Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy

Background: Delayed gastric emptying(DGE) is one of the most common complications after pancreaticoduodenectomy(PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE. Data sources: Studies were identified by searching Pub Med for relevant articles published up to December 2022. The following search terms were used: “pancreaticoduodenectomy”, “pancreaticojejunostomy”, “pancreaticogastrostomy”, “gastric emptying”, “gastroparesis” and “postoperative complications”. The search was limited to English publications. Additional articles were identified by a manual search of references from key articles. Results: In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE. Conclusions: Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.

Preoperative and postoperative complications as risk factors for delayed gastric emptying following pancreaticoduodenectomy: A single-center retrospective study

BACKGROUND Mortality rates after pancreaticoduodenectomy(PD)have significantly decreased in specialized centers.However,postoperative morbidity,particularly delayed gastric emptying(DGE),remains the most frequent complication following PD.AIM To identify risk factors associated with DGE after the PD procedure.METHODS In this retrospective,cross-sectional study,clinical data were collected from 114 patients who underwent PD between January 2015 and June 2018.Demographic factors,pre-and perioperative characteristics,and surgical complications were assessed.Univariate and multivariate analyses were performed to identify risk factors for post-PD DGE.RESULTS The study included 66 males(57.9%)and 48 females(42.1%),aged 33-83 years(mean:62.5),with a male-to-female ratio of approximately 1.4:1.There were 63 cases(55.3%)of PD and 51 cases(44.7%)of pylorus-preserving pancreatoduodenectomy.Among the 114 patients who underwent PD,33(28.9%)developed postoperative DGE.Univariate analysis revealed significant differences in four of the 14 clinical indexes observed:pylorus preservation,retrocolonic anastomosis,postoperative abdominal complications,and early postoperative albumin(ALB).Logistic regression analysis further identified postoperative abdominal complic-ations[odds ratio(OR)=4.768,P=0.002],preoperative systemic diseases(OR=2.516,P=0.049),and early postoperative ALB(OR=1.195,P=0.003)as significant risk factors.CONCLUSION Postoperative severe abdominal complications,preoperative systemic diseases,and early postoperative ALB are identified as risk factors for post-PD DGE.

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

Pylorus-preserving pancreaticoduodenectomy （PPPD） is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying （DGE） comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/IVledline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy （PD） vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported （but not yet tested in largescale studies） modification, that is, PPPD with antecolic duodenojejunostomy.

The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy

BACKGROUND:A number of definitions have been used for delayed gastric emptying(DGE) after pancreatoduodenectomy and the reported rates varied widely.The International Study Group of Pancreatic Surgery(ISGPS) definition is the current standard but it is not used universally.In this comprehensive review,we aimed to determine the acceptance rate of ISGPS definition of DGE,the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence.DATA SOURCE:We searched PubM ed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition,DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles.RESULTS:Out of 435 search results,178 were selected for data extraction.The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7%(range:0-100%;median:18.7%) and 14.3%(range:1.8%-58.2%;median:13.6%),respectively.Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates.Although pyloric dilatation,Braun’s entero-enterostomy and Billroth Ⅱ reconstruction were associated with significantly lower DGE rates,pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies.CONCLUSIONS:ISGPS definition of DGE has been used in majority of studies published after 2010.Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications.Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.

Does antecolic reconstruction for duodenojejunostomy improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? A systematic review and meta-analysis

AIM:To evaluate whether antecolic reconstruction for duodenojejunostomy (DJ) can decrease delayed gastric emptying (DGE) rate after pylorus-preserving pancreaticoduodenectomy (PPPD) through literature review and meta-analysis. METHODS:Articles published between January 1991 and April 2012 comparing antecolic and retrocolic reconstruction for DJ after PPPD were retrieved from the databases of MEDLINE (PubMed), EMBASE, OVID and Cochrane Library Central. The primary outcome of interest was DGE. Either fixed effects model or random effects model was used to assess the pooled effect based on the heterogeneity. RESULTS:Five articles were identified for inclusion:two randomized controlled trials and three non-randomized controlled trials. The meta-analysis revealed that antecolic reconstruction for DJ after PPPD was associated with a statistically significant decrease in the incidence of DGE [odds ratio (OR), 0.06; 95% CI, 0.02-0.17; P < 0.00 001] and intra-operative blood loss [mean difference (MD), -317.68; 95% CI, -416.67 to -218.70; P < 0.00 001]. There was no significant difference between the groups of antecolic and retrocolic reconstruction in operative time (MD, 25.23; 95% CI, -14.37 to 64.83; P = 0.21), postoperative mortality, overall morbidity (OR, 0.54; 95% CI, 0.20-1.46; P = 0.22) and length of postoperative hospital stay (MD, -9.08; 95% CI, -21.28 to 3.11; P = 0.14). CONCLUSION:Antecolic reconstruction for DJ can decrease the DGE rate after PPPD.

Does antecolic reconstruction decrease delayed gastric emptying after pancreatoduodenectomy?

Delayed gastric emptying(DGE) is a frequent complication after pylorus-preserving pancreatoduodenectomy(PpPD).Kawai and colleagues proposed pylorus-resecting pancreatoduodenectomy(PrPD) with antecolic gastrojejunal anastomosis to obviate DGE occurring after PpPD.Here we debate the reported differences in the prevalence of DGE in antecolic and retrocolic gastro/duodeno-jejunostomies after PrPD and PpPD,respectively.We concluded that the route of the gastro/duodeno-jejunal anastomosis with respect to the transverse colon;i.e.,antecolic route or retrocolic route,is not responsible for the differences in prevalence of DGE after pancreatoduodenectomy(PD) and that the impact of the reconstructive method on DGE is related mostly to the angulation or torsion of the gastro/duodeno-jejunostomy.We report a prevalence of 8.9% grade A DGE and 1.1% grade C DGE in a series of 89 subtotal stomach-preserving PDs with Roux-en Y retrocolic reconstruction with anastomosis of the isolated Roux limb to the stomach and single Roux limb to both the pancreatic stump and hepatic duct.Retrocolic anastomosis of the isolated first jejunal loop to the gastric remnant allows outflow of the gastric contents by gravity through a "straight route".

Delayed gastric emptying following pancreaticoduodenectomy:Incidence,risk factors,and healthcare utilization

AIM To characterize incidence and risk factors for delayed gastric emptying(DGE) following pancreaticoduodenectomy and examine its implications on healthcare utilization. METHODS A prospectively-maintained database was reviewed. DGE was classified using International Study Group of Pancreatic Surgery criteria. Patients who developed DGE and those who did not were compared. RESULTS Two hundred and seventy-six patients underwent pancreaticoduodenectomy(PD)(> 80% pyloruspreserving, antecolic-reconstruction). DGE developed in 49 patients(17.8%): 5.1% grade B, 3.6% grade C. Demographic, clinical, and operative variables were similar between patients with DGE and those without. DGE patients were more likely to present multiplecomplications(32.6% vs 4.4%, ≥ 3 complications, P < 0.001), including postoperative pancreatic fistula(POPF)(42.9% vs 18.9%, P = 0.001) and intra-abdominal abscess(IAA)(16.3% vs 4.0%, P = 0.012). Patients with DGE had longer hospital stay(median, 12 d vs 7 d, P < 0.001) and were more likely to require transitional care upon discharge(24.5% vs 6.6%, P < 0.001). On multivariate analysis, predictors for DGE included POPF [OR = 3.39(1.35-8.52), P = 0.009] and IAA [OR = 1.51(1.03-2.22), P = 0.035].CONCLUSION Although DGE occurred in < 20% of patients after PD, it was associated with increased healthcare utilization. Patients with POPF and IAA were at risk for DGE. Anticipating DGE can help individualize care and allocate resources to high-risk patients.

Is delayed gastric emptying so terrible after pylorus-preserving pancreaticoduodenectomy? Prevention and management

AIM： To explore some operative techniques to prevent the occurrence of delayed gastric emptying （DGE） alter pylorus-preserving pancreaticoduodenectomy （PPPD）.METHODS： One hundred and eighty-six patients in a single medical center who accepted PPPD were retrospectively studied. The incidence of DGE was investigated and the influence of some operative techniques on the prevention of DGE was analyzed.RESULTS： During the operative process of PPPD, the methods of detached drainage of pancreatic fluid and bile and gastric fistulization were used. Postoperatively, six patients suffered DGE among the 186 cases; the incidence was 3.23% （6/186）. One of them was complicated with intraabdominal infection at the same time, and two with pancreatic leakage.CONCLUSION： Appropriate maneuvers during operation are essential to avoid postoperative DGE in PPPD. The occurrence of DGE is avoidable. It should not be used as an argument to advocate hemigastrectomy in PPPD.

Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy

AIM To investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy.METHODS In this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying(DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed.RESULTS Technical success was achieved in all patients(100%). Early symptom improvement was observed in 15 of 20 patients(75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d(range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients(70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients(95%).CONCLUSION Endoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

Influencing factors of postoperative early delayed gastric emptying after minimally invasive Ivor-Lewis esophagectomy

BACKGROUND The main clinical treatment for esophageal cancer is surgery. Since traditional open esophageal cancer resection has the disadvantages of large trauma, long recovery period, and high postoperative complication rate, its clinical application is gradually reduced. The current report of minimally invasive Ivor-Lewis esophagectomy(MIILE) is increasing. However, researchers found that patients with MIILE had a higher incidence of early delayed gastric emptying(DGE).AIM To investigate the influencing factors of postoperative early DGE after MIILE.METHODS A total of 156 patients diagnosed with esophageal cancer at Deyang People's Hospital were enrolled. According to the criteria of DGE, patients were assigned to a DGE group(n = 49) and a control group(n = 107). The differences between the DGE group and the control group were compared. Multivariate logistic regression analysis was used to further determine the influencing factors of postoperative early DGE. The receiver operating characteristic(ROC) curve was used to assess potential factors in predicting postoperative early DGE.RESULTS Age, intraoperative blood loss, chest drainage time, portion of anxiety score ≥ 45 points, analgesia pump use, postoperative to enteral nutrition interval, and postoperative fluid volume in the DGE group were higher than those in the control group. Perioperative albumin level in the DGE group was lower than that in the control group(P < 0.05). Age, anxiety score, perioperative albumin level,and postoperative fluid volume were independent factors influencing postoperative early DGE, and the differences were statistically significant(P <0.05). The ROC curve analysis revealed that the area under the curve(AUC) foranxiety score was 0.720. The optimum cut-off value was 39, and the sensitivity and specificity were 80.37% and 65.31%, respectively. The AUC for postoperative fluid volume were 0.774. The optimal cut-off value was 1191.86 mL, and the sensitivity and specificity were 65.3% and 77.6%, respectively. The AUC for perioperative albumin level was 0.758. The optimum cut-off value was 26.75 g/L,and the sensitivity and specificity were 97.2% and 46.9%, respectively.CONCLUSION Advanced age, postoperative anxiety, perioperative albumin level, and postoperative fluid volume can increase the incidence of postoperative early DGE.

Complete resection of the gastric antrum decreased incidence and severity of delayed gastric emptying after pancreaticoduodenectomy

Background:Delayed gastric emptying(DGE)is the main complication after pancreaticoduodenectomy(PD),but the mechanism is still unclear.The aim of this study was to elucidate the role of complete resection of the gastric antrum in decreasing incidence and severity of DGE after PD.Methods:Sprague-Dawley rats were divided into three groups:expanded resection(ER group),complete resection(CR group),and incomplete resection(IR group)of the gastric antrum.The tension(g)of remnant stomach contraction was observed.We analyzed the histological morphology of the gastric wall by different excisional methods after distal gastrectomy.Moreover,patients underwent PD at our department between January 2012 and May 2016 were included in the study.These cases were divided into IR group and CR group of the gastric antrum,and the clinical data were retrospectively analyzed.Results:The ex vivo remnant stomachs of CR group exhibited much greater contraction tension than others(P<0.05).The contraction tension of the remnant stomach increased with increasing acetylcholine concentration,while remained stable at the concentration of 10×10^(-5 )mol/L.Furthermore,174 consecutive patients were included and retrospectively analyzed in the study.The incidence of DGE was significantly lower(3.5%vs.21.3%,P<0.01)in CR group than in IR group.In addition,hematoxylin-eosin staining analyses of the gastric wall confirmed that the number of transected circular smooth muscle bundles were higher in IR group than in CR group(8.24±0.65 vs.3.76±0.70,P<0.05).Conclusions:The complete resection of the gastric antrum is associated with decreased incidence and severity of DGE after PD.Gastric electrophysiological and physiopathological disorders caused by damage to gastric smooth muscles might be the mechanism underlying DGE.

Diaphragmatic suture with tubular stomach to prevent early delayed gastric emptying after esophagectomy

Objective The objective of this study was to evaluate the clinical efficacy of a diaphragmatic suture with tubular stomach to prevent delayed gastric emptying(DGE) after esophagectomy through the cervico-thoracoabdominal approach. Methods A total of 980 patients with esophageal cancer undergoing esophagectomy through the cervico-thoracoabdominal approach were retrospectively included in this study and divided into two groups. All patients underwent tubular stomach creation(group A; n = 530) or a diaphragmatic suture and tubular stomach creation(group B; n = 450). The incidence of early DGE was observed. Results The incidence of early DGE in group A was significantly higher than that in group B(P < 0.05). Conclusion This observation study suggests that the use of a diaphragmatic suture with tubular stomach through the cervico-thoracoabdominal approach can decrease the incidence of early DGE after esophagectomy.

Risk factors for postoperative delayed gastric emptying in ovarian cancer treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy(CRSHIPEC)has shown promising results in improving the survival of ovarian cancer patients.Although the safety profiles of CRS-HIPEC exist,more attention should be paid to gastrointestinal complications,as the procedure involves a considerable proportion of bowel resection and anastomosis.AIM To identify the risk factors for delayed gastric emptying in ovarian cancer treated with CRS-HIPEC.METHODS A cross-sectional study was conducted.According to the inclusion and exclusion criteria,we retrospectively analyzed 77 patients admitted between March 2014 and April 2018 with advanced and recurrent ovarian cancer treated with CRSHIPEC in Beijing Shijitan Hospital of Capital Medical University.Risk factors for delayed gastric emptying were analyzed using univariate analysis.All of the statistically significant variables in the univariate analysis were entered into the multivariable logistic regression model to determine factors independently associated with delayed gastric emptying.RESULTS Among the 77 included patients,36.4%(28/77)had delayed gastric emptying after CRS-HIPEC.The median age and body mass index of all patients were 59 years and 22.83 kg/m^(2),respectively.Preoperative chemotherapy was administered in 55 patients(71%).Sixty-two patients(81%)had a history of at least one previous pelvic surgery.The median operation time and intraoperative hemorrhage volume were 630 min and 600 mL,respectively.Omentectomy was performed in 32 cases of primary ovarian cancer and 24 cases of recurrence.The median peritoneal cancer index was 16.The risk factors for delayed gastric emptying from the univariate analysis were body mass index<23 kg/m2(X2=5.059,P=0.025),history of pelvic surgery(X^(2)=4.498,P=0.034),history of chemotherapy(X^(2)=4.334,P=0.037),operation time≥7 h(X2=4.827,P=0.047),and intraoperative hemorrhage≥800 mL(X^(2)=7.112,P=0.008).Multivariable analysis revealed that age≥70 years(HR=7.127;95%CI 1.122-45.264;P=0.037)and intraoperative hemorrhage≥800 mL(HR=3.416;95%CI 1.067-10.939;P=0.039)were independently associated with postoperative delayed gastric emptying after CRS-HIPEC.CONCLUSION Postoperative gastrointestinal management,including prolonged nasogastric intubation,should be promoted for patients over 70 years or those with intraoperative bleeding exceeding 800 mL.

Dual loop(Roux en Y) reconstruction with isolated gastric limb reduces delayed gastric emptying after pancreatico-duodenectomy

BACKGROUND Single loop reconstruction(SLR) was routine in our institution for patients undergoing pancreatico-duodenectomy(PD). Roux-en Y reconstruction with an isolated gastric limb(RIGL) recently became the reconstruction of choice.AIM To evaluate the impact of RIGL on incidence and severity of delayed gastric emptying(DGE).METHODS This is a single institution, retrospective analysis of patients undergoing PD. All patients undergoing PD from July 2010 through December 2016 were included in the study. Outcome of RIGL were compared to SLR. Primary measure of outcome included incidence and severity of DGE. Secondary measures of outcome were overall complications and postoperative mortality.RESULTS One hundred and seventy-nine patients were included in the study. Fifty-two had RIGL, 127 had SLR. Overall complication rate was 40.2%, patients in the RIGL group experienced lower rates of DGE(15.4% vs 59.1%, P = 0.001). Other patient related outcomes were also significantly reduced: day of nasogastric tube removal(3 vs 5, P < 0.001), regain of normal diet(8 vs 9, P < 0.001). On multivariate analysis RIGL was associated independently with reduced rates of DGE(P < 0.001, OR 0.14)CONCLUSION The current study shows that RIGL reduces the rate of DGE after PD. Further prospective randomized controlled trials are required to affirm the current data.

Improvement of gastric emptying by enhanced recovery after pancreaticoduodenectomy

BACKGROUND： Enhanced recovery after surgery（ERAS） has improved postoperative outcomes particularly in colorectal surgery. This study aimed to assess compliance with an ERAS protocol and evaluate its effect on postoperative outcomes in patients undergoing pancreaticoduodenectomy. METHODS： Fifty patients who had received conventional peri operative management from 2005 to 2009（conventional group）were compared with 75 patients who had received perioperative care with an ERAS protocol（fast-track group） from 2010 to2014. Mortality, complications, readmissions and length of hospital stay were evaluated and compared in the groups.RESULTS： Compliance with each element of the ERAS pro tocol ranged from 74.7% to 100%. Uneventful patients had a significant higher adherence to the ERAS protocol（87.5% vs40.7%; P〈0.001）. There were no significant differences in de mographics and perioperative characteristics between the two groups. Patients in the fast-track group had a shorter time to remove the nasogastric tube, start liquid diet and solid food pass flatus and stools, and remove drains. No difference was found in mortality, relaparotomy, readmission rates and over all morbidity. However, delayed gastric emptying and length of hospital stay were significantly reduced in the fast-track group. The independent effect of the ERAS protocol in reduc ing delayed gastric emptying and length of hospital stay was confirmed by multivariate analysis.CONCLUSION： ERAS pathway was feasible and safe in improving gastric emptying, yielding an earlier postoperative recovery, and reducing the length of hospital stay.

Can pH Monitoring Predict Gastric Emptying Measured by ¹³C-Acetate Breath Test in Gastroesophageal Reflux with Neurological Impairment?

Introduction: Delayed gastric emptying (DGE) often occurs in patients with gastroesophageal reflux (GER) due to neurological impairment (NI). 13C has been used as an alternative tool for measuring the gastric emptying rates. The aim of this study was to predict gastric emptying in children with GER using 13C-acetate breath test (ABT) by 24-hour pH monitoring. Methods: Nineteen patients were divided into 2 groups: a DGE group with NI (14 patients), and normal-emptying group without NI (5 patients). The liquid test meal consisted of RacolTM (5 ml/kg) mixed with 13C-acetate (50 mg for infants, 100 mg for children, and 150 mg for adolescents). 13CO2 was measured using a gas chromatograph-isotope ratio mass spectrometer. The results are expressed as the % of 13C expired per hour and cumulative 13C excretion over a 3-hour periods including the parameters of half excretion and lag time. Results: The mean half excretion time was 1.762 hour in the DGE group and 1.095 hour in the normal-emptying group (P = 0.0196). The mean lag time was 0.971 hour in the DGE group and 0.666 hour in the normal-emptying group (P = 0.0196). Therefore, DGE was significantly more prevalent in the DGE compared to the normal-emptying group. The percentage of the time when the pH was less than 4 on 24-hour esophageal pH monitoring was 21.6% ± 9.2% in the DGE group and 28.5% ± 11.6% in the normal-emptying group (P = 0.4634). Conclusion: The percentage of time when the pH is less than 4 on 24-hour pH monitoring cannot predict DGE measured by the 13C-ABT in GER.

Perioperative risk factors for delayed gastric emptying after pancreaticoduodenectomy:a meta-analysis of the complications

Objective:To evaluate the correlation between the incidence of delayed gastric emptying(DGE)in pancreaticoduodenectomy(PD)and the perioperative possible risk factors.Methods:We searched PubMed,Embase,Cochrane Library,and Medline for studies describing complications related to PD from 2018 to 2022.Statistical analysis was performed using Stata/SE16.0 software.Results:In 6 retrospective studies,1 systematic review,and 1 randomized controlled trial(RCT)experiment,12,419 patients(2174 and 10,245 patients,respectively,in DGE and no delayed gastric emptying[NDGE]groups).The preoperative American Society of Anesthesiologists(ASA)score between DGE and NDGE groups(log odds ratio[OR]=0.23,95%credible interval[CI]:0.11-0.35,P<.01),operation time(mean diff.=21.87,95%CI:15.96-27.78,P<.01),estimated intraoperative blood loss(EIBL;mean diff.=70.67,95%CI:17.75-123.58,P<.05),postoperative pancreatic fistula(POPF)(log OR=0.85,95%CI:0.24-1.46,P<.05)were statistically significant.No significant differences in preoperative body mass index(BMI),preoperative biliary drain-age,and pancreatic texture were observed(P>.05).Conclusion:The incidence of DGE is significantly correlated with the operation time,preoperative ASA score,POPF,and EIBL,which suggests that the surgeon should thoroughly evaluate the patient through adequate preoperative examination before the operation.Finally,standardized practice and perfect technology are undoubtedly necessary to reduce complications.

Pyonex in treatment of 23 patients with delayed gastric emptying after esophagectomy

Objective To evaluate the effect of Pyonex in treatment of patients with delayed gastric emptying after esophagectomy.Methods Twenty-three patients were treated with Pyonex at Pishu（脾俞 BL 20,bilateral）,Weishu（胃俞 BL 21,bilateral）,Neiguan（内关 PC 6）,Zusanli（足三里 ST 36）,Sanyinjiao（三阴交 SP 6） and Shidao（食道 CO 2） on the basis of conventional treatment.The pyonexs were changed every four days,and change for five times was considered as one course of treatment.The efficacy was evaluated after treatment for one course.Results One patient was cured after treatment for one time,with the effective rate of 4.4%;two patients were cured after treatment for two times,with the effective rate of 8.7%;ten patients were cured after treatment for three times,with the effective rate of 44.5%;seven patients were cured after treatment for four times,with the effective rate of30.4%;and three patients were cured after treatment for five times,with the effective rate of 13.0%.23 patients were cured after treatment for five times,with the total effective rate of 100%.Conclusion Pyonex has sound effect in treatment of patients with delayed gastric emptying after esophagectomy.

Braun吻合对胰十二指肠切除术后并发症影响的Meta分析

目的系统评价Braun吻合(BEE)对胰十二指肠切除术(PD)术后并发症的影响,重点分析对术后胃排空障碍(DGE)的影响,以探讨BEE的价值和意义,为临床应用提供循证医学方面的客观依据。方法计算机检索Cochrane Library、Pub Med、Embase、Web of Science、中国生物医学文献数据库(CBM)、中国期刊全文数据库(CNKI)、维普和万方数据库关于BEE的相关文献,检索时间均从建库至2016年3月。按Cochrane系统评价的方法评价纳入研究的质量,使用Rev Man 5.3软件对研究资料进行统计分析。结果共纳入10篇文献,总计1544例患者。Meta分析结果显示:所有纳入文献中BEE组术后总并发症发生率(OR=0.61,95%CI=0.47~0.81,P=0.0006)和术后总DGE发生率(OR=0.36,95%CI=0.19~0.67,P=0.001)要低于非BEE组。同样,采用国际胰腺外科研究学组(ISGPS)标准的8篇文献中,BEE组总DGE发生率(OR=0.36,95%CI=0.18~0.72,P=0.004),B级DGE发生率(OR=0.36,95%CI=0.11~1.17,P=0.09)和C级DGE发生率(OR=0.28,95%CI=0.16~0.48,P<0.01)均要低于非BEE组。结论 Meta分析显示,BEE可以降低PD术后总并发症的发生率和DGE的发生率,尤其是可以降低C级DGE的发生率。

Early enteral nutrition vs parenteral nutrition following pancreaticoduodenectomy: Experience from a single center

AIM: To analyze and compare postoperative morbidity between patients receiving total parenteral nutrition (TPN) and early enteral nutrition supplemented with parenteral nutrition (EEN + PN).METHODS: Three hundred and forty patients receiving pancreaticoduodenectomy (PD) from 2009 to 2013 at our center were enrolled retrospectively. Patients were divided into two groups depending on postoperative nutrition support scheme: an EEN + PN group (n = 87) and a TPN group (n = 253). Demographic characteristics, comorbidities, preoperative biochemical parameters, pathological diagnosis, intraoperative information, and postoperative complications of the two groups were analyzed.RESULTS: The two groups did not differ in demographic characteristics, preoperative comorbidities, preoperative biochemical parameters or pathological findings (P &#x0003e; 0.05 for all). However, patients with EEN + PN following PD had a higher incidence of delayed gastric emptying (16.1% vs 6.7%, P = 0.016), pulmonary infection (10.3% vs 3.6%, P = 0.024), and probably intraperitoneal infection (18.4% vs 10.3%, P = 0.059), which might account for their longer nasogastric tube retention time (9 d vs 5 d, P = 0.006), postoperative hospital stay (25 d vs 20 d, P = 0.055) and higher hospitalization expenses (USD10397 vs USD8663.9, P = 0.008), compared to those with TPN.CONCLUSION: Our study suggests that TPN might be safe and sufficient for patient recovery after PD. Postoperative EEN should only be performed scrupulously and selectively.