Impact of pylorus preservation on delayed gastric emptying after pancreaticoduodenectomy-analysis of 5,000 patients based on the German StuDoQ|Pancreas-Registry.

BACKGROUND: Delayed gastric emptying (DGE) is one of the most common complications after pancreatic head resection. It leads to increased length of hospital stay, high costs for healthcare systems and reduced quality of life. The primary aim of the study was to assess the impact of pylorus preservation, respectively resection on the occurrence of DGE in patients undergoing pancreaticoduodenectomy (PD). METHODS: All cases of pylorus-resecting PD (PRPD) and pylorus-preserving PD (PPPD) entered in the StuDoQ|Pancreas nationwide registry of the German Society of General and Visceral Surgery from 01/01/2014 until 31/12/2018 including demographics, surgical techniques, histopathological and perioperative data were retrospectively analyzed. This study was approved by the ethics committee of the Ruhr-University Bochum, Germany. RESULTS: Data of 5,080 patients were enrolled. PPPD was the method of choice (70.4%). Pylorus preservation had no impact on the occurrence of DGE (20.3% vs. 21.5%, P=0.33), but further risk factors could be identified. The comparison of PPPD and PRPD groups showed statistically significant differences in the surgical approach (primary open approach, 94.8% vs. 98.0%, P<0.001), duration of surgery (326.4 vs. 352.1 minutes, P<0.001), technique of pancreatic anastomosis (pancreaticojejunostomy vs. pancreaticojejunostomy), 78.6% vs. 85.2%, P<0.001). CONCLUSIONS: Patient factors, intraoperative factors, duration of surgery and postoperative factors (postoperative pancreatic fistula, biliary leakage and other surgical complications) were identified as risk factors for DGE. Future research should focus on register-based, prospective, randomised-controlled studies such as the currently recruiting "PyloResPres trial".

Is Roux Loop a Solution to Delayed Gastric Emptying Following Pancreaticoduodenectomy? A Single Institute Analysis.

Delayed gastric emptying is one of the most common complications of pancreaticoduodenectomy (PD). It almost always results in delayed oral intake, prolonged hospital stays, and a delay in initiation of vital adjuvant treatment. A few earlier studies suggested that delayed gastric emptying (DGE) rates were better with the Roux-en Y reconstruction, but Indian literature regarding this is lacking. In our institutional study, we compared the traditional single-loop reconstruction (SL group), with the Roux loop reconstruction (RY group) following a subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). A retrospective comparative study was conducted between the conventional single loop and a Roux-en-Y method of reconstruction following a subtotal stomach preserving pancreaticoduodenectomy (SSPPD). Sixty-three consecutive Whipple's procedures were analyzed for multiple clinical parameters like removal of Ryles tube, tolerance of liquid diet and solid diet, delayed gastric emptying, duration of hospital stay and interval between surgery, and initiation of adjuvant treatment. Forty-one patients in the SL group were compared with 22 patients in the RY group. Ryles tube removal (POD 8.2 versus 2.25, p < 0.001), initiation of liquid diet (POD 8.43 versus 2.88, p < 0.001), post-operative hospital stay (13.5 days versus 9.63, p < 0.001), and interval between surgery and adjuvant treatment (37.75 days versus 28.88 days, p < 0.002) were all in favor of the RY group. The delayed gastric emptying was also found to be significantly better in the Roux-en-Y surgery group (p < 0.001). The Roux loop reconstruction following a stomach-preserving pancreaticoduodenectomy (SSPPD) is superior to single-loop reconstruction with respect to delayed gastric emptying. The lesser duration of hospital stay and early initiation of adjuvant therapy are an additional benefit of the Roux loop reconstruction.

Transduodenal surgical ampullectomy: a procedure that requires a multidisciplinary approach.

Trans-duodenal surgical ampullectomy (TSA) was first described in 1899. Nowadays its role in ampullary tumor surgery is still a matter of debate and requires a multidisciplinary approach. The aim of this study is to evaluate the results of TSA as a curative treatment for benign and selected malignant tumors arising from the ampulla in a single-institution experience. Sixteen patients with periampullary tumors that underwent TSA in our surgical units between January 2012 and January 2017 were included in the study. Patient demographic characteristics, pre or postoperative endoscopic interventions, operative procedures, postoperative morbidity and mortality, hospitalization, follow-up time, and quality of life questionnaire were analyzed. Mean operative time was 238.5 min (range 180-390), mean tumor size was 2.3 cm (range 1.5-3.9). The microscopic surgical outcome was R0 for 14 patients. The most frequent findings in terms of histological type were high-grade dysplasia/pTis (43.7%), low-grade dysplasia in 37.5% patients, invasive adenocarcinoma in 2 cases (12.5%), chronic inflammation in 1 case (6.3%). The readmission rate was 18.8% (3/16) and in 2 cases (12.5%) relaparotomy was required. The cumulative median duration of follow-up was 50 months (range 1-96). 90-days mortality was 6.2%. Mean hospital stay was 12 days (range 8-60). Our results confirm that TSA offers good results in terms of morbidity and mortality; still, it remains a challenging procedure that requires particular surgical experience and operative skills. A pre-operative planning in a multidisciplinary board should be carried out prior to the procedure.

Management of delayed gastric conduit emptying after esophagectomy.

Delayed gastric conduit emptying (DGE) is a common complication after esophagectomy. Currently, pyloric interventions are the major prevention and treatment for DGE. In this review, we attempt to evaluate the clinical effect and safety of different pyloric interventions in esophagectomy patients. Moreover, other important management of DGE, including size of esophageal substitute, erythromycin and nasogastric tube (NGT) will also be discussed.

Pylorus preservation pancreatectomy or not.

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.

Causal relationship between delayed gastric emptying and gastroesophageal reflux in patients with neurological impairment.

PURPOSE: To investigate the causal relationship between delayed gastric emptying (DGE) and gastroesophageal reflux (GER) in patients with neurological impairment (NI). METHODS: Subjects included 30 NI patients (age, 1-34 years; median, 6 years). Combined multichannel intraluminal impedance-pH (MII-pH) monitoring and (13)C-breath test evaluated acid/non-acid reflux episodes (RE) and gastric emptying rates, respectively. Values are shown with medians and ranges. RESULTS: Percentage time for esophageal pH < 4.0 (reflux index: RI) and numbers for total RE and RE > 5 min were 8.3 (0-35.7), 44 (0-129), and 5 (0-22), respectively. Total percentage time and bolus RE numbers were 1.4 (0.0-6.9) and 49 (2-159), respectively. Median bolus clearance time was 16 s (9-45). T 1/2, T lag, and GEC were 103 s (75-204), 54 s (18-97), and 3.4 (2.3-4.3), respectively. Gastric emptying rates and acid/non-acid reflux parameters were not significantly correlated, except T 1/2 correlated significantly with the numbers of RE > 5 min (p = 0.04). T 1/2 inversely correlated with bolus clearance time (p = 0.01). Reflux parameters between DGE and non-DGE patients were not significantly different, except median bolus clearance time was significantly shorter in DGE patients (p = 0.01). CONCLUSIONS: NI patients showed a wide range of gastric emptying rates without any significant causal relationship between DGE and GER.

Antecolic gastrointestinal reconstruction with pylorus dilatation. Does it improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy?

OBJECTIVE: The aim of our study focuses upon prevention of delayed gastric emptying (DGE) after pancreaticoduodenectomy using a alternative reconstruction procedure. METHOD: Forty consecutive patients underwent a typical pylorus-preserving pancreaticoduodenectomy (PPPD) with antecolic reconstruction in a two-year period (January 2002 until January 2004), while a similar group of 40 consecutive patients underwent PPPD with application of pyloric dilatation between January 2004 and January 2006. Early and late complications were compared between the two groups. RESULTS: DGE occurred significantly more often in the group of patients treated by the classical PPPD technique (nine patients -22%) compared with those operated on with the addition of pyloric dilatation technique (two patients -5%) (p<0.05). The incidence of other complications did not differ significantly between the two groups. CONCLUSIONS: The application of dilatation may decrease the incidence of DGE after PPPD and facilitates earlier hospital discharge.