Skip to main content

Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy

Abstract

The aim of this study was to prospectively analyze the possible association of delayed gastric emptying and postoperative pancreatic complications after pancreaticoduodenectomy. Although hospital mortality after pancreaticoduodenectomy is minimal, morbidity is still high; delayed gastric emptying is one of the most frequent complications. Thirty-nine consecutive patients undergoing pancreaticoduodenectomy were included in this study: 14 females and 25 males (median age 65 years; range, 7–82). Delayed gastric emptying was defined as the need for a nasogastric tube or recurrent vomiting that prevented normal feeding on the 10th postoperative day. Blood analysis was performed on postoperative days 4, 6, and 10; Gastrografin examination on day 6; CT scan on days 2 and 5; and drain amylases were measured on day 5. Pancreatitis was defined as pancreatitis changes in CT scan interpreted by an experienced radiologist without knowing other data. Pancreatic fistula was defined according to the recent international recommendations. We had no mortality. Twelve patients (31%) developed delayed gastric emptying. Surgical (9/12 vs. 5/27; P=0.001) but not medical complications occurred more often in the delayed gastric emptying group. Of the single complications, postoperative CT-detected pancreatitis (6/12 vs. 4/27; P=0.03) and postoperative pancreatic fistula (5/12 vs. 1/27; P=0.0007) were significantly associated with delayed gastric emptying compared with the patients without delayed gastric emptying. This pancreatitis was already detected in CT scan on day 2 in most patients (6/10, 60%). In delayed gastric emptying patients, the only parameters in blood analysis that differed significantly from patients without this complication were serum amylase activity (mean±SEM, 715±205 vs. 152±70 IU/L; P=0.02), blood leukocyte count (16±2 vs. 9±0.6 × 109/L; P=0.007) and serum C-reactive protein (CRP) concentration (144±28 vs. 51±14 mg/L, P=0.01). Postoperative pancreatic (subclinical) fistula was also associated with postoperative pancreatitis (6/10 vs. 0/29; P=0.003). Preoperative coronary artery disease (OR=16; 95% CI, 1.0-241; P=0.05) and soft pancreatic texture at operation (OR=9; 95% CI, 1.4-52; P=0.02) were significant risk factors for the development of postoperative pancreatitis. The diagnosis of delayed gastric emptying after pancreaticoduodenectomy often follows postoperative pancreatitis. Delayed gastric emptying is also associated with postoperative pancreatic fistula, for which this pancreatitis seems to be a risk factor. Preoperative coronary artery disease and soft texture of the pancreas are significant risk factors for postoperative CT-detected pancreatitis.

This is a preview of subscription content, access via your institution.

References

  1. 1.

    Trede M, Schwall G. The complications of pancreatectomy. Ann Surg 1988;207:39–47.

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Pellegrini CA, Heck CF, Raper S, Way LW. An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy. Arch Surg 1989;124:778–781.

    PubMed  CAS  Google Scholar 

  3. 3.

    Yeo C, Cameron J, Sohn T, et al. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma. Ann Surg 1999;229:613–624.

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    Yeo C, Cameron J, Lillemoe K, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadectomy for periampullary adenocarcinoma, part 2: Randomized controlled trial evaluating survival, morbidity, and mortality. Ann Surg 2002;236:355–368.

    PubMed  Article  Google Scholar 

  5. 5.

    Nordback I, Parviainen M, Räty S, Kuivanen H, Sand J. Resection of the head of the pancreas in Finland: Effects of hospital and surgeon on short-term and long-term results. Scand J Gastroenterol 2002;37:1453–1460.

    Article  Google Scholar 

  6. 6.

    Miedema B, Sarr M, van Heerden J, Nagorney D, Mcllrath D, Ilstrup D. Complications following pancreaticoduodenectomy. Arch Surg 1992;127:945–950.

    PubMed  CAS  Google Scholar 

  7. 7.

    Yeo CJ, Barry MK, Sauter PK, et al. Erythromycin accelerates gastric emptying after pancreaticoduodenectomy. A prospective randomized, placebo-controlled trial. Ann Surg 1993;218:229–237.

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Bassi C, Falconi M, Molinari E, et al. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: Results of a comparative study. Ann Surg 2005;242:767–771.

    PubMed  Article  Google Scholar 

  9. 9.

    Jimenez RE, Fernandez-Del Castillo C, Rattner DW, Warshaw AL. Pylorus-preserving pancreaticoduodenectomy in the treatment of chronic pancreatitis. World J Surg 2003;27:1211–1216.

    PubMed  Article  Google Scholar 

  10. 10.

    Braasch JW, Deziel DJ, Rossi RL, Watkins E Jr, Winter PF. Pyloric and gastric preserving pancreatic resection. Experience with 87 patients. Ann Surg 1986;204:411–418.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Itani KM, Coleman RE, Meyers WC, Akwari OE. Pylorus-preserving pancreaticoduodenectomy. A clinical and physiologic appraisal. Ann Surg 1986;204:655–664.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Crist DW, Sitzmann JV, Cameron JL. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg 1987;206:358–365.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Tanaka M, Sarr M. Total duodenectomy: Effect on canine gastrointestinal motility. J Surg Res 1987;42:483–493.

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Liberski SM, Koch KL, Atnip RG, Stern RM. Ischemic gastroparesis: Resolution after revascularization. Gastroenterology 1990;99:252–257.

    PubMed  CAS  Google Scholar 

  15. 15.

    Naritomi G, Tanaka M, Matsunaga H, et al. Pancreatic head resection with and without preservation of the duodenum: Different postoperative gastric motility. Surgery 1996;120:831–837.

    PubMed  Article  CAS  Google Scholar 

  16. 16.

    Strömmer L, Räty S, Henning R, et al. Delayed gastric emptying and distal gastrointestinal hormones following pancreaticoduodenectomy. Pancreatology 2005;5:537–544.

    PubMed  Article  Google Scholar 

  17. 17.

    Riediger H, Makowiec F, Schareck W, Hopt U, Adam U. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy is strongly related to other postoperative complications. J Gastrointest Surg 2003;7:758–765.

    PubMed  Article  Google Scholar 

  18. 18.

    Hashimoto N, Ohyanagi H. Pancreatic juice output and amylase level in the drainage fluid after pancreaticoduodenectomy in relation to leakage. Hepatogastroenterology 2002;49:553–555.

    PubMed  Google Scholar 

  19. 19.

    Yeo CJ, Cameron JL, Maher MM, et al. A prospective randomized trial of pancreaticogastrostomy versus pancreaticoduodenostomy after pancreaticoduodenectomy. Ann Surg 1995;222:580–588.

    PubMed  CAS  Article  Google Scholar 

  20. 20.

    Suc B, Msika S, Fingerhut A, et al. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection. Ann Surg 2003;237:57–65.

    PubMed  Article  Google Scholar 

  21. 21.

    Lillemoe KD, Cameron JL, Kim MP, et al. Does fibrin glue sealant decrease the rate of pancreatic fistula after pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2004;8:766–774.

    PubMed  Article  Google Scholar 

  22. 22.

    Howard JM. Pancreaticoduodenectomy (Whipple resection) with skeletonization of vessels for cancers of the pancreas and adjacent organs. In Howard JM, Idezuki Y, Ihse I, Prinz RA, eds. Surgical Diseases of the Pancreas. Baltimore: Lippincott Williams & Wilkins 1998, pp 529–556.

    Google Scholar 

  23. 23.

    Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005;138:8–13.

    PubMed  Article  Google Scholar 

  24. 24.

    Henegouwen M, Gulik T, DeWit L, et al. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: An analysis of 200 consecutive patients. J Am Coll Surg 1997;185:373–379.

    Google Scholar 

  25. 25.

    Jimenez RE, Fernandez-del Castillo C, Rattner DW, Chang Y, Warshaw AL. Outcome of pancreaticoduodenectomy with pylorus preservation or with antrectomy in the treatment of chronic pancreatitis. Ann Surg 2000;231:293–300.

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Park Y-C, Kim S-W, Jang J-Y, Ahn Y, Park Y-H. Factors influencing delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy. J Am Coll Surg 2003;196:859–865.

    PubMed  Article  Google Scholar 

  27. 27.

    Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: Value of CT in establishing prognosis. Radiology 1990;174:331.

    PubMed  CAS  Google Scholar 

  28. 28.

    Lepanto L, Gianfelice D, Dery R, Dagenais M, Lapointe R, Roy A. Postoperative changes, complications, and recurrent disease after Whipple’s operation: CT features. AJR Am J Roentgenol 1994;163:841–846.

    PubMed  CAS  Google Scholar 

  29. 29.

    Daly B, Sukumar SA, Krebs TL, Wong JJ, Folowers JL. Nonbiliary laparoscopic gastrointestinal surgery: Role of CT in diagnosis and management of complications. AJR Am J Roentgenol 1996;167:455–459.

    PubMed  CAS  Google Scholar 

  30. 30.

    Mortele K, Lemmerling M, De Hemptinne B, De Vos M, De Bock G, Kunnen M. Postoperative findings following Whipple procedure: Determination of prevalence and morphologic abdominal feature. Eur Radiol 2000;10:123–128.

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Johnson P, Curry C, Urban B, Fishman E. Spiral CT following the Whipple procedure: Distinguishing normal postoperative findings from complications. J Comput Assist Tomogr 2002;26:956–961.

    PubMed  Article  Google Scholar 

  32. 32.

    Balthazar E, Ranson J, Naidich D, Megibow A, Caccavale R, Cooper M. Acute pancreatitis: Prognostic value of CT. Radiology 1985;156:767–772.

    PubMed  CAS  Google Scholar 

  33. 33.

    Spitzer AL, Thoeni RF, Barcia AM, Schell MT, Harris HW. Early nonenhanced abdominal computed tomography can predict mortality in severe acute pancreatitis. J Gastrointest Surg 2005;9:928–933.

    PubMed  Article  Google Scholar 

  34. 34.

    Munoz-Bongrand N, Panis Y, Soyer P, et al. Serial computed tomography is rarely necessary in patients with acute pancreatitis: A prospective study in 102 patients. J Am Coll Surg 2001;193:146–152.

    PubMed  Article  CAS  Google Scholar 

  35. 35.

    Murakami H, Suzuki H, Nakamura T. Pancreatic fibrosis correlates with delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy with pancreaticogastrostomy. Ann Surg 2002;235:240–245.

    PubMed  Article  Google Scholar 

  36. 36.

    Steer M. Recent insights into the etiology and pathogenesis of acute biliary pancreatitis. AJR Am J Roentgenol 1995;164:811–814.

    PubMed  CAS  Google Scholar 

  37. 37.

    ÓKeefe SJ, Foody W, Gill S. Transnasal endoscopic placement of feeding tubes in the intensive care unit. J Parenter Enteral Nutr 2003;27:383–384.

    Article  Google Scholar 

  38. 38.

    Seiler C, Wagner M, Sadowski C, Kulli C, Büchler M. Randomized prospective trial of pylorus-preserving vs. classic duodenopancreatectomy (Whipple procedure): Initial clinical results. J Gastrointest Surg 2000;4:443–452.

    PubMed  Article  CAS  Google Scholar 

  39. 39.

    Cameron J, Pitt H, Yeo C, Lillemoe K, Kaufman H, Coleman J. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993;217:430–438.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Conlon KC, Labow D, Leung D, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg 2001;234:487–493.

    PubMed  Article  CAS  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Isto Nordback M.D..

Additional information

Supported by the Medical Research Fund of Tampere University Hospital, Pirkanmaa Hospital District, Finland (S.R.).

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Räty, S., Sand, J., Lantto, E. et al. Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy. J Gastrointest Surg 10, 1131–1139 (2006). https://doi.org/10.1016/j.gassur.2006.05.012

Download citation

Key words

  • Pancreaticoduodenectomy
  • complications
  • postoperative pancreatitis
  • pancreatic fistula
  • delayed gastric emptying