC9468034 DOI: 10.1007/s00423-022-02583-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 06/04/2022] [Indexed: 10/29/2022]
Abstract
PURPOSE Pylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques. METHODS This pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status. RESULTS A total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35-65%) in the study group and 62% (24/39, 95% CI: 46-75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status. CONCLUSION DGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03984734.
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Affiliation(s)
- J Busquets
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain. .,Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain.
| | - S Martín
- General and Digestive Surgery Service, Viladecans Hospital, Viladecans, Spain
| | - Ll Secanella
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - M Sorribas
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - N Cornellà
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - J Altet
- General and Digestive Surgery Service, Mar Hospital, Barcelona, Spain
| | - N Peláez
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - M Bajen
- Department of Nuclear Medicine, Bellvitge University Hospital, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - T Carnaval
- Clinical Research Support Unit (HUB·IDIBELL), Clinical Pharmacology Department, Bellvitge University Hospital, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - S Videla
- Clinical Research Support Unit (HUB·IDIBELL), Clinical Pharmacology Department, Bellvitge University Hospital, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain.,Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain
| | - J Fabregat
- Department of Hepatobiliary and Pancreatic Surgery, Bellvitge University Hospital, Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, University of Barcelona, Carrer de la Feixa Llarga s/n, 08907, L´Hospitalet de Llobregat, Barcelona, Spain.,Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), c. Casanova, 143, 08036, Barcelona, Spain
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Abstract
OBJECTIVES Delayed gastric emptying (DGE) is a complication that affects the length of hospitalization and associated cost after pancreaticoduodenectomy (PD). The reported risk factors for DGE were controversial. This study aimed to identify risk factors for the development of DGE after PD. METHODS The patients who underwent PD between October 2010 and October 2020 were retrospectively examined. Multivariate analysis was performed to predict the variables causing DGE. RESULTS In total, 225 patients underwent PD. The pylorus preserving PD was applied to 151 patients (67%), whereas standard PD to 74 (33%). The DGE was detected in 26 patients (11.5%). The majority of cases were classified as grade A (57.7%), whereas 38.4% as grade B and 3.9% as grade C. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 3.48; 95% confidence interval [CI], 1.45-8.34; P = 0.05), the preoperative biliary stent (OR, 2.5; 95% CI, 1.04-5.99; P = 0.039), and the pylorus resection (OR, 3.05; 95% CI, 1.28-7.25; P = 0.012) were independently associated with DGE. CONCLUSIONS We demonstrated that implementation of the preoperative stent, pylorus resection, and diabetes mellitus are independent risk factors for DGE. Pylorus preservation should remain the standard of care in PD.
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16
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Hillebrecht HC, Fichtner-Feigl S, Diener M. RCTs in der Pankreaschirurgie der letzten 10 Jahre – ein Update. Zentralbl Chir 2022; 147:196-208. [DOI: 10.1055/a-1765-4402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ZusammenfassungRandomisiert kontrollierte Studien (RCT) stellen eine der wichtigsten Quellen neuer Evidenz für die Behandlung insbesondere onkologischer Patienten dar. Insbesondere auf dem Gebiet der
Pankreaschirurgie, wo Komplikationen vergleichsweise häufig und schwerwiegend sind, sind innovative operativ-technische wie auch periinterventionelle Innovationen gefragt, die in der Lage
sind, Morbidität und Mortalität zu reduzieren. Trotz der mannigfaltigen methodischen Herausforderungen bei der Durchführung chirurgischer RCTs konnten in den letzten 10 Jahren große und
wissenschaftlich hochwertige Studien verzeichnet werden.Dieser Review gibt einen Überblick über wichtige, bereits abgeschlossene und publizierte, aber auch über interessante und wichtige ausstehende RCTs in der Pankreaschirurgie.
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Affiliation(s)
- H Christian Hillebrecht
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Stefan Fichtner-Feigl
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Markus Diener
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
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17
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Schrempf MC, Pinto DRM, Wolf S, Geissler B, Sommer F, Hoffmann M, Vlasenko D, Gutschon J, Anthuber M. Intraoperative endoluminal pyloromyotomy for reduction of delayed gastric emptying after pylorus preserving partial pancreaticoduodenectomy (PORRIDGE trial): study protocol for a randomised controlled trial. Trials 2022; 23:74. [PMID: 35078510 PMCID: PMC8787914 DOI: 10.1186/s13063-022-06032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 01/15/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Pylorus-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.
Methods
This 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.
Discussion
DGE 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 registration
German Clinical Trials RegisterDRKS00013503. Registered on 27 December 2017.
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Gumbs AA, Chouillard E, Abu Hilal M, Croner R, Gayet B, Gagner M. The experience of the minimally invasive (MI) fellowship-trained (FT) hepatic-pancreatic and biliary (HPB) surgeon: could the outcome of MI pancreatoduodenectomy for peri-ampullary tumors be better than open? Surg Endosc 2021; 35:5256-5267. [PMID: 33146810 DOI: 10.1007/s00464-020-08118-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained (FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques. METHOD We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery. RESULTS From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (p = 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p < 0.001 and p = 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min), p < 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively, p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively, p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (p = 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (p = 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (p = 0.03). CONCLUSION FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.
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Affiliation(s)
- Andrew A Gumbs
- Département de Chirurgie Digestive, Centre Hospitalier Intercommunal de POISSY/SAINT-GERMAIN-EN-LAYE, 10, Rue du Champ Gaillard, 78300, Poissy, France
| | - Elie Chouillard
- Département de Chirurgie Digestive, Centre Hospitalier Intercommunal de POISSY/SAINT-GERMAIN-EN-LAYE, 10, Rue du Champ Gaillard, 78300, Poissy, France
| | - Mohamed Abu Hilal
- Unità Chirurgia Epatobiliopancreatica, Robotica e Mininvasiva, Fondazione Poliambulanza Istituto Ospedaliero, via Bissolati, 57, Brescia, 25124, Italia
| | - Roland Croner
- Department of General-, Visceral-, Vascular- and Transplantation Surgery, University of Magdeburg, Haus 60a, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Brice Gayet
- Department of Digestive Diseases, Institut Mutaliste Montsouris, 42, Boulevard Jourdan, 75014, Paris, France
| | - Michel Gagner
- Clinique Michel Ganger, Inc, 1 Carré Westmount Suite 801, Westmount, QC, H3Z 2P9, Canada.
- Department of Surgery, Hôpital du Sacre Coeur, Montréal, QC, H4J 1C5, Canada.
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Tewari M, Swain JR, Mahendran R. Update on Management Periampullary/Pancreatic Head Cancer. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02053-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Varghese C, Bhat S, Wang THH, O’Grady G, Pandanaboyana S. Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials. BJS Open 2021; 5:zrab035. [PMID: 33989392 PMCID: PMC8121488 DOI: 10.1093/bjsopen/zrab035] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/10/2021] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several 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. METHODS 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 enteroenterostomy (Braun). 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 Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6 per cent (647 patients). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35 per cent of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32 per cent of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (odds ratio 2.10, 95 per cent credibility interval (cr.i.) 0.92 to 4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when this was used (odds ratio 1.90, 95 per cent cr.i. 0.92 to 3.90). Having a Braun enteroenterostomy ranked the best in 96 per cent of comparisons. CONCLUSION Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE. PREREGISTRATION PROSPERO submitted 23 December 2020. CRD42021227637.
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Affiliation(s)
- C Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - S Bhat
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - T H -H Wang
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - G O’Grady
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - S Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Niwano F, Babaya N, Hiromine Y, Matsumoto I, Kamei K, Noso S, Taketomo Y, Takeyama Y, Kawabata Y, Ikegami H. Glucose Metabolism After Pancreatectomy: Opposite Extremes Between Pancreaticoduodenectomy and Distal Pancreatectomy. J Clin Endocrinol Metab 2021; 106:e2203-e2214. [PMID: 33484558 PMCID: PMC8063252 DOI: 10.1210/clinem/dgab036] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT The rate of glucose metabolism changes drastically after partial pancreatectomy. OBJECTIVE This work aims to analyze changes in patients' glucose metabolism and endocrine and exocrine function before and after partial pancreatectomy relative to different resection types (Kindai Prospective Study on Metabolism and Endocrinology after Pancreatectomy: KIP-MEP study). METHODS A series of 278 consecutive patients with scheduled pancreatectomy were enrolled into our prospective study. Of them, 109 individuals without diabetes, who underwent partial pancreatectomy, were investigated. Data were compared between patients with pancreaticoduodenectomy (PD, n = 73) and those with distal pancreatectomy (DP, n = 36). RESULTS Blood glucose levels during the 75-g oral glucose tolerance test (75gOGTT) significantly decreased after pancreatectomy in the PD group (area under the curve [AUC] -9.3%, P < .01), and significantly increased in the DP population (AUC + 16.8%, P < .01). Insulin secretion rate during the 75gOGTT and glucagon stimulation test significantly decreased after pancreatectomy both in the PD and DP groups (P < .001). Both groups showed similar homeostasis model assessment of insulin resistance (HOMA-IR) values after pancreatectomy. Decrease in exocrine function quality after pancreatectomy was more marked in association with PD than DP (P < .01). Multiple regression analysis indicated that resection type and preoperative HOMA-IR independently influenced glucose tolerance-related postoperative outcomes. CONCLUSIONS Blood glucose levels after the OGTT differed markedly between PD and DP populations. The observed differences between PD and DP suggest the importance of individualization in the management of metabolism and nutrition after partial pancreatectomy.
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Affiliation(s)
- Fumimaru Niwano
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Naru Babaya
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Yoshihisa Hiromine
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Keiko Kamei
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Shinsuke Noso
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Yasunori Taketomo
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Yumiko Kawabata
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
| | - Hiroshi Ikegami
- Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, Osaka-sayama, Osaka, Japan
- Correspondence: Hiroshi Ikegami, MD, PhD, Department of Endocrinology, Metabolism and Diabetes, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osaka-sayama, Osaka, 589-8511, Japan.
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Xiao Y, Hao X, Yang Q, Li M, Wen J, Jiang C. Effect of Billroth-II versus Roux-en-Y reconstruction for gastrojejunostomy after pancreaticoduodenectomy on delayed gastric emptying: A meta-analysis of randomized controlled trials. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:397-408. [PMID: 32897643 DOI: 10.1002/jhbp.828] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/PURPOSE 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. METHODS 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. RESULTS 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. CONCLUSIONS B-II reconstruction after PD has a lower incidence of grade B and C DGE and shorter operation time compared with R-Y reconstruction.
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Affiliation(s)
- Yuqing Xiao
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Xiaofei Hao
- Department of General Medicine, Chengdu Fifth People's Hospital, Chengdu, China
| | - Qin Yang
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Ming Li
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Jun Wen
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
| | - Cuina Jiang
- Department of Hepatopancreatobiliary Surgery, Chengdu Third People's Hospital, Chengdu, China
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23
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Schrempf MC, Pinto DRM, Gutschon J, Schmid C, Hoffmann M, Geissler B, Wolf S, Sommer F, Anthuber M. Intraoperative endoluminal pyloromyotomy as a novel approach to reduce delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy-a retrospective study. Langenbecks Arch Surg 2020; 406:1103-1110. [PMID: 33057756 PMCID: PMC8208917 DOI: 10.1007/s00423-020-02008-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/01/2020] [Indexed: 01/26/2023]
Abstract
Background Delayed gastric emptying (DGE) is one of the most common complications after pylorus-preserving partial pancreaticoduodenectomy (ppPD). The aim of this retrospective study was to assess whether an intraoperative pyloromyotomy during ppPD prior to the creation of duodenojejunostomy reduces DGE. Methods Patients who underwent pylorus-preserving pancreaticoduodenectomy between January 2015 and December 2017 were divided into two groups on the basis of whether an intraoperative pyloromyotomy was performed (pyloromyotomy (PM) group) or not (no pyloromyotomy (NP) group). The primary endpoint was DGE according to the ISGPS definition. The confirmatory analysis of the primary endpoint was performed with multivariate analysis. Results One hundred and ten patients were included in the statistical analysis. Pyloromyotomy was performed in 44 of 110 (40%) cases. DGE of any grade was present in 62 patients (56.4%). The DGE rate was lower in the PM group (40.9%) compared with the NP group (66.7%), and pyloromyotomy was associated with a reduced risk for DGE in univariate (OR 0.35, 95% CI 0.16–0.76; P = 0.008) and multivariate analyses (OR 0.32, 95% CI 0.13–0.77; P = 0.011). The presence of an intra-abdominal complication was an independent risk factor for DGE in the multivariate analysis (OR 5.54, 95% CI 2.00–15.36; P = 0.001). Conclusion Intraoperative endoluminal pyloromyotomy during ppPD was associated with a reduced risk for DGE in this retrospective study. Pyloromyotomy should be considered a simple technique that can potentially reduce DGE rates after ppPD.
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Affiliation(s)
- Matthias C Schrempf
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany.
| | - David R M Pinto
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Johanna Gutschon
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Christoph Schmid
- Department of Hematology and Oncology, University Hospital Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Michael Hoffmann
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Bernd Geissler
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Sebastian Wolf
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Florian Sommer
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
| | - Matthias Anthuber
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Stenglinstrasse 2, Augsburg, 86156, Germany
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Is delayed gastric emptying associated with pylorus ring preservation in patients undergoing pancreaticoduodenectomy? Asian J Surg 2020; 44:137-142. [PMID: 32951961 DOI: 10.1016/j.asjsur.2020.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/OBJECTIVE A high incidence of delayed gastric emptying (DGE) is observed in patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). However, DGE incidence after pancreaticoduodenectomy varied because of heterogeneity in surgical techniques, number of surgeons, and DGE definition. This study aimed to evaluate the difference in the incidence of DGE following PpPD and pylorus-resecting pancreaticoduodenectomy (PrPD) and to analyze the risk factor of DGE by a single surgeon to determine whether pylorus preservation was the main factor of DGE. METHODS This retrospective study included 115 patients who underwent PpPD (with pylorus ring preservation) and PrPD (without pylorus ring preservation) with laparotomy by a single surgeon at a tertiary center. RESULTS The overall incidence of DGE was 23.1%. For comparison, 20 patients (39.2%) in the PpPD group and 5 patients (8.8%) in the PrPD group had DGE, showing a significant difference (p < 0.001). On univariate analysis, hypertension, PpPD, operation time, intraoperative bleeding, packed red blood cell transfusion ≥500 mL, and clinically relevant postoperative pancreatic fistula were associated with DGE. Multivariate analysis identified pylorus preservation and clinically relevant postoperative pancreatic fistula as risk factors for DGE. CONCLUSION Compared with PpPD, PrPD significantly reduced the incidence of DGE.
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Cai X, Zhang M, Liang C, Xu Y, Yu W. Delayed gastric emptying after Pancreaticoduodenectomy: a propensity score-matched analysis and clinical Nomogram study. BMC Surg 2020; 20:149. [PMID: 32646466 PMCID: PMC7346444 DOI: 10.1186/s12893-020-00809-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/29/2020] [Indexed: 01/08/2023] Open
Abstract
Background Delayed gastric emptying (DGE) is a common and frustrating complication of pancreaticoduodenectomy (PD). Studies suggest that surgical methods and other clinical characteristics may affect the occurrence of DGE. Nevertheless, the results of such studies are conflicting. The objective of this work was to perform a propensity score matching analysis to compare the differences between pylorus-preserving pancreaticoduodenectomy (PPPD) and pylorus-removing pancreaticoduodenectomy (PrPD) and to develop and validate a nomogram to predict the probability of severe DGE (SDGE). Methods This retrospective study enrolled patients who underwent PD at our institution from December 2009 to December 2018. Propensity score matching was applied at a ratio of 1:1 to compare PPPD and PrPD groups. We compared incidence of complications, DGE, lengths of hospital stay, hospitalization costs, and mortality. Univariate and multivariate logistic regression analysis were performed to identify potential risk factors of severe DGE. Finally, a nomogram was developed and validated to predict severe DGE. Results The PPPD group had a significantly higher rate of postoperative pancreatic fistula (29.9% versus 17.4%, P < 0.05) and less blood loss (463.7 ml versus 694.9 ml, P < 0.05). After propensity score matching, the PPPD group had a significantly higher rate of postoperative DGE (19.2% versus 3.8%, P < 0.05), especially severe DGE (17.3% versus 0%) than the PrPD group. There were no significant differences in terms of lengths of hospital stay, hospitalization costs or mortality between the groups. Surgical method, biliary leakage, abdominal infection, and diabetes were independent risk factors for SDGE. The nomogram predicted SDGE with a training C - index of 0.798 and a validation C - index of 0.721. Conclusion PPPD increases the risk of DGE than PrPD, especially SDGE. Our prediction nomogram gives good prediction of SDGE after pancreaticoduodenectomy.
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Affiliation(s)
- Xianlei Cai
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China
| | - Miaozun Zhang
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China
| | - Chao Liang
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China
| | - Yuan Xu
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China
| | - Weiming Yu
- Department of Gastrointestinal Surgery, Ningbo Medical Center Lihuili Hospital, 57 Xingning Road, 315000, Ningbo, PR China.
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Influence of the Retrocolic Versus Antecolic Route for Alimentary Tract Reconstruction on Delayed Gastric Emptying After Pancreatoduodenectomy: A Multicenter, Noninferiority Randomized Controlled Trial. Ann Surg 2020; 274:935-944. [PMID: 32773628 DOI: 10.1097/sla.0000000000004072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to determine whether retrocolic alimentary tract reconstruction is noninferior to antecolic reconstruction in terms of DGE incidence after pancreatoduodenectomy (PD) and investigated patients' postoperative nutritional status. SUMMARY OF BACKGROUND DATA The influence of the route of alimentary tract reconstruction on DGE after PD is controversial. METHODS Patients from 9 participating institutions scheduled for PD were randomly allocated to the retrocolic or antecolic reconstruction groups. The primary outcome was incidence of DGE, defined according to the 2007 version of the International Study Group for Pancreatic Surgery definition. Noninferiority would be indicated if the incidence of DGE in the retrocolic group did not exceed that in the antecolic group by a margin of 10%. Patients' postoperative nutrition data were compared as secondary outcomes. RESULTS Total, 109 and 103 patients were allocated to the retrocolic and antecolic reconstruction group, respectively (n = 212). Baseline characteristics were similar between both groups. DGE occurred in 17 (15.6%) and 13 (12.6%) patients in the retrocolic and antecolic group, respectively (risk difference; 2.97%, 95% confidence interval; -6.3% to 12.6%, which exceeded the specified margin of 10%). There were no differences in the incidence of other postoperative complications and in the duration of hospitalization. Postoperative nutritional indices were similar between both groups. CONCLUSIONS This trial could not demonstrate the noninferiority of retrocolic to antecolic alimentary tract reconstruction in terms of DGE incidence. The alimentary tract should not be reconstructed via the retrocolic route after PD, to prevent DGE.
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Snyder RA, Ewing JA, Parikh AA. Delayed gastric emptying after pancreaticoduodenectomy: A study of the national surgical quality improvement program. Pancreatology 2020; 20:205-210. [PMID: 31875832 DOI: 10.1016/j.pan.2019.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/22/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) remains common after pancreaticoduodenectomy (PD). Risk factors for DGE have been difficult to identify due to a lack of a standard definition. The purpose of this study was to identify factors associated with DGE using a standard definition across a national cohort of patients. METHODS A retrospective cohort study of patients who underwent PD from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific module was performed. Multivariable (MV) regression was used to determine perioperative risk factors for DGE. RESULTS Of 10,249 patients undergoing PD, 16.6% developed DGE and were older (65.3 vs. 64.3 years), more often male (62.5% vs. 51.9%), overweight/obese (66.7% vs. 61.3%), and American Society of Anesthesiologist (ASA) class 3 (80.0% vs. 76.0%). Rates of pylorus preservation (41.4% vs. 38.7%) were higher, and median operative time (373 vs. 354 min) longer. On MV analysis, age≥65 years [OR 1.26 (95%CI 1.13-1.41)], male sex [OR 1.54 (95%CI 1.38-1.72), body mass index (BMI) > 30 [OR 1.22 (95%CI 1.06-1.40)], ASA class≥3 [OR 1.24 (95%CI 1.08-1.42)], pylorus preservation [OR 1.08 (95%CI 1.02-1.14)], and longer operative time [OR 1.26 (95%CI 1.13-1.40)] remained associated with DGE. Preoperative chemotherapy was associated with decreased risk of DGE [OR 0.77 (95%CI 0.64-0.93)]. CONCLUSION In this national, multicenter cohort of patients undergoing PD, 16.6% of patients developed DGE based on a standardized definition. Perioperative factors including age, BMI, ASA class, pylorus preservation, and operative time were associated with increased risk of DGE. Further research is warranted to identify opportunities for prevention via preoperative rehabilitation strategies and treatment.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, University of South Carolina School of Medicine- Greenville, Greenville, SC, USA; Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Joseph A Ewing
- Department of Surgery, University of South Carolina School of Medicine- Greenville, Greenville, SC, USA
| | - Alexander A Parikh
- Department of Surgery, University of South Carolina School of Medicine- Greenville, Greenville, SC, USA; Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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Klaiber U, Probst P, Hüttner FJ, Bruckner T, Strobel O, Diener MK, Mihaljevic AL, Büchler MW, Hackert T. Randomized Trial of Pylorus-Preserving vs. Pylorus-Resecting Pancreatoduodenectomy: Long-Term Morbidity and Quality of Life. J Gastrointest Surg 2020; 24:341-352. [PMID: 30671796 DOI: 10.1007/s11605-018-04102-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/29/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The randomized controlled PROPP trial (DKRS00004191) showed that pylorus-resecting pancreatoduodenectomy (PR) is not superior to the pylorus-preserving procedure (PP) in terms of perioperative outcome, specifically in reduction of delayed gastric emptying. Non-superiority of PR was also confirmed in a recent meta-analysis of randomized controlled trials. However, long-term data on morbidity and quality of life after PP compared to PR are sparse. The aim of this study was to investigate long-term outcomes of patients included in the PROPP trial. METHODS Between February 2013 and June 2016, a total of 188 patients underwent PD and were intraoperatively randomized to either preservation or resection of the pylorus (95 vs. 93 patients). For long-term follow-up, morbidity and quality of life (EORTC QLQ-C30/PAN26) were monitored until January 1, 2018. Statistical analysis was performed on an intention-to-treat basis. RESULTS The mean duration of follow-up was 34.3 (± 11.3) months. Sixty-three of the 188 patients had died (PP n = 33, PR n = 30), 29 patients were lost to follow-up (PP n = 17, PR n = 12), and the remaining 96 patients were included in long-term follow-up (PP n = 45, PR n = 51). There was no difference between PP and PR patients regarding endocrine and exocrine pancreatic function, receipt of adjuvant/palliative chemotherapy, cancer recurrence, and other relevant characteristics. Late cholangitis occurred significantly more often in patients following pylorus resection (P = 0.042). Reoperations, readmissions to hospital, and quality of life scores except pain were comparable between the two study groups. CONCLUSIONS Similar to short-term results, long-term follow-up showed no significant differences between pylorus resection compared to pylorus preservation.
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Affiliation(s)
- Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Felix J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Pylorus Resection Does Not Reduce Delayed Gastric Emptying After Partial Pancreatoduodenectomy: A Blinded Randomized Controlled Trial (PROPP Study, DRKS00004191). Ann Surg 2019; 267:1021-1027. [PMID: 28885510 DOI: 10.1097/sla.0000000000002480] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the effect of pylorus resection on postoperative delayed gastric emptying (DGE) after partial pancreatoduodenectomy (PD). BACKGROUND PD is the standard treatment for tumors of the pancreatic head. Preservation of the pylorus has been widely accepted as standard procedure. DGE is a common complication causing impaired oral intake, prolonged hospital stay, and postponed further treatment. Recently, pylorus resection has been shown to reduce DGE. METHODS Patients undergoing PD for any indication at the University of Heidelberg were randomized to either PD with pylorus preservation (PP) or PD with pylorus resection and complete stomach preservation (PR). The primary endpoint was DGE within 30 days according to the International Study Group of Pancreatic Surgery definition. RESULTS Ninety-five patients were randomized to PP and 93 patients to PR. There were no baseline imbalances between the groups. Overall, 53 of 188 patients (28.2%) developed a DGE (grade: A 15.5%; B 8.8%; C 3.3%). In the PP group 24 of 95 patients (25.3%) and in the PR group 29 of 93 patients (31.2%) developed DGE (odds ratio 1.534, 95% confidence interval 0.788 to 2.987; P = 0.208). Higher BMI, indigestion, and intraabdominal major complications were significant risk factors for DGE. CONCLUSIONS In this randomized controlled trial, pylorus resection during PD did not reduce the incidence or severity of DGE. The development of DGE seems to be multifactorial rather than attributable to pyloric dysfunction alone. Pylorus preservation should therefore remain the standard of care in PD. TRIAL REGISTRATION German Clinical Trials Register DRKS00004191.
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Miyamoto R, Oshiro Y, Sano N, Inagawa S, Ohkohchi N. Remnant pancreatic volume as an indicator of poor prognosis in pancreatic cancer patients after resection. Pancreatology 2019; 19:716-721. [PMID: 31178397 DOI: 10.1016/j.pan.2019.05.464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/21/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Remnant pancreatic volume (RPV) is a well-known marker for short-term outcomes in pancreatic cancer patients after resection. However, in terms of the long-term outcomes, the significance of the RPV value remains unclear. Here, we address whether the RPV value is a predictor of the long-term outcomes in pancreatic cancer patients after resection by comparing various cancer-, patient-, and surgery-related prognostic factors and systemic inflammatory response markers in a retrospective cohort. METHODS The RPV was measured on a three-dimensional (3D) image, revealing the actual pancreatic parenchymal remnant volume. Ninety-one patients who underwent pancreaticoduodenectomy were retrospectively enrolled. We divided the cohort into high- and low-RPV groups based on a cut-off value (>31.5 cm3, n = 66 and ≤31.5 cm3, n = 25, respectively). The median survival times (MSTs) were compared between the two groups. Using multivariate analysis, the RPV and other well-known prognostic factors were independently assessed. RESULTS The MSTs (days) were significantly different between the two groups (high, 823 vs. low, 482, p = 0.001). Multivariate analysis identified the RPV (≤31.5 cm3) (hazard ratio [HR], 2.015; p = 0.011), lymph node metastasis (HR, 8.415; p = 0.002), lack of adjuvant chemotherapy (HR, 5.352; p < 0.001), stage III/IV disease (HR, 2.352; p = 0.029), and pathological fibrosis (HR, 1.771; p = 0.031) as independent prognostic factors. CONCLUSIONS The present study suggests that the RPV value is also useful for predicting long-term outcomes in pancreatic cancer patients after resection.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan; Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Yukio Oshiro
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naoki Sano
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Satoshi Inagawa
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Ellis RJ, Gupta AR, Hewitt DB, Merkow RP, Cohen ME, Ko CY, Bilimoria KY, Bentrem DJ, Yang AD. Risk factors for post-pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra-abdominal infection. J Surg Oncol 2019; 119:925-931. [PMID: 30737792 PMCID: PMC7747058 DOI: 10.1002/jso.25398] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/08/2019] [Accepted: 01/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), but the rate of DGE in the absence of other intra-abdominal complications is poorly understood. The objectives of this study were to define the incidence of DGE and identify risk factors for DGE in patients without pancreatic fistula or other intra-abdominal infections. METHODS Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy variables to identify patients with DGE following PD without evidence of fistula or intra-abdominal infection. Multivariable models were developed to assess preoperative, intraoperative, and technical factors associated with DGE. RESULTS The rate of DGE was 11.7% in 10502 cases without pancreatic fistula or intra-abdominal infection. Patients were more likely to develop DGE if age ≥75 (odds ratio [OR], 1.22; P = 0.003), male (OR, 1.29; P < 0.001), underwent pylorus-sparing PD (OR, 1.27; P = 0.004), or had a prolonged operative time (OR, 1.38 if greater than seven vs less than 5 hours; P = 0.005). Factors not associated with DGE included BMI, pathologic indication, and surgical approach. CONCLUSION The incidence of DGE after PD is notable even in patients without other abdominal complications. Identification of patients at increased risk for DGE may aid patient counseling as well as decisions regarding surgical technique, enteral feeding access, and enhanced-recovery pathways.
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Affiliation(s)
- Ryan J. Ellis
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Aakash R. Gupta
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - D. Brock Hewitt
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan P. Merkow
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Mark E. Cohen
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Clifford Y. Ko
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, California
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Karl Y. Bilimoria
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - David J. Bentrem
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Anthony D. Yang
- Department of Surgery, Surgical Outcomes and Quality Improvement Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Northwestern Institute for Comparative Effectiveness Research in Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
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Abstract
OBJECTIVES Delayed gastric emptying (DGE) is a critical complication after pancreaticoduodenectomy (PD). Antecolic gastrojejunostomy has long been adopted as standard procedure because it is thought to reduce DGE. However, we have used retrocolic gastrojejunostomy (retro-GJ) for more than 10 years and have not observed high DGE rates. We aimed to clarify whether our retro-GJ approach produced comparable outcomes in preventing DGE. METHODS A total of 211 patients who underwent pylorus-resecting PD with retro-GJ at our institution between 2005 and 2016 were retrospectively analyzed. The incidence rate of DGE and the length of postoperative hospital stay were assessed. RESULTS The overall incidence of DGE with our retro-GJ procedure was 13% (n = 28), and the rate of clinically relevant DGE (grade B or C based on the International Study Group of Pancreatic Surgery criteria) was 4% (n = 8). The median postoperative hospital stay was 17 days (interquartile range, 13-25 days). Major complications (Clavien-Dindo grade ≥III) occurred in 37% (n = 79) of patients and were not associated with the occurrence of clinically relevant DGE (P = 0.47). CONCLUSIONS Our retro-GJ approach after PD with gastrojejunostomy, which involves careful positioning at the left-sided inframesocolic point, satisfactorily prevents DGE.
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Miyamoto R, Oshiro Y, Sano N, Inagawa S, Ohkohchi N. Three-Dimensional Remnant Pancreatic Volumetry Predicts Postoperative Pancreatic Fistula in Pancreatic Cancer Patients after Pancreaticoduodenectomy. Gastrointest Tumors 2018; 5:90-99. [PMID: 30976580 DOI: 10.1159/000495406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/11/2018] [Indexed: 12/11/2022] Open
Abstract
Background Postoperative pancreatic fistula (POPF) is a serious complication that can occur following pancreaticoduodenectomy (PD). Recent studies suggest that remnant pancreatic volume (RPV) values from preoperative multidetector computed tomography (MDCT) are highly predictive of POPF. We performed three-dimensional (3D) surgical simulation of PD including RPV measurements. The aim of this study was to determine whether 3D-measured RPV is predictive of POPF after PD. Methods We used the SYNAPSE VINCENT® medical imaging system (Fujifilm Medical Co., Ltd., Tokyo, Japan) to construct 3D images after integrating MDCT and magnetic resonance cholangiopancreatography images. RPV was measured using this 3D image, which simulated actual intraoperative pancreatic parenchymal remnant volume. Ninety-one patients who underwent PD were retrospectively enrolled. Using multivariate analysis, RPV and other well-known POPF risk factors were independently assessed. Results Multivariate analysis identified high RPV values (hazard ratio [HR] = 8.41, p = 0.01), pancreatic duct diameter < 3.0 mm (HR = 5.48, p < 0.01), no pathological fibrosis (HR = 3.41, p < 0.01), and body mass index > 25 kg/m2 (HR = 1.53, p = 0.02) as independent risk factors for POPF. Conclusion The present study indicates that preoperative 3D-measured RPV is predictive of POPF after PD.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan.,Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Yukio Oshiro
- Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Naoki Sano
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Satoshi Inagawa
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Nobuhiro Ohkohchi
- Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
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Miyamoto R, Oshiro Y, Sano N, Inagawa S, Ohkohchi N. Three-dimensional surgical simulation of the bile duct and vascular arrangement in pancreatoduodenectomy: A retrospective cohort study. Ann Med Surg (Lond) 2018; 36:17-22. [PMID: 30370052 PMCID: PMC6199778 DOI: 10.1016/j.amsu.2018.09.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/21/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS We evaluated the usefulness of three-dimensional (3D) images for pancreatoduodenectomy (PD), including the classification of the bile duct and vascular arrangement, i.e., hepatic artery, inferior mesenteric vein (IMV) and left gastric vein (LGV). We evaluated the extent to which this simulation affected the perioperative outcomes of PD. METHODS In all, 117 patients who underwent PD were divided into the without-3D (n = 53) and with-3D (n = 64) groups, and perioperative outcomes were compared. We evaluated the arrangement of the accessory bile duct and the hepatic artery (type I: the right hepatic artery arising from the superior mesenteric artery, type II: the left hepatic artery arising from the left gastric artery, type III: the most common pattern) and the confluence pattern of the LGV and the IMV [type i: portal vein (PV):splenic vein (SV), type ii: PV:superior mesenteric vein (SMV), type iii: SV:SV, and type iv: SV:SMV] between the two groups. RESULTS Two patients had an accessory bile duct. The 3D images were classified as type I (n = 4), type II (n = 10), type III (n = 48) and other patterns (n = 2); type ii (n = 27) was the most frequent confluence pattern (p < 0.05). Intraoperative blood loss was reduced in the with-3D group (p < 0.05). CONCLUSIONS We propose that the 3D imaging technique is useful for preoperative assessment in PD.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Yukio Oshiro
- Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Naoki Sano
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Satoshi Inagawa
- Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Sato N, Hasegawa Y, Saito A, Motoi F, Ariake K, Katayose Y, Nakagawa K, Kawaguchi K, Fukudo S, Unno M, Sato F. Association between chronological depressive changes and physical symptoms in postoperative pancreatic cancer patients. Biopsychosoc Med 2018; 12:13. [PMID: 30288172 PMCID: PMC6162953 DOI: 10.1186/s13030-018-0132-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background Pancreatic cancer (PC) has poorer prognosis and higher surgical invasiveness than many other cancers, with associated psychiatric symptoms including depression and anxiety. Perioperative depression has not been investigated in PC patients regarding surgical stress and relevant interventions. Methods We evaluated chronological depressive changes and subjective physical symptoms in surgically treated PC patients preoperatively and at 3 and 6 months postoperatively. Enrolled patients undergoing pancreatic tumor surgery completed questionnaires based on the Self-Rating Depression Scale (SDS) and Functional Assessment of Cancer Therapy for Patients with Hepatobiliary Cancer (FACT-Hep) preoperatively, and at 3 and 6 months postoperatively. Responses were analyzed with JMP® Pro using one-way and two-way ANOVA, Spearman’s rank correlation coefficient, and multiple regression analysis. Results Malignancy was diagnosed in 73 of 101 patients postoperatively; SDS score was significantly higher in these patients than in those with benign tumors at all timepoints: malignant/benign, 41.8/37.9 preoperatively (p = 0.004); 43.5/37.8 3 months postoperatively (p = 0.006); and 42.9/37.7 6 months postoperatively (p = 0.020). SDS scores were significantly higher in patients < 65 years old with malignancy at 3 months than at 6 months postoperatively (44.6/42.5, p = 0.046) and in patients with malignancy who underwent pancreaticoduodenectomy at 3 months postoperatively than preoperatively (43.4/41.1; p = 0.028). SDS scores moderately correlated with 8 physical symptom-related FACT-Hep items 3 months postoperatively (p < 0.05), showing low-to-moderate correlation with 16 physical symptom-related FACT-Hep items at 6 months postoperatively (p < 0.05). Multiple regression analysis of FACT-Hep symptoms significantly correlated with SDS scores revealed the following significant variables: “lack of energy” (p < 0.000) and “pain” (p = 0.018) preoperatively (R2 = 0.43); “able to perform usual activities” (p = 0.031) and “lack of energy” (p < 0.000) at 3 months postoperatively (R2 = 0.51); and “stomach swelling or cramps” (p = 0.034) and “bowel control” (p = 0.049) at 6 months postoperatively (R2 = 0.52). Conclusions PC patients experience persistently high levels of depression preoperatively through 6 months postoperatively, with associated subjective symptoms including pain and gastrointestinal symptoms. Trial registration UMIN Clinical Trials Registry 000009592, Registered 20 December 2012.
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Affiliation(s)
- Naoko Sato
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan.,5Department of Oncology Nursing, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, 980-8575 Japan
| | - Yoshimi Hasegawa
- 2Department of Nursing, Tohoku University School of Health Sciences, Sendai, Japan
| | - Asami Saito
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fuyuhiko Motoi
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kyohei Ariake
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Katayose
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Nakagawa
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Kawaguchi
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shin Fukudo
- 4Department of Behavioral Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumiko Sato
- 1Department of Oncology Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
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Klaiber U, Probst P, Strobel O, Michalski CW, Dörr-Harim C, Diener MK, Büchler MW, Hackert T. Meta-analysis of delayed gastric emptying after pylorus-preserving versus pylorus-resecting pancreatoduodenectomy. Br J Surg 2018; 105:339-349. [PMID: 29412453 DOI: 10.1002/bjs.10771] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/22/2017] [Accepted: 10/30/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pylorus-preserving pancreatoduodenectomy. Recent studies have suggested that resection of the pylorus is associated with decreased rates of DGE. However, superiority of pylorus-resecting pancreatoduodenectomy was not shown in a recent RCT. This meta-analysis summarized evidence of the effectiveness and safety of pylorus-preserving compared with pylorus-resecting pancreatoduodenectomy. METHODS RCTs and non-randomized studies comparing outcomes of pylorus-preserving and pylorus-resecting pancreatoduodenectomy were searched systematically in MEDLINE, Web of Science and CENTRAL. Random-effects meta-analyses were performed and the results presented as weighted odds ratios (ORs) or mean differences with their corresponding 95 per cent confidence intervals. Subgroup analyses were performed to account for interstudy heterogeneity between RCTs and non-randomized studies. RESULTS Three RCTs and eight non-randomized studies with a total of 992 patients were included. Quantitative synthesis across all studies showed superiority for pylorus-resecting pancreatoduodenectomy regarding DGE (OR 2·71, 95 per cent c.i. 1·48 to 4·96; P = 0·001) and length of hospital stay (mean difference 3·26 (95 per cent c.i. -1·04 to 5·48) days; P = 0·004). Subgroup analyses including only RCTs showed no significant statistical differences between the two procedures regarding DGE, and for all other effectiveness and safety measures. CONCLUSION Pylorus-resecting pancreatoduodenectomy is not superior to pylorus-preserving pancreatoduodenectomy for reducing DGE or other relevant complications.
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Affiliation(s)
- U Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - P Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - O Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C W Michalski
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C Dörr-Harim
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Miyamoto R, Oshiro Y, Nakayama K, Ohkohchi N. Impact of Three-Dimensional Surgical Simulation on Pancreatic Surgery. Gastrointest Tumors 2017; 4:84-89. [PMID: 29594109 DOI: 10.1159/000484894] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 11/02/2017] [Indexed: 01/22/2023] Open
Abstract
Background/Aims Anatomical variations are frequently encountered during hepato-biliary-pancreatic surgeries, requiring surgeons to have a precise understanding of the surgical anatomy in order to perform a safe surgery. We evaluated the impact of novel three-dimensional (3D) surgical simulation on pancreatic surgeries to enhance surgical residents' understanding. Methodology Between January 2013 and May 2014, 61 preoperative 3D surgical simulations were performed. The consistency (0-10, with 10 representing 100% consistency) among the 15 surgical residents' anatomical drawings from multidetector computed tomography images and the simulated 3D images by SYNAPSE VINCENT® was assessed. We divided the surgical residents into two groups - first- to fifth-year postgraduate doctors (group A) and sixth- to tenth-year postgraduate doctors (group B) - and compared the self-assessment scores between these two groups. Results In terms of the self-assessment scores, a statistically significant difference was observed between the two groups (p < 0.001). Conclusions In this study, 3D surgical simulation was useful for preoperative assessments prior to pancreatic surgery, especially in younger postgraduate surgeons.
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Affiliation(s)
- Ryoichi Miyamoto
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Yukio Oshiro
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Ken Nakayama
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
| | - Nobuhiro Ohkohchi
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, Tsukuba, Japan
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Klaiber U, Probst P, Büchler MW, Hackert T. Pylorus preservation pancreatectomy or not. Transl Gastroenterol Hepatol 2017; 2:100. [PMID: 29264438 DOI: 10.21037/tgh.2017.11.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 11/23/2017] [Indexed: 12/12/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is the treatment of choice for various benign and malignant tumors of the pancreatic head or the periampullary region, and the only hope for cure in patients with cancer at this side. While it has been associated with high morbidity and mortality rates in the last century, its centralization in specialized institutions together with refinements in the operative technique and better management of postoperative complications have made PD a standardized, safe procedure. Besides the classic Whipple procedure including distal gastrectomy, two variations of PD with or without pylorus resection, but preservation of the entire stomach in either procedure exist today. Pylorus-preserving PD has gained wide acceptance as standard procedure and is being performed by an increasing number of pancreatic surgeons. After its oncological adequacy was questioned initially, pylorus-preserving PD was shown to be equivalent to the classic Whipple procedure regarding tumor recurrence and long-term survival. Moreover, operation time and blood loss were shown to be reduced in the pylorus-preserving procedure and benefits in nutritional status and quality of life were observed. However, preservation of the pylorus has been suggested to result in an increased incidence of postoperative delayed gastric emptying (DGE). In this context, pylorus-resecting PD has become popular especially in Japan with the aim to prevent DGE by removal of the pylorus but preservation of the stomach. In contrast to positive results from early studies, latest high-quality randomized controlled trial (RCT) data show that pylorus resection does not reduce DGE compared to the pylorus-preserving operation. Non-superiority of pylorus resection was also confirmed in current meta-analysis on this topic. This article summarizes the existing evidence on PD with or without pylorus preservation and derives recommendations for daily practice.
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Affiliation(s)
- Ulla Klaiber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Tsutaho A, Nakamura T, Asano T, Okamura K, Tsuchikawa T, Noji T, Nakanishi Y, Tanaka K, Murakami S, Kurashima Y, Ebihara Y, Shichinohe T, Ito YM, Hirano S. Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Pancreaticoduodenectomy: Result of a Propensity Score Matching. J Gastrointest Surg 2017; 21:1635-1642. [PMID: 28819791 DOI: 10.1007/s11605-017-3540-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is one of the most common morbidities of pancreaticoduodenectomy (PD). The aim of this study was to clarify whether the incidence of DGE can be reduced by side-to-side gastric greater curvature-to-jejunal anastomosis in subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). METHODS The clinical data of 253 patients who had undergone PD were examined. Of a total of 188 patients who had undergone SSPPD, a gastrojejunostomy (GJ) was performed with end-to-side anastomosis in 87 patients (SSPPD-ETS group), and a GJ was performed with a greater curvature side-to-jejunal side anastomosis in 101 patients (SSPPD-STS group). After propensity score matching, the matched cohort consisted of 74 patients in each group. The postoperative data were evaluated according to the International Study Group of Pancreatic Surgery grade of DGE. RESULTS The total incidence of DGE was 9.4% in the SSPPD-ETS group and 4% in the SSPPD-STS group, with no significant difference (p = 0.1902). A significant difference was observed between the two groups in the incidence of DGE grade C (p = 0.0426). CONCLUSIONS The incidence of total DGE was not reduced statistically in the STS group compared with the ETS group, but reduced DGE grade C. Side-to-side anastomosis might be associated with a reduced incidence of DGE grade C.
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Affiliation(s)
- Akio Tsutaho
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan.
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Soichi Murakami
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yo Kurashima
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yuma Ebihara
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Yoichi M Ito
- Department of Biostatistics, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, 060-8638, Japan
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Panwar R, Pal S. The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy. Hepatobiliary Pancreat Dis Int 2017; 16:353-363. [PMID: 28823364 DOI: 10.1016/s1499-3872(17)60037-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 02/03/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence. DATA SOURCE We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles. RESULTS Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0-100%; median: 18.7%) and 14.3% (range: 1.8%-58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Braun's entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies. CONCLUSIONS ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.
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Affiliation(s)
- Rajesh Panwar
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India
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Torres OJM, Vasques RR, Torres CCS. THE OBITUARY OF THE PYLORUS-PRESERVING PANCREATODUODENECTOMY. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:71-2. [PMID: 27438028 PMCID: PMC4944737 DOI: 10.1590/0102-6720201600020001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Siriwardana RC, Lokubandara RWMA, De Silva Hewavisenthi SJ, Liyanage SK, Jayatunge DSP, Liyanage CAH. Quality of life and impact of bile reflux after retro colic retro gastric gastrojejunostomy in Whipple surgery. BMC Gastroenterol 2017; 17:19. [PMID: 28109253 PMCID: PMC5251213 DOI: 10.1186/s12876-017-0573-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/11/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Delayed gastric emptying and bile reflux are common concerns in long-term survivors after Whipple surgery. The study was designed to assess modified retro colic retro gastric gastrojejunostomy in reducing macro and microscopic bile reflux and impact on dyspepsia related quality of life in long-term survivors. METHODS Out of 43 patients operated, 23 long-term survivors were included. All underwent gastroscopy and bile reflux was grouped as normal, yellowish bile lakes and presence of greenish bile lakes. Six standard gastric biopsies were taken. Microscopic bile reflux index (BRI) was calculated and a score more than 14 was considered significant. Validated Nepean dyspepsia index-short form (NDI-SF) was used to assess the severity of dyspepsia-related quality of life and compared with age and gender-matched control. RESULTS The median age was 48 (21-70) years. Median survival of the group was 37 months (6-40). Endoscopically, 20/23 (87%) had macroscopic bile reflux (74% yellowish bile lakes, 13% greenish bile lakes). None had stomal ulcers or macroscopic inflammation. Mean bile reflux index score was 9.7 (range 1.77-34). Mean NDI-SF score of Whipple group was 23.1 (SD 8.88). In controls, mean score was 19.9 (SD 8.23), showing no significant difference (p = 0.245). CONCLUSIONS Though there was macroscopic bile reflux, clinical symptoms and microscopic changes were minimal. The modified technique had good long-term results.
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Shahbazov R, Yoshimatsu G, Haque WZ, Khan OS, Saracino G, Lawrence MC, Kim PT, Onaca N, Naziruddin B, Levy MF. Clinical effectiveness of a pylorus-preserving procedure on total pancreatectomy with islet autotransplantation. Am J Surg 2016; 213:1065-1071. [PMID: 27760705 DOI: 10.1016/j.amjsurg.2016.09.051] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The impact of pylorus preserving procedures (PP) on total pancreatectomy with islet autotransplantation (TPIAT) has not been examined. This study aimed to investigate the clinical impact of the PP on TPIAT. METHODS The Baylor Simmons Transplant Institute database was queried to identify seventy-three patients who underwent TPIAT from 2006 to 2014. All patients were investigated in postoperative complications, long-term nutritional status, and graft function. RESULTS Patients with PP did not face worse outcomes in terms of delayed gastric emptying and length of hospital stay. Also, nutritional status and metabolic outcome, such as body weight, serum albumin level, serum vitamin level, HbA1c level, graft survival rate and insulin independent rate, were similar between both groups. CONCLUSIONS Clinical results including the graft function indicated that patients undergoing TPIAT with PP did not amplify surgical complications such as delayed gastric emptying and showed no significant advantage of nutrition and metabolic outcome.
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Affiliation(s)
- Rauf Shahbazov
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Waqas Z Haque
- Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - Omar S Khan
- Islet Cell Laboratory, Baylor Research Institute, Dallas, TX, USA
| | - Giovanna Saracino
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | - Peter T Kim
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Nicholas Onaca
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Bashoo Naziruddin
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
| | - Marlon F Levy
- Transplant Division, Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Miyamoto R, Oshiro Y, Nakayama K, Kohno K, Hashimoto S, Fukunaga K, Oda T, Ohkohchi N. Three-dimensional simulation of pancreatic surgery showing the size and location of the main pancreatic duct. Surg Today 2016; 47:357-364. [PMID: 27368278 DOI: 10.1007/s00595-016-1377-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/17/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE We performed three-dimensional (3D) surgical simulation of pancreatic surgery, including the size and location of the main pancreatic duct on the resected pancreatic surface. METHODS The subjects of this retrospective analysis were 162 patients who underwent pancreatic surgery. This cohort was sequentially divided into a "without-3D" group (n = 81) and a "with-3D" group (n = 81). We compared the pancreatic duct diameter and its location, using nine sections in a grid pattern, with the intraoperative findings. The perioperative outcomes were also compared between patients who underwent pancreaticoduodenectomy (PD) and those who underwent distal pancreatectomy (DP). RESULTS There were no significant differences in the main pancreatic duct diameter between the 3D-simulated values and the operative findings. The 3D-simulated main pancreatic duct location was consistent with its actual location in 80 % of patients (65/81). In comparing the PD and DP groups, the intraoperative blood loss was 1174 ± 867 and 817 ± 925 ml in the without-3D group, and 828 ± 739 and 307 ± 192 ml in the with-3D group, respectively (p = 0.024, 0.026). CONCLUSION The 3D surgical simulation provided useful information to promote our understanding of the pancreatic anatomy, including details on the size and location of the main pancreatic duct.
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Affiliation(s)
- Ryoichi Miyamoto
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yukio Oshiro
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Ken Nakayama
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Keisuke Kohno
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shinji Hashimoto
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kiyoshi Fukunaga
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tatsuya Oda
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Nobuhiro Ohkohchi
- Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Department of Surgery, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Hanna MM, Gadde R, Allen CJ, Meizoso JP, Sleeman D, Livingstone AS, Merchant N, Yakoub D. Delayed gastric emptying after pancreaticoduodenectomy. J Surg Res 2016; 202:380-8. [DOI: 10.1016/j.jss.2015.12.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 12/26/2015] [Accepted: 12/31/2015] [Indexed: 12/15/2022]
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Postoperative Changes in Body Composition After Pancreaticoduodenectomy Using Multifrequency Bioelectrical Impedance Analysis. J Gastrointest Surg 2016; 20:611-8. [PMID: 26691149 DOI: 10.1007/s11605-015-3055-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 12/07/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Nutritional status is one of the most important clinical determinants of outcome after surgery. The aim of this study was to compare changes in the body composition of patients undergoing pancreaticoduodenectomy (PD), distal gastrectomy (DG), or total gastrectomy (TG). METHODS The parameters of body composition were measured using multifrequency bioelectrical impedance analysis with an inBody 720 (Biospace Inc. Tokyo. Japan) in 60 patients who had undergone PD (n = 18), DG (n = 30), or TG (n = 12). None of the patients had recurrence or were treated with chemotherapy. Changes between the preoperative data and results and those obtained 12 months after surgery were evaluated. RESULTS Twelve months after surgery, the body weight change in the PD group was significantly lower than in the TG and DG groups (-1.2 ± 3.8 vs -7.4 ± 4.4 and -4.0 ± 3.2 kg, respectively; p < 0.01 vs TG, p < 0.05 vs DG). The body weight change correlated with the fat mass change in all groups. CONCLUSIONS The type and extent of surgery has a different effect on long-term body weight and body composition. Bioelectric impedance analysis can be used to assess body composition and may be useful for nutritional assessment in patients who have undergone these surgeries.
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Chen QJ, He ZQ, Yang Y, Zhang YS, Chen XL, Yang HJ, Zhu SK, Zhong PY, Yang C, Wu HS. Is there comparable morbidity in pylorus-preserving and pylorus-resecting pancreaticoduodenectomy? A meta-analysis. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2015; 35:793-800. [PMID: 26670427 DOI: 10.1007/s11596-015-1509-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 11/08/2015] [Indexed: 12/17/2022]
Abstract
Pancreaticoduodenectomy (PD) is the most effective treatment for patients with pancreatic head or periampullary lesions. Two major strategies exist: pylorus-preserving pancreaticoduodenectomy (PPPD) and pylorus-resecting pancreaticoduodenectomy (PRPD). However, it is yet unclear regarding the morbidity after PPPD and PRPD. This study analyzed the morbidity after PPPD and PRPD to determine the optimal surgical treatment of masses in the pancreatic head or periampullary region. A systematic search of databases identifying randomized controlled trials (RCTs) from the Cochrane Library, PubMed, EMBASE and Web of Science was performed. Outcome was compared by postoperative morbidity including overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding, biliary leakage, ascites and delayed gastric emptying (DGE) rate between PPPD and PRPD. The DGE rate in the PRPD subgroups (conventional PD [CPD] and subtotal stomach-preserving PD [SSPPD], respectively) was also analyzed. The results showed that 9 RCTs including 722 participants were included for meta-analysis. Among these RCTs, 7 manuscripts described PRPD as CPD, and 2 manuscripts described PRPD as SSPPD. There were no significant differences in the overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding, or biliary leakage between PPPD and PRPD. There was a lower rate of DGE with PRPD than that with PPPD (RR=2.15, P=0.03, 95% CI, 1.09-4.23). Further subgroup analysis indicated a comparable DGE rate for the CPD but a lower DGE rate for the SSPPD group than the PPPD group. However, the result did not indicate any difference between CPD and SSPPD regarding the DGE rate (P=0.92). It is suggested that PPPD is comparable to PRPD in overall morbidity, pancreatic fistulas, wound infections, postoperative bleeding and biliary leakage. The current data are not sufficient to draw a conclusion regarding which surgical procedure is associated with a lower postoperative DGE rate. Our conclusions were limited by the available data. Further evaluations of RCTs are needed.
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Affiliation(s)
- Qi-Jun Chen
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhi-Qiang He
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yan Yang
- Community Health Service Center, the 9th Hospital of Wuhan, Wuhan, 430081, China
| | - Yu-Shun Zhang
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xing-Lin Chen
- Key Laboratory of Geriatrics of Health Ministry, Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hong-Ji Yang
- Organ Transplantation Center, Hospital of the University of Electronic Science and Technology of China and Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Shi-Kai Zhu
- Organ Transplantation Center, Hospital of the University of Electronic Science and Technology of China and Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Ping-Yong Zhong
- Organ Transplantation Center, Hospital of the University of Electronic Science and Technology of China and Sichuan Provincial People's Hospital, Chengdu, 610072, China
| | - Chong Yang
- Organ Transplantation Center, Hospital of the University of Electronic Science and Technology of China and Sichuan Provincial People's Hospital, Chengdu, 610072, China.
| | - He-Shui Wu
- Pancreatic Disease Institute, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Samaddar A, Kaman L, Dahiya D, Bhattachyarya A, Sinha SK. Objective assessment of delayed gastric emptying using gastric scintigraphy in post pancreaticoduodenectomy patients. ANZ J Surg 2015; 87:E80-E84. [DOI: 10.1111/ans.13360] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2015] [Indexed: 01/04/2023]
Affiliation(s)
- Avishek Samaddar
- Department of General Surgery; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Lileswar Kaman
- Department of General Surgery; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Divya Dahiya
- Department of General Surgery; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Anish Bhattachyarya
- Department of Nuclear Medicine; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Saroj Kant Sinha
- Department of Gastroenterology; Postgraduate Institute of Medical Education and Research; Chandigarh India
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Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand? Indian J Surg 2015; 77:409-25. [PMID: 26722205 DOI: 10.1007/s12262-015-1366-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic resection has become a feasible treatment of pancreatic neoplasms, and with improvements in surgical techniques and perioperative management, mortality associated with pancreatic surgery has decreased considerably. Despite this improvement, a high rate of complications is still associated with these procedures. Among these complications, delayed gastric emptying (DGE) and postoperative pancreatic fistula (POPF) have a substantial impact on patient outcomes and burden our healthcare system. Technical modifications and postoperative approaches have been proposed to reduce rates of both POPF and DGE in patients undergoing pancreatectomy; however, to date, their rates have remained unchanged. In the present study, we summarize the findings of the most significant studies that have investigated these complications. In particular, several studies focused on technical modifications including extent of dissection, stent placement, nature of anastomosis, type of reconstruction, and application of biological or non-biological agents to site of anastomosis. Moreover, postoperatively, drain placement, duration of drain usage, postoperative feeding, and use of pharmacological agents were studied to reduce rates of POPF and DGE. In this review, we summarize the most relevant literature on this fundamental aspect of pancreatic surgery. Despite studies identifying the potential benefit of technical modifications and postoperative approaches, these findings remain controversial and suggest need for further extensive investigation. Most importantly, we recommend that all surgeons performing these procedures base their practice on the most updated and highest available level of evidence.
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Eisenberg JD, Rosato EL, Lavu H, Yeo CJ, Winter JM. Delayed Gastric Emptying After Pancreaticoduodenectomy: an Analysis of Risk Factors and Cost. J Gastrointest Surg 2015; 19:1572-80. [PMID: 26170145 DOI: 10.1007/s11605-015-2865-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 05/25/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Delayed 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. METHODS In 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. RESULTS ISGPS-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). CONCLUSION DGE 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.
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Affiliation(s)
- Joshua D Eisenberg
- Department of Surgery, The Jefferson Pancreas, Biliary, and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
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