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Original Article |
1 Department of Surgery, Winthrop-University Hospital, Mineola, New York 11501
2 Department of Hematology/Oncology, Winthrop-University Hospital, Mineola, New York 11501
3 Department of Gastroenterology, Winthrop-University Hospital, Mineola, New York 11501
4 Department of Gastroenterology, New York Hospital Queens, Flushing, New York 11355
5 Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina 27710
6 School of Medicine, State University of New York at Stony Brook, Stony Brook, New York 11794
7 Weil Medical College, Cornell University, New York, New York 10021
Correspondence: Address correspondence and reprint requests to: Dong K. Kim, MD, 877 Stewart Avenue, Garden City, NY 11530, USA; E-mail: kimdongkyu{at}yahoo.com.
Background: Delayed gastric emptying (DGE) occurs in 14% to 61% of patients after pylorus-preserving pancreaticoduodenectomy, but its pathogenesis is unclear. We hypothesized that DGE may be due to pylorospasm secondary to vagal injuries at operation and may be preventable by the addition of pyloromyotomy.
Methods: Patients operated on consecutively between April 2000 and August 2003 were studied. Pyloromyotomy was of the Fredet-Ramstedt type combined with antroplasty. DGE-free recovery was defined as tolerance of a diet for three successive days by postoperative day 8. The symptom of nausea was used as a basis for nasogastric tube removal and diet resumption. A gastric emptying test (GET) with solid food was obtained. Patients with difficulty swallowing were fed via a feeding tube.
Results: There were 47 patients. Two patients were excluded because of death (n = 1) and ileus with pancreatic fistula (n = 1). Diagnoses were pancreatic cancer (n = 23), chronic pancreatitis (n = 11), ampullary cancer (n = 5), mucinous cystic neoplasm (n = 5), and duodenal villous adenoma (n = 3). Median times to nasogastric tube removal, start of liquid diet, and start of solid diet were postoperative days 2, 3, and 5, respectively. Two patients had tube feedings. Preoperative GET was abnormal in 51% , and postoperative GET was abnormal in 37% . The average length of stay was 9.5 days (median, 7 days). DGE occurred in only one patient (2.2%). There were no late complications during a 6-month follow-up.
Conclusions: The addition of pyloromyotomy to pylorus-preserving pancreaticoduodenectomy is effective in preventing DGE. Results are supportive of the hypothesis that DGE may be caused by operative injuries of the vagus innervating the pyloric region.
Key Words: Delayed gastric emptying • Pylorus-preserving pancreaticoduodenectomy • Pylorus-preserving Whipple procedure
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