ORIGINAL ARTICLE ANZJSurg.com
Risk factors of delayed gastric emptying following pancreaticoduodenectomy Qi-Yu Liu,* Li Li,* Hong-Tian Xia,† Wen-Zhi Zhang,† Shou-Wang Cai† and Shi-Chun Lu† *Department of Hepatobiliary Surgery, 1st People’s Hospital of Kunming, Kunming, China and †Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China
Key words complication, delayed gastric emptying, pancreatic fistula, pancreaticoduodenectomy, pylorus. Correspondence Dr Shi-Chun Lu, Department of Hepatobiliary Surgery, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing 100853, China. Email:
[email protected] Q.-Y. Liu MD; L. Li MD; H.-T. Xia MD; W.-Z. Zhang MD; S.-W. Cai MD; S.-C. Lu MD, PhD. Accepted for publication 7 August 2014. doi: 10.1111/ans.12850
Abstract Background: This study aims to explore the morbidity and risk factors of delayed gastric emptying (DGE) following pancreaticoduodenectomy. Methods: Between 1 January 2013 and 31 December 2013, data from 196 consecutive patients who underwent pancreaticoduodenectomy in the Chinese PLA General Hospital were recorded retrospectively. A total of 17 factors were examined with univariate analysis, and multivariate logistic regression analysis was used to estimate relative risks. Results: DGE occurred in 71 patients (36.2%). The incidence rates of grade A, grade B and grade C DGE were 22.4% (44/196), 6.1% (12/196) and 7.7% (15/196), respectively. There were three post-operative deaths for the entire series, with an overall mortality rate of 1.5%. Braun enteroenterostomy, clinically relevant post-operative pancreatic fistula (CR-POPF) and intra-abdominal collection correlated with DGE rates significantly in univariate analysis, whereas CR-POPF and intra-abdominal collection were independent risk factors in multivariate logistic regression analysis. Body mass index ≥25 kg/m2, CR-POPF and intra-abdominal collection correlated with clinically relevant DGE rates significantly and were independent risk factors in univariate analysis and multivariate regression. Conclusion: Only post-operative complications instead of operative methods were associated with DGE. Early diagnosis and timely treatment for pancreatic fistula and intra-abdominal collection were helpful to decrease morbidity and promote recovery of DGE.
Introduction Advances in strict patient selection, surgical techniques, postoperative management and interventional therapy have enabled safe pancreaticoduodenectomy (PD) in high-volume centres. PD is one of the therapeutic methods for the different kinds of benign and malignant disease of the peri-ampullary region and head of pancreas. Compared with the past four decades, a prodigious reduction in operative mortality has been developed in patients who are receiving PD. According to recent literature, the mortality of PD is less than 5%.1–5 Delayed gastric emptying (DGE) is one of the most common complications following PD, with an incidence rate ranging from 14% to 61%.6–8 DGE following PD, otherwise named as ‘gastroparesis’, was primarily reported by Warshaw and Torchiana in 1985.9 DGE following PD is a multifactorial phenomenon and the
aetiology is still unclear. Several risk factors have been associated with DGE, including septic and other intra-abdominal complications. Furthermore, several technical causes, such as preservation of the pylorus or not, the route of reconstruction of gastro/ duodenojejunostomy (antecolic versus retrocolic), have been shown to affect DGE. DGE is associated with prolonged length of stay, increased hospitalization expense and a decreased quality of life, although it is not life threatening. Due to variations in definition, the true morbidity of DGE has been difficult to account. Recently, standard definition of post-operative pancreatic fistula (POPF) has been proposed by the International Study Group on Pancreatic Fistula (ISGPF) and it looks as if most researchers agree.10 The primary objective of this study is to analyse the risk factors for DGE among 196 patients who underwent PD in 2013 in a Chinese high-volume centre.
© 2014 The Authors ANZ Journal of Surgery published by Wiley Publishing Asia Pty Ltd on behalf of Royal Australasian College of Surgeons ANZ J Surg •• (2014) ••–•• This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
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Methods Subject enrolment and data collection A retrospective review of 196 patients, who underwent PD from 1 January 2013 to 31 December 2013 in the Chinese PLA General Hospital, was conducted. Demographic information and clinical data include gender, age, body mass index (BMI), hypertension, diabetes mellitus, serum CA19-9, preoperative jaundice, preoperative bile drain, serum albumin, blood loss volume, Braun enteroenterostomy, pyloruspreserving, POPF, clinically relevant POPF (CR-POPF), intraabdominal collection, incision infection and primary disease. Postoperative complications with a specific focus on POPF, CR-POPF, DGE, clinically relevant DGE (CR-DGE), incision infection, intraabdominal collection and mortality were recorded. No patient was excluded from the series.
Operative procedure Patients underwent either pylorus-preserving or classic (hemigastrectomy) PD. Reconstruction of pancreatic and biliary system was performed in retrocolic fashion, and gastro/duodenojejunostomy was implemented in anticolic way. If possible, a pancreatic tube was inserted into the pancreatic duct with several perforations as a stent from the jejunum and fixed at the edge of transected pancreatic duct. In some of them, an external stent across pancreaticojejunal anastomosis through the abdominal wall was used (complete external drainage of the pancreatic juice). Whether a duct-to-mucosa anastomosis or an invaginated anastomosis is to be performed in the pancreaticojejunostomy is mainly according to surgeon’s preference. No pancreaticogastrostomy was performed in the series. Some drains were placed routinely anterior and posterior to the pancreaticojejunostomy and choledochojejunostomy anastomosis. Prophylactic octreotide was not routinely used.
Classification and detailed definition of POPF and DGE Recently, the standard definition of POPF has been proposed by the ISGPF and it looks as if most researchers agree.11 The ISGPF definition consisted of grades A, B and C based upon the clinical influence on the patient’s hospitalization process and ultimate outcome. The CR-POPF consisted of grades B and C. DGE was classified into grades A, B and C based upon the definition also proposed by the International Study Group of Pancreatic Surgery (ISGPS).10 Because the timing of serving of food was influenced by the preference of each attending surgeon, grade A was not considered to be a clinically relevant complication, but grade B and grade C DGE.
Statistical analysis Quantitative data are expressed as mean ± SD. An independent sample Student’s t-test was used to compare quantitative variables. The chi-square test and Fisher’s exact test were used to compare categorical variables. Of all the variables tested in univariate analysis, only those with P-values
