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The Incidence and Management of Delayed Gastric Emptying Following Pancreaticoduodenectomy: a Large Single-Institution Analysis
Joshua D. Eisenberg*, JanáE a. Ritz-Romeo, Ernest L. Rosato, Harish Lavu, Charles J. Yeo, Jordan M. Winter
Thomas Jefferson University, Philadelphia, PA
Background: Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD), yet the evaluation, management, and impact remain incompletely understood. The International Study Group of Pancreatic Surgery (ISGPS) in 2007 defined a three-tiered grading system to standardize studies of DGE.
Methods: Data were collected on 721 consecutive patients undergoing PD between October 2006 and May 2012 at a high-volume academic medical center. Patients with DGE were retrospectively categorized according to the ISGPS criteria (grades A, B, or C), as well as a modified grading system (referred to herein as primary DGE), in which DGE was designated only in instances when gastric symptoms were not attributable to another complication (e.g., abdominal infection) or gastric function was abnormal by fluoroscopy. Predictors of DGE and the impact of DGE on outcomes were determined.
Results: Using ISGPS criteria, DGE was diagnosed in 140 (19.4%) patients, including 78 (56%) grade A, 36 (26%) grade B, and 26 (19%) grade C. DGE was associated with an increased rate of abdominal infections (55% vs. 19%, p<0.001), including pancreatic fistula (34% vs. 10%, p<0.001) and abscess (24% vs. 8%, p<0.001), as well as higher rates of re-hospitalization (29% vs. 13%, p<0.001) and length-of-stay (median 12.5 days vs. 7 days, p<0.001). Primary DGE occurred in 12.2% of the cohort (66% grade A; 19% grade B and 15% grade C). In a multivariate logistic regression model (Table), abdominal infection (OR 5.5, p<0.001), male gender (OR 1.92, p=0.007), smoking history (OR 1.75 p=0.033), and periampullary adenocarcinoma (OR 1.66, p=0.041) were statistically significant risk factors for DGE. Statistically significant predictors of primary DGE included abdominal infection (OR 3.15, p<0.001) and smoking history (OR 2.04, p=0.008). Tests and interventions performed on patients with grade B or C ISGPS DGE included total parenteral nutrition (87%), pro-kinetic therapy (80%), upper-GI fluoroscopy (80%), endoscopy (23%), and gastrostomy tube placement (17%). Median total hospital charges increased by more than \,000 with each severity grade of ISGPS DGE (p<0.001).
Conclusions: DGE is a morbid complication after PD and it is associated with a substantial increase in hospital cost. In many instances, DGE is likely secondary to abdominal infection or other non-gastric complications, and interventions aimed at preventing these complications may be the most effective strategy towards preventing DGE.
Risk Factors for DGE (Multivariate)
| ISGPS DGE | Risk Factor | Odds Ratio | P-value | | Primary DGE | Risk Factor | Odds Ratio | P-value | | Abdominal infection | 5.50 | <0.001* | | Abdominal infection | 3.15 | <0.001* | | Gender (M) | 1.92 | 0.007* | Smoking history | 2.04 | 0.008* | | Smoking history | 1.75 | 0.033* | Malignant tumor | 1.54 | 0.347 | | Periampullary adenocarcinoma | 1.66 | 0.041* | Periampullary adenocarcinoma | 1.35 | 0.421 | | Soft gland texture | 1.32 | 0.263 | Gender (M) | 1.29 | 0.314 | | EBL | 1.00 | 0.649 | |
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