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Braun Enteroenterostomy Affects Delayed Gastric Emptying After Pylorus-Preserving Pancreatoduodenectomy: a Retrospective Review
Yusuke Watanabe*, Takao Ohtsuka, Hideyo Kimura, Taketo Matsunaga, Koji Tamura, Noboru Ideno, Teppei Aso, Yoshihiro Miyasaka, Junji Ueda, Shunichi Takahata, Masao Tanaka
Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan
Background: Delayed gastric emptying (DGE) is one of the most common adverse events after pancreatoduodenectomy. DGE is not a life-threatening complication and can be treated conservatively; however, it results in a prolonged hospital stay, which increases costs and affects quality of life. Various surgical techniques to reduce the incidence of DGE have been reported, and several recent studies have suggested that enteroenterostomy between the afferent and efferent limbs distal to the gastroenterostomy site during conventional pancreatoduodenectomy might decrease DGE. This anastomosis is known as Braun enteroenterostomy (BEE). However, the advantages and disadvantages of performing BEE during pylorus-preserving pancreatoduodenectomy (PPPD) remain controversial. The aim of this study was to evaluate the effect of BEE during PPPD on the postoperative course.
Methods: The medical records of consecutive 185 patients who underwent PPPD either with or without BEE between January 2008 and June 2013 were retrospectively reviewed. We have been routinely performing BEE during PPPD at our institution to date, while we did not perform BEE between May 2010 and February 2013 to evaluate the effect of BEE on the postoperative course. The postoperative clinical course including complications was compared between the two groups.
Results: Ninety-eight patients underwent PPPD with BEE and 87 without BEE. Table 1 shows that there was no differences in the patients' background characteristics between the two groups. The operation time was significantly shorter in the group without BEE than that with BEE (P < 0.01). Table 2 shows comparison of the postoperative course, and DGE occurred more frequently in patients without BEE (21%) than those with BEE (4%) (P < 0.01). The addition of BEE did not affect postoperative complications other than DGE, and no complications directly attributed to BEE were observed. By univariate analysis to evaluate the predictive factors for DGE, the omission of BEE and shorter operative time were significant factors associated with DGE. By multivariate analysis, the omission of BEE was the only independent factor associated with DGE (odds ratio of 5.04, 95% confidence interval: 1.59-19.66; P < 0.01).
Conclusions: BEE during PPPD can lead to a significant reduction in the incidence of DGE, while is not associated with other adverse events. Therefore, BEE is recommended during PPPD. Table 1. Comparison of the patients' background characteristics and operative details between the two groups with and without Braun enteroenterostomy. | With Braun enteroenterostomy (n-98) | | Without Braun enteroenterostomy (n=87) | | P value | | Value | % | Value | % | | | Background characteristics | | | | | | | Age, years | 67 (22-85) | | 70 (27-91) | | 0.31 | | Gender | | | | | 0.77 | | Male | 57 | 58 | 47 | 54 | | | Female | 41 | 42 | 40 | 46 | | | Body mass index, kg/m2 | 21.3 (14.2-31.3) | | 22 (14.8-32.7) | | 0.18 | | Albumin, g/dL | 4.0 (2.7-4.8) | | 3.9 (2.4-5.0) | | 0.12 | | Benign/Malignant tumors | | | | | 1.00 | | Benign tumors | 17 | 17 | 15 | 17 | | | Malignant tumors | 81 | 83 | 72 | 83 | | | Pancreatic adenocarcinoma | 37 | 38 | 29 | 33 | 0.54 | | IPMN† | 21 | 21 | 16 | 18 | 0.71 | | Bile duct carcinoma | 17 | 17 | 18 | 21 | 0.58 | | Ampullary adenocarcinoma | 14 | 14 | 15 | 17 | 0.69 | | Neuroendocrine tumor | 5 | 5 | 4 | 5 | 1.00 | | Liposarcoma | 1 | 1 | 1 | 1 | 1.00 | | Other disease | 3 | 3 | 4 | 5 | 0.71 | | Operative details | | | | | | | Operation time, min | 475 (255-914) | | 380 (228-662) | | < 0.01 | | Intraoperative bleeding, mL | 800 (191-3889) | | 710 (97-3202) | | 0.20 | | Intraoperative blood transfusion | 20 | 20 | 13 | 15 | 0.34 |
The value is expressed as median (range), or the number of the patients. †IPMN, intraductal papillary mucinous neoplasm Table 2. Comparison of the postoperative course between the two groups with and without Braun enteroenterostomy. | With Braun enteroenterostomy (n=98) | | Without Braun enteroenterostomy (n=87) | | P Value | | Value | % | Value | % | | | Delayed gastric emptying | 4 | 4 | 18 | 21 | < 0.01 | | Pancreatic fistula | 21 | 21 | 22 | 25 | 0.60 | | Intra-abdominal hemorrhage | 2 | 2 | 0 | 0 | 0.50 | | Bile leakage | 1 | 1 | 1 | 1 | 1.00 | | Intra-abdominal abscess | 3 | 3 | 3 | 4 | 1.00 | | Bowel obstruction | 1 | 1 | 2 | 2 | 0.60 | | Wound infection | 9 | 9 | 10 | 12 | 0.64 | | Pulmonary complications | 1 | 1 | 2 | 2 | 0.60 | | Cholangitis | 6 | 6 | 5 | 6 | 1.00 | | Pancreatitis | 2 | 2 | 1 | 1 | 1.00 | | Pseudomembranous enteritis | 3 | 3 | 0 | 0 | 0.25 | | Sepsis | 3 | 3 | 3 | 4 | 1.00 | | Anastomotic site ulceration | 4 | 4 | 1 | 1 | 0.37 | | Overall intra-abdominal complications | 31 | 32 | 30 | 35 | 0.75 | | Relaparotomy | 0 | 0 | 2 | 2 | 0.22 | | Days until regular diet was tolerated orally | 7 (2-37) | | 7 (3-36) | | 0.90 | | Reinsertion of nasogastric tube | 2 | 2 | 6 | 7 | 0.15 | | Postoperative hospital stay, days | 23 (12-151) | | 22 (10-111 | | 0.29 | | Readmission | 5 | 5 | 8 | 9 | 0.39 |
The value is expressed as median (range), or the number of the patients. Overall intra-abdominal complications include patients with pancreatic fistula, hemorrhage, bile leakage, intra-abdominal abscess, cholangitis, and pancreatitis. When two or more complications occurred in one patient, they were regarded as a single consequence.
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