Braun enteroenterostomy during pancreaticoduodenectomy decreases postoperative delayed gastric emptying

Background

Modified digestive reconstruction during pancreaticoduodenectomy (PD) may affect the postoperative incidence of delayed gastric emptying (DGE). The purpose of this study is to investigate whether Braun enteroenterostomy following PD can reduce the incidence of DGE.

Methods

Four hundred seven patients who received PD with child reconstruction from June 2000 to March 2013 were divided into 2 groups: 206 patients with Braun enteroenterostomy (Child-Braun group) and 201 patients without Braun enteroenterostomy (Child-non-Braun group). Clinical data were retrospectively extracted; univariate and multivariate analyses were performed to investigate the association between Braun enteroenterostomy and DGE.

Results

DGE was less frequent in the Child-Braun group than in the Child-non-Braun group (6.7% vs 26.87%, P < .001). The multivariate logistic regression analysis showed that Braun enteroenterostomy was the only significant independent factor associated with the reduced DGE after PD with Child reconstruction, with an odds ratio of 4.485 (95% confidence interval: 2.372 to 8.482, P < .001).

Conclusion

Braun enteroenterostomy reduces the incidence of postoperative DGE associated with PD.     

胰十二指肠切除术后胃排空障碍危险因素的Logistic回归分析

目的 分析胰十二指肠切除术后胃排空障碍的危险因素.方法 回顾性分析中日友好医院1994年1月至2008年1月间101例胰十二指肠切除术病例,以手术后是否发生胃排空障碍为因变量,对病人临床资料进行单因素及多因素非条件Logistic回归分析.结果 该组胃排空障碍发生率为27.7%(28/101),单变量分析结果表明手术方式、术中输血量、术后血糖、术后腹腔感染、术后胰胆肠瘘发生是胃排空障碍发生的危险因素.多因素Logistic回归分析结果表明,术后腹腔感染、手术方式、术中输血量、术后高血糖是胃排空障碍发生的独立危险因素,相对危险度(OR)分别为7.892、7.071、5.882和2.882.结论 术后并发腹腔感染、PPPD术后、术中输血量多、术后高血糖病人易发生胃排空障碍.     

Complications after pancreaticoduodenectomy: the problem of current definitions

Pancreaticoduodenectomy nowadays represents a complex procedure and a challenge for the surgeon. Even though mortality is reported to be below 5% for experienced surgeons, morbidity is still around 30%–50%, often leading to prolongation of hospital stay, demanding postoperative investigations and procedures, and outpatient monitoring of the patients with complications. In the literature there is no agreement on the definitions of postoperative complications following pancreaticoduodenectomy, leading to a wide range of complication rates in different specialist units, particularly regarding the source of every complication, postoperative pancreatic fistula, and others such as delayed gastric emptying. Some authors have demonstrated that applying different definitions in homogeneous, single-center series, the incidence of a complication varied with statistical significance, implying the impossibility of correctly comparing different experiences. It seems essential to organize a Consensus Meeting among expert surgeons to prepare world-wide accepted definitions. The aim of this article is to review the current controversial definitions and to suggest a new clinical-based approach to the problem of the feasibility and reliability of the definitions themselves.     

全腹腔镜下胰十二指肠切除术20例分析

目的探讨全腹腔镜下胰十二指肠切除术的可行性及疗效。方法回顾性分析自2016年1月至2016年12月安徽医科大学附属省立医院胆胰外科收治并行腹腔镜下胰十二指肠切除术病人围手术期的临床资料,其中男性10例,女性10例,年龄25~71岁,平均年龄为(56.2±12.4)岁,分析手术疗效及术后并发症及预后。结果 20例完全腹腔镜下胰十二指肠切除术,其中手术平均时间为(645.0±139.9)min;本组病人术后胰瘘发生率为30.0%(6/20),其中A级胰瘘4例(20.0%),B级胰瘘2例(10.0%);术后胃排空延迟病人为5例(25.0%),其中A、B、C级分别为:3例(15.0%)、1例(5.0%)、1例(5.0%);术后胆瘘1例(5.0%);术后消化道出血病人2例(10.0%)。总并发症发生例数为6例(30%)。结论完全腹腔镜下胰十二指肠切除术具有术后恢复时间较快,创伤小等特点,随着经验的积累,未来值得推广。     

保留幽门胰十二指肠切除术后发生胃排空延迟的影响因素分析

目的 探讨保留幽门胰十二指肠切除术（PPPD）后胃排空延迟（DGE）的影响因素及预防措施。方法 回顾性分析2000年1月至2006年7月42例PPPD与同期104例标准胰十二指肠切除（SPD）围手术期并发症,对可能影响PPPD术后发生DGE的原因进行分析。结果 PPPD与SPD手术时问、失血量相当,PPPD组术后胰瘘明显少于SPD组,两组术后死亡率差异无统计学意义。PPPD组DGE发生率为35．7％,显著高于SPD组的18．3％（P=0．024）。与手术时间〈6h者相比,手术时间〉6h者DGE发生率明显增加（17．2％对76．9％,P〈0．05）。结肠后十二指肠空肠吻合术后DGE的发生率显著高于结肠前十二指肠空肠吻合者（50％对20％,P=0．043）。多因素分析显示,术后胰瘘、胆瘘等腹腔并发症并非导致DGE的危险因素,预防性使用生长抑素也无预防DGE的效果。结论 PPPD术后DGE是其最常见的并发症,缩短手术时间、采取结肠前十二指肠空肠吻合可有效降低其发生率,目前尚无确切药物预防方法。     

降低胰十二指肠切除术后外科并发症的临床体会

目的探讨减少胰十二指肠切除术后外科并发症的方法。方法对我科2004年1月-2010年1月行胰十二指肠切除术的77例患者术式选择和术后并发症进行回顾性分析。结果77例均作标准的Whipple术,胰颈空肠套人端侧吻合51例,套入端端吻合21例,胰管空肠粘膜吻合5例,全组77例中共9例发生外科并发症,其中胰漏3例,上消化道出血2例,腹腔出血1例,功能性胃排空障碍3例。结论注意术式选择的个体化和精细的手术技巧是减少胰十二指肠切除术后严重并发症发生的重要措施。     

An invaginated pancreaticogastrostomy following subtotal stomach-preserving pancreaticoduodenectomy: A prospective observational study

Background/objectivePostoperative pancreatic fistula (POPF) leads to life-threatening complications after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) often adopted as a reconstruction technique after PD to prevent POPF. Delayed gastric emptying (DGE) following PD is the most common complication that compromises the quality of life. Subtotal stomach-preserving PD (SSPPD) preserves the pooling ability of the stomach and minimize the occurrence of DGE. This study aimed to describe our PG technique following SSPPD and evaluate the perioperative outcomes.MethodsThe study included patients who underwent PG following SSPPD from August 2013 to July 2020 at our institution. An invaginated PG was performed by one-layer eight interrupted sutures with a lost stent. Patients’ demographics and perioperative outcomes were documented.ResultsThis technique was applied in 72 patients with a median age of 75 years. The median operative time was 342 min. The clinically relevant POPF, DGE and post-pancreatectomy hemorrhage was 4 (5.6%), 5 (6.9%), and 10 (13.9%), respectively. Although the drain fluid amylase concentration on postoperative day 3 was significantly higher in clinically relevant POPF (CR-POPF) positive group (median, 2006 U/L vs. 74 U/L in CR-POPF negative group, p = 0.002), none of the risk factors including disease pathology, pancreatic duct diameter, texture of pancreas and excessive blood loss were significantly associated with CR-POPF. Other morbidity ≥ Clavien-Dindo classification II occurred in 29 patients (40.3%). The 90-days operative mortality was two (2.8%).ConclusionsThis novel method of one-layer invaginated PG following SSPPD is safe and dependable procedure with acceptable morbidity and mortality.     

Preoperative cholangitis during biliary drainage increases the incidence of postoperative severe complications after pancreaticoduodenectomy

Background

It remains controversial how preoperative biliary drainage affects occurrence of severe complications after pancreaticoduodenectomy (PD).

Methods

One hundred twenty-seven patients (60 external drainage and 67 internal drainage) required biliary drainage before PD were retrospectively reviewed.

Results

Preoperative cholangitis in internal drainage group (22.4%) occurred significantly more often than in external drainage group (1.7%; P < .001). The incidence of severe complications (grade III or more) was significantly higher in patients with cholangitis (62.5%) than in those without it (25.2%; P = .002). The incidence of delayed gastric emptying was significantly higher in patients with cholangitis (31.2%) than in those without it (5.4%; P = .001). A multivariate logistic regression analysis revealed that preoperative cholangitis (odds ratio 4.61, 95% confidence interval 1.3 to 16.5; P = .019) was the independent risk factor for severe complications after PD.

Conclusions

Preoperative cholangitis during biliary drainage significantly increases incidence of severe complications after PD.     

A comprehensive strategy for perioperative care of pancreaticoduodenectomy according to the risk stratification by pancreatic fistula and delayed gastric emptying

Background/ObjectivePancreaticoduodenectomy (PD) is highly invasive with unsatisfactory postoperative complication rates. Nutritional and fluid management after major surgery attracts much attention with regard to the reduction in severe postoperative complications. We retrospectively analyzed PD cases and proposed a novel strategy for perioperative fluid and nutritional therapy according to the risk stratification by pancreatic fistula (PF) and delayed gastric emptying (DGE).MethodsBetween 2003 and 2018, 140 patients underwent PD at our institute of which 134 patients were enrolled. We evaluated the clinicopathological factors affecting severe (≥10%) body weight loss (BWL), factors affecting the incidence of PF and intraabdominal complications (IAC), and factors related to DGE.ResultsMultivariate analysis indicated that male sex, severe PF, and DGE are significant risk factors for BWL ≥10%. PF and IAC were predominantly observed in male patients and those with non-pancreatic cancer. A fluid balance ≥6000 ml on postoperative day 2 was the sole risk factor for primary DGE. Secondary DGE significantly correlated with stomach preserving PD. Importantly, the average BWL was around 15% in grade B or C secondary DGE.ConclusionSevere postoperative complications resulted in significant BWL. Enteral feeding is unnecessary in cases with a hard pancreas and dilated pancreatic duct if appropriate perioperative fluid management is performed. Secondary DGE followed by PF or IAC is unavoidable to some extent, especially in the case of soft pancreas with a fine pancreatic duct. In such cases, enteral feeding with tube ileostomy should be considered, and stomach preserving PD is likely to be harmful.     

Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection

BACKGROUND: Delayed gastric emptying (DGE) is one of the most troublesome postoperative complications following pancreatic resection. Not only does it contribute considerably to prolonged hospitalization, but it is also associated with increased postoperative morbidity and mortality. METHODS: We performed an electronic and manual search of the international literature for studies dealing with the treatment of DGE following pancreatic resection using the Medline database. The search items used were "delayed gastric emptying," "pancreaticoduodenectomy," "Whipple procedure," "pylorus-preserving pancreaticoduodenectomy," and "complications following pancreatic resection" in various combinations. RESULTS: A number of studies were identified regarding possible therapeutic alternatives for the treatment of DGE. From the class of prokinetic regimens, most studies seem to support the use of erythromycin. However, its use has not gained wide acceptance. Regarding the operative technique, both standard Whipple and pylorus-preserving pancreatic resection carry similar rates of DGE. Billroth II type-like gastrointestinal reconstruction is the most widely accepted method and is associated with lower rates of DGE. Reoperations for managing severe DGE were very rarely reported. CONCLUSIONS: The incidence of DGE in high-volume centers specialized in pancreatic surgery is well below 20%, thus following the improved rates that have been reported in the last decade regarding mortality and length of hospital stay after pancreatic surgery. DGE mandates a uniform definition and method of evaluation to achieve homogeneity among studies. Standardization of the operative technique, as well as "centralizing" pancreatic resections in high-volume centers, should aid to improve the occurrence of this bothersome postoperative complication.     

Pylorus resection in partial pancreaticoduodenectomy: impact on delayed gastric emptying

Background

Partial pancreaticoduodenectomy (PD) is complicated by postoperative delayed gastric emptying (DGE) in up to 45% of patients. The aim of this study was to evaluate the impact of pylorus resection on DGE following PD.

Methods

Forty PD patients underwent pylorus resection with complete stomach preservation (prPD). They were compared with a pair-matched group of PD patients with pylorus preservation (ppPD) in a 1:1 ratio (age, sex, histopathology). The objectives were operative parameters, DGE incidence, morbidity, and length of hospital stay.

Results

DGE incidence was significantly lower after prPD (15.0% vs 42.5%; P = .0066). Operative parameters and surgical morbidity (other than DGE) were not different (27.5% prPD vs 30.0% ppPD). There was a trend toward a shorter hospital stay in the prPD group.

Conclusions

Resection of the pylorus with stomach preservation significantly reduces the frequency of DGE after PD without showing any disadvantage when compared with standard ppPD. This finding could be of high relevance for the clinical practice in routine PD and should consequently be investigated in a large randomized multicenter trial to create further evidence.     

腹腔镜辅助胰十二指肠切除术14例分析

目的探讨腹腔镜辅助胰十二指肠切除术的可行性及疗效。方法回顾性分析自2015年3月~2015年12月安徽医科大学附属省立医院胆胰外科收治并行腹腔镜辅助胰十二指肠切除术患者的围手术期的临床资料,分析手术疗效及术后并发症及预后。结果自2015年3月~2015年12月安徽医科大学附属省立医院共收治并完成14例腹腔镜辅助胰十二指肠切除术,其中男性5例,女性9例,年龄40~74岁,平均年龄60.14±9.85岁,其中手术平均时间为568.71±107.75min,手术术中平均出血量为614.2±443.5ml,术后胰瘘发生率为28.5%,其中A级胰瘘为3例(21.4%);B级胰瘘1例(7.1%),未出现C级胰瘘患者,术后DGE发生率为21.4%,其中A级胃排空延迟1例(7.1%),B级胃排空延迟1例(7.1%),C级胃排空延迟1例(7.1%),总并发症发生率为42.8%。结论与传统的开腹PD相比,LPD具有术后恢复时间较快,手术安全、可行,值得临床推广。     

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

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

胰十二指肠切除胰肠/胃常见吻合方式的选择

胰腺癌是一种较为常见的消化道恶性肿瘤,胰腺癌中胰头癌占60％～70％,其手术方式是胰十二指肠切除术,该手术创伤大,术后并发症多,死亡率高,而胰瘘是其中最为严重的并发症之一.胰腺重建是胰十二指肠切除术最关键的一步,其大致分为胰肠吻合和胰胃吻合,每种吻合又有若干吻合方式.术者需要根据具体情况选择合适的吻合方式.本文就胰腺常见重建方式进行综述.     

Postoperative jejunal feeding and outcome of pancreaticoduodenectomy

Complications following pancreaticoduodenectomy are common, partly because of nutritional debilitation. The aim of this study was to evaluate the impact of early postoperative tube feeding on outcome of pancreaticoduodenectomy and determine the best method for delivering enteral feeding. A retrospective review of 180 consecutive patients undergoing Whipple operations from 1994 to 2000 was performed. Two nonrandomized patient groups were retrospectively studied: those with early postoperative tube feeding vs. those with no planned feeding. Ninety-eight patients (54%) received postoperative jejunal feeding, whereas 82 patients (46%) did not. Jejunal feeding was delivered via a bridled nasojejunal tube in 55 patients (56%) and a gastrojejunal tube in 43 (44%). Vomiting (10% vs. 29%; P = 0.002) and use of total parenteral nutrition (6% vs. 27%; P < 0.0001) were less in the jejunal feeding group as well as rates of readmission (12% vs. 27%; P= 0.022), early (52% vs. 62%; P = 0.223) and late (12% vs. 31%, P = 0.005) complications, and infections (13% vs. 20%, P = 0.014). Tube-related complications occurred in 6 of 98 patients, all of which were associated with gastrojejunal tubes (P = 0.021). Early postoperative tube feeding after pancreaticoduodenectomy is associated with significantly less use of total parenteral nutrition and lower rates of readmission and complications. A bridled nasojejunal feeding tube appears to be a safe and reliable method of short-term enteral feeding. Presented at the 2003 meeting of the Americas Hepato-Pancreato-Biliary Congress, Miami Beach, Florida, February 27–March 2, 2003.     

A new reconstruction method for preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy

BACKGROUND: With the aim of preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy (PPPD), we devised a new reconstruction method in which the pancreas and the bile duct are anastomosed to the proximal jejunum brought through the transverse mesocolon, and the duodenum is antecolically anastomosed to the jejunum below the mesocolon. The right gastric artery is divided in order to place the stomach, the duodenum, and the jejunum in a straight line. METHODS: Thirty patients underwent PPPD with the new reconstruction method (n = 12) or the conventional method (all anastomoses performed retrocolically; n = 18). Early and late complications were compared between the two groups. RESULTS: Delayed gastric emptying occurred respectively in 1 patient (8%) and 13 patients (72%) operated on by the new and conventional method (P <0.001). The incidences of other complications did not differ significantly between the two groups. CONCLUSIONS: The new reconstruction method may prevent delayed gastric emptying after PPPD.     

不同吻合器在腹腔镜远端胃癌根治术Roux-en-Y式吻合中的安全性及卫生经济学对比

目的:比较直线切割吻合器与圆形吻合器在腹腔镜辅助远端胃癌根治术Roux-en-Y吻合中的安全性与卫生经济学的差异。方法:回顾分析2017年8月至2019年2月192例接受腹腔镜辅助远端胃癌根治术并Roux-en-Y式吻合患者的临床资料。根据胃肠吻合所用吻合器材类型,将患者分为直线切割吻合器组(A组,n=40,20.8%)与圆形吻合器组(B组,n=152,79.2%)。比较两组手术安全性、术后消化道功能恢复及卫生经济学的差异。结果:A组术中出血量[(59.75±38.397)mL vs.(63.29±67.792)mL,(P=0.752)]、手术时间[(249.28±65.72)min vs.(255.03±62.67)min,P=0.609]、淋巴结清扫数量[(30.68±11.74)枚vs.(32.43±12.61)枚,P=0.429]、Ⅱ度及以上并发症发生率[7.5%(3/40)vs.7.9%(12/152),P=0.934]、手术耗材费用(中位数:30758元vs.32749元,P=0.064)及住院费用(中位数:70759元vs.70851元,P=0.527)与B组差异无统计学意义。A组术后首次排气时间[(3.46±0.767)d vs.(3.98±1.190)d,P=0.013]、首次进流食时间[(4.32±1.029)d vs.(4.91±0.996)d,P=0.020]、拔除腹腔引流管时间[(6.00±0.882)d vs.(6.56±1.764)d,P=0.008]均短于B组,差异均有统计学意义。结论:腹腔镜辅助远端胃癌根治术Roux-en-Y吻合中使用直线切割吻合器或圆形吻合器行消化道重建均是安全、可行的,使用直线切割吻合器术后首次排气时间、首次进流食时间更短,在术后胃肠道功能恢复方面存在优势。     

Preservation of the left gastric vein in delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy

The definition of delayed gastric emptying (DGE) after pyloric-preserving pancreaticoduodenectomy (PPPD) varies among surgeons. We compared and evaluated three different definitions reported elsewhere. In addition, we investigated the correlation between multiple surgical factors and recovery of gastric motility. First, 55 consecutive patients were reviewed to assess the three different definitions. Second, surgical factors affecting gastric motility were investigated in 46 patients showing no major complications. All 55 patients underwent PPPD, which was reconstructed with antecolic duodenojejunostomy, with aggressive lymph node dissection and with no mortality. The duration of nasogastric intubation was 2 days, and a solid diet started on the 12th postoperative day (median). Re-nasogastric intubation or emesis was observed in 12.7% of patients. Overall, DGE occurrence rate was 5.5%-29.1%, with striking differences depending on the type of definition. Technically, division of the left gastric vein was accompanied with significantly delayed removal of the nasogastric tube (3 versus 2 days, P = 0.0002) and delayed start on a solid diet (14 versus 9 days, P < 0.0001) compared with its preservation. Antecolic duodenojejunostomy after PPPD improved DGE occurrence despite aggressive surgery, and preservation of LGV accelerated restoration of gastric motility in our experiments. However, an understanding of a common definition of DGE is needed when discussing the outcome of the various interventions.