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Delayed gastric emptying after pancreatoduodenectomy: One complication, two different entities

  • Giovanni Marchegiani
    Affiliations
    Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy
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  • Anthony Di Gioia
    Affiliations
    Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy
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  • Tommaso Giuliani
    Affiliations
    Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy
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  • Michela Lovo
    Affiliations
    Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy
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  • Eleonora Vico
    Affiliations
    Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
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  • Marco Cereda
    Affiliations
    Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
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  • Claudio Bassi
    Correspondence
    Reprint requests: Claudio Bassi, MD, FACS, Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, “Giambattista Rossi” Hospital - Borgo Roma, Piazzale Ludovico Antonio Scuro 10, 37134, Verona, Italy.
    Affiliations
    Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy
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  • Luca Gianotti
    Affiliations
    Unit of Hepatobiliary Pancreatic Surgery, Department of Surgery, San Gerardo Hospital, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
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  • Roberto Salvia
    Affiliations
    Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, "Giambattista Rossi" Hospital - Borgo Roma, Verona, Italy
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Published:January 24, 2023DOI:https://doi.org/10.1016/j.surg.2022.12.013

      Abstract

      Background

      Delayed gastric emptying (DGE) is a common complication after pancreatoduodenectomy associated with a low complication burden but a prolonged hospital stay. The present study aimed to characterize DGE, with a particular focus on its subtypes and related predictors.

      Methods

      A 2-center retrospective analysis was performed including consecutive pancreatoduodenectomy over 5 years. Primary delayed gastric emptying (pDGE) and secondary delayed gastric emptying (sDGE) were defined according to the presence of concomitant causing factors. Predictors of DGE, pDGE and sDGE were assessed through logistic regression.

      Results

      Out of 1,170 patients considered, 188 developed delayed gastric emptying (16.1%). Most DGE (71.8%) were secondary. sDGE resolved later (P = .007), with hospital stay, duration of total parenteral nutrition, and of enteral nutrition being longer than for pDGE (all P < .005). Smoking status, total operative time, indication for surgery other than pancreatic cancer, estimated blood loss, and soft pancreatic texture were independent predictors of DGE. In the subgroup analysis of pDGE, smoking was the only independent predictor, whereas pylorus-preservation was a protective factor. Smoking, indication for surgery, estimated blood loss, soft gland texture, and main pancreatic duct diameter were independent predictors of sDGE.

      Conclusion

      DGE after pancreatoduodenectomy consists of 2 different subtypes. The primary form resolves earlier, and its occurrence might be reduced by pylorus preservation. For the secondary form, clinicians should focus on preventing and treating other trigger complications. The diagnosis of the DGE subtype has critical therapeutic implications and paves the way for further systematic studies.
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      References

        • Bassi C
        • Marchegiani G
        • Giuliani T
        • et al.
        Pancreatoduodenectomy at the verona pancreas institute: the evolution of indications, surgical techniques, and outcomes: a retrospective analysis of 3000 consecutive cases.
        Ann Surg. 2022; 276: 1029-1038
        • Giuliani T.
        • Marchegiani G.
        • Di Gioia A.
        • et al.
        Patterns of mortality after pancreatoduodenectomy: a root cause, day-to-day analysis.
        Surgery. 2022; 172: 329-335
        • Balzano G.
        • Zerbi A.
        • Capretti G.
        • Rocchetti S.
        • Capitanio V.
        • Di Carlo V.
        Effect of hospital volume on outcome of pancreaticoduodenectomy in Italy.
        Br J Surg. 2008; 95: 357-362
        • Di Gioia A.
        • Giuliani T.
        • Marchegiani G.
        • et al.
        Pancreatoduodenectomy in obese patients: surgery for nonmalignant tumors might be deferred.
        HPB. 2022; 24: 885-892
        • Wente M.N.
        • Bassi C.
        • Dervenis C.
        • et al.
        Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS).
        Surgery. 2007; 142: 761-768
        • Francken M.F.G.
        • van Roessel S.
        • Swijnenburg R.J.
        • et al.
        Hospital costs of delayed gastric emptying following pancreatoduodenectomy and the financial headroom for novel prophylactic treatment strategies.
        HPB. 2021; 23: 1865-1872
        • Eisenberg J.D.
        • Rosato E.L.
        • Lavu H.
        • Yeo C.J.
        • Winter J.M.
        Delayed gastric emptying after pancreaticoduodenectomy: an analysis of risk factors and cost.
        J Gastrointest Surg. 2015; 19: 1572-1580
        • Mohammed S.
        • II G.V.B.
        • McElhany A.
        • Silberfein E.J.
        • Fisher W.E.
        Delayed gastric emptying following pancreaticoduodenectomy: incidence, risk factors, and healthcare utilization.
        World J Gastrointest Surg. 2017; 9: 73-81
        • Kawai M.
        • Tani M.
        • Hirono S.
        • et al.
        Pylorus ring resection reduces delayed gastric emptying in patients undergoing pancreatoduodenectomy: a prospective, randomized, controlled trial of pylorus-resecting versus pylorus-preserving pancreatoduodenectomy.
        Ann Surg. 2011; 253: 495-501
        • Parmar A.D.
        • Sheffield K.M.
        • Vargas G.M.
        • et al.
        Factors associated with delayed gastric emptying after pancreaticoduodenectomy.
        HPB. 2013; 15: 763-772
        • Hanna M.M.
        • Gadde R.
        • Allen C.J.
        • et al.
        Delayed gastric emptying after pancreaticoduodenectomy.
        J Surg Res. 2016; 202: 380-383
        • Paraskevas K.I.
        • Avgerinos C.
        • Manes C.
        • Lytras D.
        • Dervenis C.
        Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: a review of the literature and critical reappraisal of the implicated pathomechanism.
        World J Gastroenterol. 2006; 12: 5951-5958
        • Tani M.
        • Terasawa H.
        • Kawai M.
        • et al.
        Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy: results of a prospective, randomized, controlled trial.
        Ann Surg. 2006; 243: 316-320
        • Horstmann O.
        • Markus P.M.
        • Ghadimi M.B.
        • Becker H.
        Pylorus preservation has no impact on delayed gastric emptying after pancreatic head resection.
        Pancreas. 2004; 28: 69-74
        • Busquets J.
        • Martín S.
        • Secanella L.
        • et al.
        Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD).
        Langenbecks Arch Surg. 2022; 407: 2247-2258
        • Werba G.
        • Sparks A.D.
        • Lin P.P.
        • Johnson L.B.
        • Vaziri K.
        The PrEDICT-DGE score as a simple preoperative screening tool identifies patients at increased risk for delayed gastric emptying after pancreaticoduodenectomy.
        HPB. 2022; 24: 30-39
        • Courvoisier T.
        • Donatini G.
        • Faure J.P.
        • Danion J.
        • Carretier M.
        • Richer J.P.
        Primary versus secondary delayed gastric emptying (DGE) grades B and C of the International Study Group of Pancreatic Surgery after pancreatoduodenectomy: a retrospective analysis on a group of 132 patients.
        Updat Surg. 2015; 67: 305-309
        • Ellis R.J.
        • Gupta A.R.
        • Hewitt D.B.
        • et al.
        Risk factors for postpancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra-abdominal infection.
        J Surg Oncol. 2019; 119: 925-931
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • Pocock S.J.
        • Gøtzsche P.C.
        • Vandenbroucke J.P.
        The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Int J Surg. 2014; 12: 1495-1499
        • Salvia R.
        • Malleo G.
        • Marchegiani G.
        • Butturini G.
        • Esposito A.
        • Bassi C.
        Pancreaticoduodenectomy with Harmonic Focus curved shears for cancer.
        Dig Surg. 2014;
        • Callery M.P.
        • Pratt W.B.
        • Kent T.S.
        • Chaikof E.L.
        • Vollmer C.M.
        A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy.
        J Am Coll Surg. 2013; 216: 1-14
        • Andrianello S.
        • Marchegiani G.
        • Malleo G.
        • et al.
        Pancreaticojejunostomy with externalized stent vs pancreaticogastrostomy with externalized stent for patients with high-risk pancreatic anastomosis: a single-center, phase 3, randomized clinical trial.
        JAMA Surg. 2020; 155: 313-321
        • Melloul E.
        • Lassen K.
        • Roulin D.
        • et al.
        Guidelines for perioperative care for pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019.
        World J Surg. 2020; 44: 2056-2084
        • Gianotti L.
        • Besselink M.G.
        • Sandini M.
        • et al.
        Nutritional support and therapy in pancreatic surgery: a position paper of the International Study Group on Pancreatic Surgery (ISGPS).
        Surgery. 2018; 164: 1035-1048
        • Bassi C.
        • Marchegiani G.
        • Dervenis C.
        • et al.
        The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after.
        Surgery. 2017; 161: 584-591
        • Wente M.N.
        • Veit J.A.
        • Bassi C.
        • et al.
        Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition.
        Surgery. 2007; 142: 20-25
        • Besselink M.G.
        • van Rijssen L.B.
        • Bassi C.
        • et al.
        Definition and classification of chyle leak after pancreatic operation: a consensus statement by the International Study Group on Pancreatic Surgery.
        Surgery. 2017; 161: 365-372
        • Marchegiani G.
        • Barreto S.G.
        • Bannone E.
        • et al.
        Postpancreatectomy acute pancreatitis (PPAP): definition and grading from the International Study Group for Pancreatic Surgery (ISGPS).
        Ann Surg. 2022; 275: 663-672
        • Koch M.
        • Garden O.J.
        • Padbury R.
        • et al.
        Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery.
        Surgery. 2011; 149: 680-688
        • Strasberg S.M.
        • Hall B.L.
        Postoperative morbidity index: a quantitative measure of severity of postoperative complications.
        J Am Coll Surg. 2011; 213: 616-626
        • Vollmer C.M.
        • Lewis R.S.
        • Hall B.L.
        • et al.
        Establishing a quantitative benchmark for morbidity in pancreatoduodenectomy using ACS-NSQIP, the accordion severity grading system, and the postoperative morbidity index.
        Ann Surg. 2015; 261: 527-536
        • Maggino L.
        • Liu J.B.
        • Ecker B.L.
        • Pitt H.A.
        • Vollmer C.M.
        Impact of operative time on outcomes after pancreatic resection: a risk-adjusted analysis using the American College of Surgeons NSQIP database.
        J Am Coll Surg. 2018; 226: 844-857.e3
        • Hackert T.
        • Hinz U.
        • Hartwig W.
        • et al.
        Pylorus resection in partial pancreaticoduodenectomy: impact on delayed gastric emptying.
        Am J Surg. 2013; 206: 296-299
        • Fahlbusch T.
        • Luu A.M.
        • Höhn P.
        • et al.
        Impact of pylorus preservation on delayed gastric emptying after pancreaticoduodenectomy: analysis of 5,000 patients based on the German StuDoQ Pancreas Registry.
        Gland Surg. 2022; 11: 67-76
        • Hackert T.
        • Probst P.
        • Knebel P.
        • et al.
        Pylorus resection does not reduce delayed gastric emptying after partial pancreatoduodenectomy: a blinded randomized controlled trial (PROPP Study, DRKS00004191).
        Ann Surg. 2018; 267: 1021-1027
        • Hackert T.
        • Weitz J.
        • Büchler M.W.
        Reinsertion of the gastric coronary vein to avoid venous gastric congestion in pancreatic surgery.
        HPB. 2015; 17: 368-370
      1. Malleo G, Maggino L, Qadan M, et al. Reassessment of the optimal number of examined lymph nodes in pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Ann Surg. 20202;276:e518–e526.