Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials

Abstract

IntroductionDelayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several randomised controlled trials (RCTs) have explored operative strategies to minimise DGE, however, the optimal combination of gastric resection approach, anastomotic route, and configuration, role of Braun enteroenterostomy remains unclear.MethodsMEDLINE, Embase, and CENTRAL databases were systematically searched for RCTs comparing gastric resection (Classic Whipple, pylorus-resecting, and pylorus-preserving), anastomotic route (antecolic vs retrocolic) and configuration (Billroth II vs Roux-en-Y), and enteroenterostomy (Braun vs no Braun). A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimising DGE.ResultsTwenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6% (n = 647). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35% of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32% of comparisons. Pairwise meta-analysis of retrocolic vs antecolic route of gastro-jejunostomy found increased risk of DGE with the retrocolic route (OR 2.1, 95% CrI; 0.92 - 4.7). Pairwise meta-analysis of Braun enteroenterostomy found a trend towards lower DGE rates with Braun compared to no Braun (OR 1.9, 95% CrI; 0.92 - 3.9). Having a Braun enteroenterostomy ranked the best in 96% of comparisons.ConclusionBased on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy may be associated with the lowest rates of DGE.

The impact of race/ethnicity on pancreaticoduodenectomy outcomes for pancreatic cancer

“…Preoperative patients' nutrition presented by serum albumin levels was independently associated with multiple adverse outcomes emphasizing the importance of perioperative nutritional optimization. Pylorus preservation was associated with higher rates of postoperative delayed gastric emptying, compared to classic Whipple, a finding that agrees with results from a recent meta‐analysis of RCTs 40,41 . We also found that short pancreatic duct and soft gland texture were independent risk factors for the development of pancreatic fistula (data shown in Supporting Information: Table ), similar to reports from previous retrospective studies 42,43 .…”

“…Pylorus preservation was associated with higher rates of postoperative delayed gastric emptying, compared to classic Whipple, a finding that agrees with results from a recent meta-analysis of RCTs. 40,41 We also found that short pancreatic duct and soft gland texture were independent risk factors for the development of pancreatic fistula (data shown in Supporting Information: Table 2), similar to reports from previous retrospective studies. 42,43 Younger age, male gender, and having a preoperative biliary stent were associated with higher rates of NAT receipt.…”

Gastric stasis following pancreatoduodenal resection: terminology and prevention issues

“…Пересечение желудка при этой операции осуществляют на 2-3 см проксимальнее привратника [16]. Идея последних 2 модификаций заключается в сохранении моторной функции желудка за счет сохранения антрального отдела, играющего важную роль в обеспечении пассажа твердой пищи и измельчительной функции желудка [17], а разница между этими способами достаточно условна. Рассматривают также ПДР с субтотальной резекцией желудка [18], однако считаем, что практически полное удаление еще одного органа для уменьшения вероятности гастростаза не может быть оправданным.…”

“…Наименьшая частота гастростаза отмечена после ПДР с резекцией привратника и впередиободочной реконструкцией по Б2 с дополнительным брауновским анастомозом. Наибольшая частота гастростаза, а также летальность отмечены после стандартной ПДР с позадиободочным анастомозом по Б2 с брауновским соустьем [17]. В исследование не включен анализ влияния способов панкреатического анастомоза на развитие гастростаза.…”