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Delayed Gastric Emptying (DGE) After Pancreatcoduodenectomy (PD): Is Subtotal Stomach Preserving PD (SSPPD) Better Than Pylorus Preserving PD (Pppd)?
Mena Hanna*1, Rahul Gadde1, Leonardo Tamariz2, Casey Allen1, Jonathan P. Meizoso1, Danny Sleeman1, Alan S. Livingstone1, Danny Yakoub1
1Department of Surgery, University of Miami - Miller School of Medicine, Miami, FL; 2Internal Medicine, University of Miami, Miami, FL
Background: DGE is one of the main complications after PD; various techniques have been tried to avoid it. Literature review and meta-analysis was used to evaluate whether SSPPD may have less incidence of DGE than PPPD.
Methods: A search for studies comparing PPPD to SSPPD was done in PubMed, MEDLINE, EMBASE, SCOPUS, and COCHRANE databases (2007 to present). Meta-analysis of included studies was done. Primary outcome was DGE. Secondary outcomes included other postoperative complications. Quality of included studies was evaluated by CONSORT and STROBE criteria. Relative Risk (RR) and 95% Confidence Intervals (CI) were calculated from pooled data in RCTs and retrospective studies. Heterogeneity was assessed.
Results: The search strategy yielded 233 studies of which 8 studies met our selection criteria. The included studies comprised a total of 663 patients undergoing pancreaticoduodenectomy; 309 underwent PPPD and 354 underwent SSPPD. Median age was 66 years IQR (64.1 - 67). Male /Female ratio was 57% vs. 43%, respectively. Meta-analysis showed lower incidence of DGE with SSPPD (RR 0.527; 95% CI 0.363 - 0.763; p < 0.001), Less post-operative nasogastric tube days with SSPPD (RR -0.544; 95% CI -1.080 - -0.008; p = 0.047). Operative blood loss was more in SSPPD (RR 0.285; 95% CI 0.071 - 0.499; p = 0.009). There was no statistical difference between the two groups regarding length of hospital stay, incidence of pancreatic fistula, abscesses, overall morbidity or postoperative mortality.
Conclusion: SSPPD may be associated with less DGE than PPPD. Other complications did not seem to be significantly different. Larger prospective randomized studies are needed to investigate these outcomes in more depth.
Postoperative outcomes of the included studies
| Author | Year | DGE definition | DGE N(%) | Postoperative NGT days
(mean ± sd) | Pancreatic Fistula N(%) | Abscess collection N(%) | | PPPD | SSPPD | PPPD | SSPPD | PPPD | SSPPD | PPPD | SSPPD | | Akizuki | 2007 | NGT ≥ POD 10 / solid food ≥ POD 14 | 3(9%) | 3(10%) | 1 ± 0.25 | 1 ± 1.75 | 5(15%) | 5(17%) | 2(6%) | 2(7%) | | Hayashibe | 2007 | NGT ≥ POD 10 / regular Diet ≥ POD 14 | 6(50%) | 3(14%) | 10.5 ± 6.4 | 6.1 ± 1.3 | N/A | N/A | N/A | N/A | | Kurahara | 2010 | ISGPS | 31(65%) | 35(55%) | N/A | N/A | 19(40%) | 15(23%) | 3(6%) | 4(6%) | | Kawai | 2011 | ISGPS | 11(17%) | 3(5%) | 0.6 ± 0.9 | 0.6 ± 1 | 19(30%) | 19(29%) | 8(13%) | 6(9%) | | Fujii | 2012 | ISGPS | 9(27%) | 3(5%) | 2.7 ± 6.1 | 1.3 ± 0.7 | 7(21%) | 7(30%) | N/A | N/A | | Hackert | 2012 | ISGPS | 17(43%) | 6(15%) | N/A | N/A | N/A | N/A | N/A | N/A | | Nanashima | 2013 | ISGPS | 27(96%) | 16(59%) | 15 ± 7 | 6 ± 5 | 4(14%) | 4(15%) | 5(18%) | 3(11%) | | Matsumoto | 2014 | ISGPS | 10(20%) | 6(12%) | N/A | N/A | 11(22%) | 11(20%) | 1(2%) | 4(8%) |
Abbreviation: DGE - Delayed gastric emptying; NGT - Nasogastric tube; PPPD - Pylorus preserving pancreaticoduodenectomy; SSPPD - Subtotal stomach preserving pancreaticoduodenectomy; POD - postoperative day; N/A - data not available  DGE forest plot
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