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      Management and prevention of delayed gastric emptying after pancreaticoduodenectomy

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          Abstract

          Although technical advances have been made in pancreaticoduodenectomy, the incidence of delayed gastric emptying (DGE) is reported as being high. Postoperative DGE is not fatal, but often results in prolonging the length of patients' stay in hospital, increasing their medical expenses, and further lowering their quality of life. DGE is a complex process caused by disorder and incoordination of various factors in charge of gastric mobility, such as smooth muscle cells (myogenic), enteric neuron (hormonal), and autonomic nervous system (neural). DGE often occurs after operative maneuvers that cause the loss of organs responsible for gastric motility and emptying or kinetic muscular or neuromuscular ischemia. To prevent DGE, it is most important to develop and universalize a standardized surgical technique in a way to reduce factors that are considered to cause DGE after pancreaticoduodenectomy. Moreover, if it is suspected that DGE occurred after pancreaticoduodenectomy, a differential diagnosis from diseases with similar symptoms via an accurate diagnostic approach should be implemented.

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          Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes.

          C J Yeo, J L Cameron, T Sohn … (1997)
          The authors reviewed the pathology, complications, and outcomes in a consecutive group of 650 patients undergoing pancreaticoduodenectomy in the 1990s. Pancreaticoduodenectomy has been used increasingly in recent years to resect a variety of malignant and benign diseases of the pancreas and periampullary region. Between January 1990 and July 1996, inclusive, 650 patients underwent pancreaticoduodenal resection at The Johns Hopkins Hospital. Data were recorded prospectively on all patients. All pathology specimens were reviewed and categorized. Statistical analyses were performed using both univariate and multivariate models. The patients had a mean age of 63 +/- 12.8 years, with 54% male and 91% white. The number of resections per year rose from 60 in 1990 to 161 in 1995. Pathologic examination results showed pancreatic cancer (n = 282; 43%), ampullary cancer (n = 70; 11%), distal common bile duct cancer (n = 65; 10%), duodenal cancer (n = 26; 4%), chronic pancreatitis (n = 71; 11%), neuroendocrine tumor (n = 31; 5%), periampullary adenoma (n = 21; 3%), cystadenocarcinoma (n = 14; 2%), cystadenoma (n = 25; 4%), and other (n = 45; 7%). The surgical procedure involved pylorus preservation in 82%, partial pancreatectomy in 95%, and portal or superior mesenteric venous resection in 4%. Pancreatic-enteric reconstruction, when appropriate, was via pancreaticojejunostomy in 71% and pancreaticogastrostomy in 29%. The median intraoperative blood loss was 625 mL, median units of red cells transfused was zero, and the median operative time was 7 hours. During this period, 190 consecutive pancreaticoduodenectomies were performed without a mortality. Nine deaths occurred in-hospital or within 30 days of operation (1.4% operative mortality). The postoperative complication rate was 41%, with the most common complications being early delayed gastric emptying (19%), pancreatic fistula (14%), and wound infection (10%). Twenty-three patients required reoperation in the immediate postoperative period (3.5%), most commonly for bleeding, abscess, or dehiscence. The median postoperative length of stay was 13 days. A multivariate analysis of the 443 patients with periampullary adenocarcinoma indicated that the most powerful independent predictors favoring long-term survival included a pathologic diagnosis of duodenal adenocarcinoma, tumor diameter <3 cm, negative resection margins, absence of lymph node metastases, well-differentiated histology, and no reoperation. This single institution, high-volume experience indicates that pancreaticoduodenectomy can be performed safely for a variety of malignant and benign disorders of the pancreas and periampullary region. Overall survival is determined largely by the pathology within the resection specimen.
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            TREATMENT OF CARCINOMA OF THE AMPULLA OF VATER.

            A Whipple, W B Parsons, C Mullins (1935)
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              Perioperative mortality for pancreatectomy: a national perspective.

              James T McPhee, Joshua Hill, Giles Whalen … (2007)
              To analyze in-hospital mortality after pancreatectomy using a large national database. Pancreatic resections, including pancreaticoduodenectomy, distal pancreatectomy, and total pancreatectomy, remain the only potentially curative interventions for pancreatic cancer. The goal of this study was to define factors affecting outcomes after pancreatectomy for neoplasm. A retrospective analysis was performed using all patients undergoing pancreatic resections for neoplastic disease identified from the Nationwide Inpatient Sample from 1998 to 2003. Crude in-hospital mortality was analyzed by chi. A multivariable model was constructed to adjust for age, sex, hospital teaching status, hospital surgical volume, year of resection, payer status, and selected comorbid conditions. In all, 279,445 patient discharges were identified with a primary diagnosis of pancreatic neoplasm. A total of 39,463 (14%) patients underwent resection during that hospitalization. In-hospital mortality was 5.9% with a significant decrease from 7.8% to 4.6% from 1998 to 2003 by trend analysis (P 18/year)-volume centers (low-volume odds ratio = 3.3; 95% confidence interval, 2.3-4.; medium-volume, odds ratio = 2.1; 95% confidence interval, 1.5-3.0). The proportion of procedures performed at high volume centers increased from 30% to 39% over the 6-year time period (P < 0.0001) by trend test. This large observational study demonstrates an improvement in operative mortality for patients undergoing pancreatectomy for neoplastic disease from 1998 to 2003. In addition, a greater proportion of pancreatectomies were performed at high-volume centers in 2003. The regionalization of pancreatic surgery may have partially contributed to the observed decrease in mortality rates.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Korean J Hepatobiliary Pancreat Surg
                Journal ID (iso-abbrev): Korean J Hepatobiliary Pancreat Surg
                Journal ID (publisher-id): KJHBPS
                Title: Korean Journal of Hepato-Biliary-Pancreatic Surgery
                Publisher: Korean Association of Hepato-Biliary-Pancreatic Surgery
                ISSN (Print): 1738-6349
                ISSN (Electronic): 2288-9213
                Publication date (Print): February 2012
                Publication date (Electronic): 29 February 2012
                Volume: 16
                Issue: 1
                Pages: 1-6
                Affiliations
                Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Keimyung University School of Medicine, Daegu, Korea.
                Author notes
                Corresponding author: Yong Hoon Kim. Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Keimyung University School of Medicine, 56, Dalseong-ro, Jung-gu, Daegu 700-712, Korea. Tel: +82-53-250-7387, Fax: +82-53-250-7322, hbps@ 123456dsmc.or.kr
                Article
                DOI: 10.14701/kjhbps.2012.16.1.1
                PMC ID: 4575017
                SO-VID: 4d2e815c-0f37-4538-ad08-965710b84326
                Copyright © Copyright © 2012 by The Korean Association of Hepato-Biliary-Pancreatic Surgery
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 22 January 2012
                Date revision received : 05 February 2012
                Date accepted : 11 February 2012
                Categories
                Subject: Review Article

                Keywords: pancreaticoduodenectomy,delayed gastric emptying,therapy,prevention
                Data availability:
                Keywords: pancreaticoduodenectomy, delayed gastric emptying, therapy, prevention

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