Abstract
Objective
To study the effect of antecolic vs. retrocolic reconstruction on delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) and to analyze factors which may be associated with post-PD DGE.
Summary Background Data
DGE is a troublesome complication occurring in 30–40% of patients undergoing PD leading to increased postoperative morbidity. Many factors have been implicated in the pathogenesis of DGE. Among the various methods employed to reduce the incidence, recent reports have suggested that an antecolic reconstruction of gastro/duodenojejunostomy may decrease the incidence of DGE.
Methods
Between Sep 2006 and Nov 2008, 95 patients requiring PD (for both malignant and benign conditions) were eligible for the study. Of these, 72 patients finally underwent a PD and were randomized to either a retrocolic or antecolic reconstruction of the gastro/duodenojejunostomy. All patients underwent the standard Whipple’s or a pylorus preserving pancreaticoduodenectomy (PPPD), and the randomization was stratified according to the type of PD done. DGE was assessed clinically using the Johns Hopkins criteria (Yeo et al. in Ann Surg 218: 229–37, 1993). In patients suspected to have DGE, mechanical causes were excluded by imaging and/or endoscopy. Occurrence of DGE was the primary endpoint, whereas duration of hospital stay and occurrence of intra-abdominal complications were the secondary end points.
Results
The antecolic and retrocolic groups were comparable with regard to patient demographics, diagnosis, and other preoperative, intraoperative, and postoperative factors. Overall, DGE occurred in 21 patients (30.9%). There was no significant difference in the incidence of DGE in the antecolic vs. the retrocolic group (34.4% vs. 27.8%; p = 0.6). On univariate analysis, older age, use of octreotide, and intra-abdominal complications were significantly associated with the occurrence of DGE; however, on a multivariate analysis, only age was found to be significant (p = 0.02). The mean postoperative stay was longer among patients who developed DGE (21.9 ± 9.3 days vs. 13 ± 6.9 days; p = 0.0001).
Conclusions
Delayed gastric emptying is a cause of significant morbidity and prolongs the duration of hospitalization following pancreaticoduodenectomy. The incidence of DGE does not appear to be related to the method of reconstruction (antecolic or retrocolic). Older age may be a risk factor for its occurrence.
Similar content being viewed by others
References
Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226: 248–57.
Trede M, Schwall G, Saeger HD. Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality. Ann Surg 1990; 211: 447–58.
Neoptolemos JP, Russell RC, Bramhall S, Theis B. Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. UK Pancreatic Cancer Group. Br J Surg 1997; 84: 1370–6.
Miedema BW, Sarr MG, van Heerden JA, Nagorney DM, McIlrath DC, Ilstrup D. Complications following PD. Current management. Arch Surg 1992; 127: 945–9.
Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR et al. Rates of complications and death after PD: risk factors and the impact of hospital volume. Ann Surg 2000; 232: 786–95.
van Berge Henegouwen MI, van Gulik TM, DeWit LT, Allema JH, Rauws EA, Obertop H, et al. Delayed gastric emptying after standard PD versus pylorus-preserving PD: an analysis of 200 consecutive patients. J Am Coll Surg 1997; 185: 373–9
Reidiger H, Makowiec F, Schareck WD, Hopt UT, Adam U. Delayed gastric emptying after pylorus-preserving PD is strongly related to other postoperative complications. J Gastrointest Surg 2003; 7: 758–65.
Kim DK, Hindenburg AA, Sharma SK, Suk CH, Gress FG, Staszewski H, et al. Is pylorospasm a cause of delayed gastric emptying after pylorus-preserving PD? Ann Surg Oncol 2005; 12(3): 222–7.
Fischer CP, Hong JC. Method of pyloric reconstruction and impact upon delayed gastric emptying and hospital stay after pylorus-preserving PD. J Gastrointest Surg 2006; 10: 215–9.
Kurosaki I, Hatakeyama K. Preservation of the left gastric vein in delayed gastric emptying after pylorus-preserving PD. J Gastrointest Surg 2005; 9: 846–52.
Yeo CJ, Barry MK, Sauter PK, Sostre S, Lillemoe KD, Pitt HA, et al. Erythromycin accelerates gastric emptying after PD. A prospective randomized, placebo-controlled trial. Ann Surg 1993; 218: 229–37.
van Berge Henegouwen MI, Akkermans LM, van Gulik TM, Masclee AA, Moojen TM, Obertop H, et al. Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy. Ann Surg 1997; 226(6): 677–85
Sugiyama M, Abe N, Ueki H, Masaki T, Mori T, Atomi Y. A new reconstruction method for preventing delayed gastric emptying after pylorus preserving pancreatoduodenectomy. Am J Surg 2004; 187: 743–6.
Hartel M, Wente MN, Hinz U, Kleeff J, Wagner M, Muller MW, et al. Effect of antecolic reconstruction on delayed gastric emptying after the pylorus preserving Whipple procedure. Arch Surg 2005; 14: 1094–9.
Tani M, Terasawa H, Kawai M, Ina S, Hirono S, Uchiyama K et al. Improvement of delayed gastric emptying in pylorus-preserving PD. Ann Surg 2006; 243: 316–320.
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP . Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5(6): 649–55.
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142: 761–8.
Horstmann O, Becker H, Post S, Nustede R. Is delayed gastric emptying following PD related to pylorus preservation? Lagenbecks Arch Surg 1999; 384: 354–9.
Resnick J, Greenwald DA, Brandt LJ. Delayed gastric emptying and postoperative ileus after nongastric abdominal surgery: part I. Am J Gastroenterol 1997; 92: 751–62.
Park C, Kim SW, Jang JY, Ahn YJ, Park YH. Factors influencing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. J Am Coll Surg 2003; 196: 859–65.
Schvarcz E, Palmer M, Aman J, Horowitz M, Stridsberg M, Berne C. Physiological hyperglycemia slows gastric emptying in normal subjects and patients with insulin-dependent diabetes mellitus. Gastroenterology 1997; 113: 60–6.
Horowitz M, O’Donovan D, Jones KL, Feinle C, Rayner CK, Samsom M. Gastric emptying in diabetes: clinical significance and treatment. Diabet Med 2002; 19: 177–94.
Fraser R, Horowitz M, Maddox A, Harding PE, Chatterton BE, Dent J. Hyperglycemia slows gastric emptying in type I diabetes mellitus. Diabetologia 1990; 30: 675–80.
Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW, et al. Pylorus preserving PD versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 2004; 240: 738–45.
Seiler CA, Wagner M, BachmannT, Redaelli CA, Schmied B, Uhl W, et al. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection—long term results. Br J Surg 2005; 92: 547–56
Diener MK, Kaebel HP, Heukaufer C, Antes G, Buchler MW and Seiler CM. A systematic review and metanalysis of pylorus preserving versus classical PD for surgical treatment of periampullary and pancreatic carcinoma. Ann Surg 2007; 245: 187–200.
Hellmig S, Von Schöning F, Gadow C, Katsoulis S, Hedderich J, Fölsch UR, et al. Gastric emptying time of fluids and solids in healthy subjects determined by 13C breath tests: influence of age, sex and body mass index. J Gastroenterol Hepatol 2006; 21: 1832–8.
Horowitz M. Changes in gastric emptying rates with age. Clin Sci (Lond)1984; 67: 213–8
Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, et al. PD with or without extended retroperitoneal Lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short term outcome. Ann Surg 1999; 229: 613–24.
Fabre JM, Burgel JS, Navarro F, Boccarat G, Lemoine C, Domergue J. Delayed gastric emptying after PD and pancreaticogastrostomy. Eur J Surg 1999; 165: 560–5.
Barkin JS, Goldberg RI, Sfakianakis GN, Levi J. Pancreatic carcinoma is associated with delayed gastric emptying. Dig Dis Sci 1986; 31: 265–7.
Lermite E, Pessaux P, Brehant O, Teyssedou C, Pelletier I, Etienne S, et al. Risk factors of pancreatic fistula and delayed gastric emptying after PD with pancreaticogastrostomy. J Am Coll Surg 2007; 204: 588–96.
Shan YS, Sy ED, Tsai ML, Tang LY, Li PS, Lin PW. Effects of somatostatin prophylaxis after pylorus-preserving PD:increased delayed gastric emptying and reduced plasma motilin. World J Surg 2005; 29: 1319–24.
van Berge Henegouwen MI, van Gulik TM, Akkermans LM, Jansen JB, Gouma DJ. The effect of octreotide on gastric emptying at a dosage used to prevent complications after pancreatic surgery: a randomised, placebo controlled study in volunteers. Gut 1997; 41: 758–62
Kollmar O, Moussavian MR, Richter S, de Roi P, Maurer CA, Schilling MK. Prophylactic octreotide and delayed gastric emptying after PD: results of a prospective randomized double-blinded placebo-controlled trial. Eur J Surg Oncol 2008; 34: 868–75.
Jimenez RE, Fernandez-del Castillo C, Rattner DW, Chang Y, Warshaw AL. Outcome of PD with pylorus preservation or with antrectomy in the treatment of chronic pancreatitis. Ann Surg 2000; 231: 293–300
Kimura F, Suwa T, Sugiura T, Shinoda T, Miyazaki M, Itoh H. Sepsis delays gastric emptying following pylorus-preserving PD. Hepatogastroenterology 2002; 49: 585–8.
Conflict of Interest
None.
Author information
Authors and Affiliations
Corresponding author
Additional information
Rights and permissions
About this article
Cite this article
Gangavatiker, R., Pal, S., Javed, A. et al. Effect of Antecolic or Retrocolic Reconstruction of the Gastro/Duodenojejunostomy on Delayed Gastric Emptying After Pancreaticoduodenectomy: A Randomized Controlled Trial. J Gastrointest Surg 15, 843–852 (2011). https://doi.org/10.1007/s11605-011-1480-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11605-011-1480-3