Advertisement

Journal of Gastrointestinal Surgery

, Volume 16, Issue 7, pp 1354–1361 | Cite as

Comprehensive Analysis of Variables Affecting Delayed Gastric Emptying Following Pancreaticoduodenectomy

  • John W. Kunstman
  • Annabelle L. Fonseca
  • Maria M. Ciarleglio
  • Xiangyu Cong
  • Abby Hochberg
  • Ronald R. Salem
Original Article

Abstract

Introduction

Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), and criteria for its clinical diagnosis have recently been standardized by an international consensus group. We evaluated 24 operative and peri-operative variables to assess which were independent risk factors for DGE development. Secondarily, we also examined DGE incidence over time and evaluated the consensus guidelines’ ability to diagnose DGE in patients with complicated post-operative courses.

Methods

A prospective, single-surgeon database of 235 patients undergoing PD at an academic tertiary center was retrospectively reviewed and DGE was assessed per published guidelines.

Results

DGE occurred in 42 patients overall (17.9 %), with incidence falling from 30.0 to 9.1 % during the study period. Post-operative abscess, pancreatic fistula formation, pulmonary comorbidity, and increased intraoperative blood loss were found to be independent risk factors (p < 0.05) for DGE on multivariate analysis. Changes in operative technique, such as pylorus preservation, did not associate with DGE. In a separate analysis, when patients with confounding post-operative events such as re-intubation or re-laparotomy were excluded, DGE incidence was 11.9 %.

Conclusions

Perturbation of the operative bed by a secondary complication seems to be the dominant risk for DGE development. The consensus guidelines for DGE diagnosis, while indispensable, may overestimate DGE incidence.

Keywords

Pancreaticoduodenectomy Delayed gastric emptying ISGPS 

Notes

Acknowledgments

We wish to thank Janis Sandlin, PA-C for her contributions to data collection. Drs. Ciarleglio, Cong, and Kunstman had access to all of the data in the study and carry responsibility for the integrity of the data and the accuracy of the data analysis.

References

  1. 1.
    Winter, J. M., Cameron, J. L., Campbell, K. A., Arnold, M. A., Chang, D. C., Coleman, J., Hodgin, M. B., Sauter, P. K., Hruban, R. H., Riall, T. S., Schulick, R. D., Choti, M. A., Lillemoe, K. D., and Yeo, C. J. 1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 10: 1199–1210; discussion 1210–1191, 2006.CrossRefGoogle Scholar
  2. 2.
    Birkmeyer, J. D., Siewers, A. E., Finlayson, E. V., Stukel, T. A., Lucas, F. L., Batista, I., Welch, H. G., Wennberg, D. E. Hospital volume and surgical mortality in the United States. The New England journal of medicine 346: 1128–1137, 2002.PubMedCrossRefGoogle Scholar
  3. 3.
    Birkmeyer, J. D., Stukel, T. A., Siewers, A. E., Goodney, P. P., Wennberg, D. E., and Lucas, F. L. Surgeon volume and operative mortality in the United States. The New England journal of medicine 349: 2117–2127, 2003.PubMedCrossRefGoogle Scholar
  4. 4.
    Balcom, J. H. t., Rattner, D. W., Warshaw, A. L., Chang, Y., and Fernandez-del Castillo, C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Archives of surgery (Chicago, Ill. : 1960) 136: 391–398, 2001.CrossRefGoogle Scholar
  5. 5.
    Balzano, G., Zerbi, A., Braga, M., Rocchetti, S., Beneduce, A. A., and Di Carlo, V. Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. The British journal of surgery 95: 1387–1393, 2008.PubMedCrossRefGoogle Scholar
  6. 6.
    Fabre, J. M., Burgel, J. S., Navarro, F., Boccarat, G., Lemoine, C., and Domergue, J. Delayed gastric emptying after pancreaticoduodenectomy and pancreaticogastrostomy. The European journal of surgery = Acta chirurgica 165: 560–565, 1999.PubMedGoogle Scholar
  7. 7.
    van Berge Henegouwen, M. I., van Gulik, T. M., DeWit, L. T., Allema, J. H., Rauws, E. A., Obertop, H., and Gouma, D. J. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. Journal of the American College of Surgeons 185: 373–379, 1997.PubMedGoogle Scholar
  8. 8.
    Yeo, C. J., Barry, M. K., Sauter, P. K., Sostre, S., Lillemoe, K. D., Pitt, H. A., and Cameron, J. L. Erythromycin accelerates gastric emptying after pancreaticoduodenectomy. A prospective, randomized, placebo-controlled trial. Annals of surgery 218: 229–237; discussion 237–228, 1993.PubMedCrossRefGoogle Scholar
  9. 9.
    Traverso, L. W., and Hashimoto, Y. Delayed gastric emptying: the state of the highest level of evidence. Journal of hepato-biliary-pancreatic surgery 15: 262–269, 2008.PubMedCrossRefGoogle Scholar
  10. 10.
    Wente, M. N., Bassi, C., Dervenis, C., Fingerhut, A., Gouma, D. J., Izbicki, J. R., Neoptolemos, J. P., Padbury, R. T., Sarr, M. G., Traverso, L. W., Yeo, C. J., Buchler, M. W. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142: 761–768, 2007.PubMedCrossRefGoogle Scholar
  11. 11.
    Park, J. S., Hwang, H. K., Kim, J. K., Cho, S. I., Yoon, D. S., Lee, W. J., and Chi, H. S. Clinical validation and risk factors for delayed gastric emptying based on the International Study Group of Pancreatic Surgery (ISGPS) Classification. Surgery 146: 882–887, 2009.PubMedCrossRefGoogle Scholar
  12. 12.
    Welsch, T., Borm, M., Degrate, L., Hinz, U., Buchler, M. W., and Wente, M. N. Evaluation of the International Study Group of Pancreatic Surgery definition of delayed gastric emptying after pancreatoduodenectomy in a high-volume centre. The British journal of surgery 97: 1043–1050, 2010.PubMedCrossRefGoogle Scholar
  13. 13.
    Malleo, G., Crippa, S., Butturini, G., Salvia, R., Partelli, S., Rossini, R., Bacchion, M., Pederzoli, P., and Bassi, C. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB: the official journal of the International Hepato Pancreato Biliary Association 12: 610–618, 2010.Google Scholar
  14. 14.
    Sakamoto, Y., Yamamoto, Y., Hata, S., Nara, S., Esaki, M., Sano, T., Shimada, K., and Kosuge, T. Analysis of Risk Factors for Delayed Gastric Emptying (DGE) after 387 Pancreaticoduodenectomies with Usage of 70 Stapled Reconstructions. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 15: 1789–1797, 2011.CrossRefGoogle Scholar
  15. 15.
    Akizuki, E., Kimura, Y., Nobuoka, T., Imamura, M., Nagayama, M., Sonoda, T., and Hirata, K. Reconsideration of postoperative oral intake tolerance after pancreaticoduodenectomy: prospective consecutive analysis of delayed gastric emptying according to the ISGPS definition and the amount of dietary intake. Annals of surgery 249: 986–994, 2009.PubMedCrossRefGoogle Scholar
  16. 16.
    Fernandez-del Castillo, C. Consensus defining postpancreatectomy complications: an opportunity we cannot ignore. Surgery 142: 771–772, 2007.PubMedCrossRefGoogle Scholar
  17. 17.
    Reber, H. A. Delayed gastric emptying—what should be required for diagnosis? Surgery 142: 769–770, 2007.PubMedCrossRefGoogle Scholar
  18. 18.
    Conlon, K. C., Labow, D., Leung, D., Smith, A., Jarnagin, W., Coit, D. G., Merchant, N., and Brennan, M. F. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Annals of surgery 234: 487–493; discussion 493–484, 2001.PubMedCrossRefGoogle Scholar
  19. 19.
    Kim, D. K., Hindenburg, A. A., Sharma, S. K., Suk, C. H., Gress, F. G., Staszewski, H., Grendell, J. H., and Reed, W. P. Is pylorospasm a cause of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? Annals of surgical oncology 12: 222–227, 2005.PubMedCrossRefGoogle Scholar
  20. 20.
    Riediger, H., Makowiec, F., Schareck, W. D., Hopt, U. T., and Adam, U. Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 7: 758–765, 2003.CrossRefGoogle Scholar
  21. 21.
    Warshaw, A. L., and Torchiana, D. L. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy. Surgery, gynecology & obstetrics 160: 1–4, 1985.Google Scholar
  22. 22.
    Lin, P. W., Shan, Y. S., Lin, Y. J., and Hung, C. J. Pancreaticoduodenectomy for pancreatic head cancer: PPPD versus Whipple procedure. Hepato-gastroenterology 52: 1601–1604, 2005.PubMedGoogle Scholar
  23. 23.
    Seiler, C. A., Wagner, M., Bachmann, T., Redaelli, C. A., Schmied, B., Uhl, W., Friess, H., and Buchler, M. W. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results. The British journal of surgery 92: 547–556, 2005.PubMedCrossRefGoogle Scholar
  24. 24.
    Tran, K. T., Smeenk, H. G., van Eijck, C. H., Kazemier, G., Hop, W. C., Greve, J. W., Terpstra, O. T., Zijlstra, J. A., Klinkert, P., Jeekel, H. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Annals of surgery 240: 738–745, 2004.PubMedCrossRefGoogle Scholar
  25. 25.
    Gangavatiker, R., Pal, S., Javed, A., Dash, N. R., Sahni, P., and Chattopadhyay, T. K. Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled trial. Journal of gastrointestinal surgery: official journal of the Society for Surgery of the Alimentary Tract 15: 843–852, 2011.CrossRefGoogle Scholar
  26. 26.
    Tani, M., Terasawa, H., Kawai, M., Ina, S., Hirono, S., Uchiyama, K., and Yamaue, H. Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy: results of a prospective, randomized, controlled trial. Annals of surgery 243: 316–320, 2006.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2012

Authors and Affiliations

  • John W. Kunstman
    • 1
  • Annabelle L. Fonseca
    • 1
  • Maria M. Ciarleglio
    • 2
  • Xiangyu Cong
    • 2
  • Abby Hochberg
    • 3
  • Ronald R. Salem
    • 1
  1. 1.Section of Surgical Oncology, Department of SurgeryYale University School of MedicineNew HavenUSA
  2. 2.Yale Center for Analytical SciencesYale University School of Public HealthNew HavenUSA
  3. 3.Drexel University College of MedicinePhiladelphiaUSA

Personalised recommendations