LETTER TO Preventing Delayed Gastric Emptying After Pancreaticoduodenectomy To the Editor: e read with great interest the article by Eshuis and colleagues published in the January 2014 issue of Annals of Surgery. The authors compared antecolic versus retrocolic gastroenteric reconstruction after pylorus-preserving pancreaticoduodenectomy (PpPD) in a well-powered multicenter randomized controlled trial. They showed that the route of gastroenteric reconstruction after pancreaticoduodenectomy (PD) does not influence the postoperative incidence of delayed gastric emptying (DGE) or other complications. They stated that the mechanisms of DGE should be investigated further and suggested that studies on gastroenterological motility and the results of a trial on pylorus resection versus pylorus preservation should be considered in view of a multidisciplinary approach for the prevention of DGE.1 The pathogenesis of DGE remains unclear, but apart from an indirect impact through postoperative complications, PD influences the prevalence of postoperative DGE directly through ‘‘demolitive effects’’ and ‘‘reconstructive effects.’’ The demolitive step of such a procedure leads to hormonal alterations (ie, postoperative decrease in plasma motilin stimulation after duodenal resection2) and vascular and neural alterations (ie, devascularization and denervation of the pylorus in PpPD with subsequent pylorospasm3), which promote DGE. The reconstructive step may affect the prevalence of DGE through the route of gastroenteric or duodenoenteric reconstruction (ie, antecolic or retrocolic4) and type of the reconstructive technique (Billroth I or Billroth II), which have been considered to be relevant for DGE.5 With regard to the prevention of DGE, we experienced that pylorus resection
W
THE
EDITOR
or subtotal stomach-preserving pancreaticoduodenectomy (PrPD) might obviate to demolitive effects by preserving the capacity and favoring emptying of the stomach, thereby avoiding the pylorospasm, denervation, and devascularization of the pylorus ring that may occur in PpPD. Moreover, after removal of the hormonal source of the duodenum, maintenance of the first jejunal loop in reconstruction of the alimentary circuit preserves the physiologic secretion of motilin, secretin, and cholecystokinin-pancreozymin of the jejunum and can compensate for the abolished hormonal release from the duodenum.6 For this reason, our research team carried out a Roux-en-Y retrocolic reconstruction with anastomosis of the isolated Roux limb (ie, first jejunal loop) to the stomach and single Roux limb (ie, second jejunal loop) to the pancreatic stump and hepatic duct.7 In accordance with the work of Eshuis et al and the results of a recent metaanalysis,8 we found that after PD, the route of the gastro/duodenojejunal anastomosis with respect to the transverse colon or type of reconstruction (Billroth I or Billroth II) conducted are not responsible for the difference in the prevalence of DGE, and that the impact of reconstructive methods on DGE is related primarily to angulation or torsion of the gastro/duodenojejunostomy.9 Then, not necessarily an antecolic but rather a ‘‘straight’’ reconstruction of the alimentary tract may prevent DGE after PD. Finally, Eshuis and colleagues recommend that gastroenteric reconstruction after PD should be routed according to the surgeon’s preference. To prevent DGE, we should take into account that while waiting for further results from a randomized controlled trial, PrPD is a promising method,10 and that the type and method of gastroenteric reconstruction should be modulated on the results of the experience of a single surgeon. Nadia Peparini, MD, PhD Azienda Sanitaria Locale Roma H
Ciampino, Rome, Italy [email protected]
REFERENCES 1. Eshuis WJ, van Eijck CHJ, Gerhards MF, et al. Antecolic versus retrocolic route of the gastroenteric anastomosis after pancreatoduodenectomy: a randomized controlled trial. Ann Surg. 2014;259:45–51. 2. Kawai M, Yamaue H. Pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: the clinical impact of a new surgical procedure; pylorus resecting pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci. 2011;18:755–761. 3. Kim DK, Hindenburg AA, Sharma SK, et al. Is pylorospasm a cause of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? Ann Surg Oncol. 2005;12:222–227. 4. Tani M, Terasawa H, Kawai M, et al. Improvement of delayed gastric emptying in pyloruspreserving pancreaticoduodenectomy: results of a prospective, randomized controlled trial. Ann Surg. 2006;243:316–320. 5. Goei TH, van Berge Henegouwen MI, Slooff MJH, et al. Pylorus-preserving pancreatoduodenectomy: influence of a Billroth I versus a Billroth II type of reconstruction on gastric emptying. Dig Surg. 2001;18:376–380. 6. Chirletti P, Peparini N, Caronna R, et al. Monitoring fibrosis of the pancreatic remnant after a pancreaticoduodenectomy with dynamic MRI: are the results independent of the adopted reconstructive technique? J Surg Res. 2010;64: e49–e52. 7. Caronna R, Peparini N, Cosimo Russillo G, et al. Pancreaticojejuno anastomosis after pancresticoduodenectomy: brief pathophysiological considerations for a rational surgical choice. Int J Surg Oncol. 2012;2012:636824. 8. Tamandl D, Sahora K, Pruckerv J, et al. Impact of the reconstruction method on delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: a prospective randomized trial. World J Surg. 2014;38:465–475. 9. Peparini N, Chirletti P. Does antecolic reconstruction decrease delayed gastric emptying after pancreatoduodenectomy? World J Gastroenterol. 2012;18:6527–6531. 10. Yang C, Wu HS, Chen XL, et al. Pylorus-preserving versus pylorus-resecting pancreaticoduodenectomy for periampullary and pancreatic carcinoma: a meta-analysis. PLoS One. 2014;9: e90316.
Disclosure: No funding source exists and there is no conflict of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000000900
e52 | www.annalsofsurgery.com
Annals of Surgery Volume 263, Number 3, March 2016
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
W
THE
EDITOR
or subtotal stomach-preserving pancreaticoduodenectomy (PrPD) might obviate to demolitive effects by preserving the capacity and favoring emptying of the stomach, thereby avoiding the pylorospasm, denervation, and devascularization of the pylorus ring that may occur in PpPD. Moreover, after removal of the hormonal source of the duodenum, maintenance of the first jejunal loop in reconstruction of the alimentary circuit preserves the physiologic secretion of motilin, secretin, and cholecystokinin-pancreozymin of the jejunum and can compensate for the abolished hormonal release from the duodenum.6 For this reason, our research team carried out a Roux-en-Y retrocolic reconstruction with anastomosis of the isolated Roux limb (ie, first jejunal loop) to the stomach and single Roux limb (ie, second jejunal loop) to the pancreatic stump and hepatic duct.7 In accordance with the work of Eshuis et al and the results of a recent metaanalysis,8 we found that after PD, the route of the gastro/duodenojejunal anastomosis with respect to the transverse colon or type of reconstruction (Billroth I or Billroth II) conducted are not responsible for the difference in the prevalence of DGE, and that the impact of reconstructive methods on DGE is related primarily to angulation or torsion of the gastro/duodenojejunostomy.9 Then, not necessarily an antecolic but rather a ‘‘straight’’ reconstruction of the alimentary tract may prevent DGE after PD. Finally, Eshuis and colleagues recommend that gastroenteric reconstruction after PD should be routed according to the surgeon’s preference. To prevent DGE, we should take into account that while waiting for further results from a randomized controlled trial, PrPD is a promising method,10 and that the type and method of gastroenteric reconstruction should be modulated on the results of the experience of a single surgeon. Nadia Peparini, MD, PhD Azienda Sanitaria Locale Roma H
Ciampino, Rome, Italy [email protected]
REFERENCES 1. Eshuis WJ, van Eijck CHJ, Gerhards MF, et al. Antecolic versus retrocolic route of the gastroenteric anastomosis after pancreatoduodenectomy: a randomized controlled trial. Ann Surg. 2014;259:45–51. 2. Kawai M, Yamaue H. Pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: the clinical impact of a new surgical procedure; pylorus resecting pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci. 2011;18:755–761. 3. Kim DK, Hindenburg AA, Sharma SK, et al. Is pylorospasm a cause of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? Ann Surg Oncol. 2005;12:222–227. 4. Tani M, Terasawa H, Kawai M, et al. Improvement of delayed gastric emptying in pyloruspreserving pancreaticoduodenectomy: results of a prospective, randomized controlled trial. Ann Surg. 2006;243:316–320. 5. Goei TH, van Berge Henegouwen MI, Slooff MJH, et al. Pylorus-preserving pancreatoduodenectomy: influence of a Billroth I versus a Billroth II type of reconstruction on gastric emptying. Dig Surg. 2001;18:376–380. 6. Chirletti P, Peparini N, Caronna R, et al. Monitoring fibrosis of the pancreatic remnant after a pancreaticoduodenectomy with dynamic MRI: are the results independent of the adopted reconstructive technique? J Surg Res. 2010;64: e49–e52. 7. Caronna R, Peparini N, Cosimo Russillo G, et al. Pancreaticojejuno anastomosis after pancresticoduodenectomy: brief pathophysiological considerations for a rational surgical choice. Int J Surg Oncol. 2012;2012:636824. 8. Tamandl D, Sahora K, Pruckerv J, et al. Impact of the reconstruction method on delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: a prospective randomized trial. World J Surg. 2014;38:465–475. 9. Peparini N, Chirletti P. Does antecolic reconstruction decrease delayed gastric emptying after pancreatoduodenectomy? World J Gastroenterol. 2012;18:6527–6531. 10. Yang C, Wu HS, Chen XL, et al. Pylorus-preserving versus pylorus-resecting pancreaticoduodenectomy for periampullary and pancreatic carcinoma: a meta-analysis. PLoS One. 2014;9: e90316.
Disclosure: No funding source exists and there is no conflict of interest. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000000900
e52 | www.annalsofsurgery.com
Annals of Surgery Volume 263, Number 3, March 2016
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
