title: Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled trial.
abstract: OBJECTIVE
  To study the effect of antecolic vs. retrocolic reconstruction on delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) and to analyze factors which may be associated with post-PD DGE. DGE is a troublesome complication occurring in 30-40% of patients undergoing PD leading to increased postoperative morbidity. Many factors have been implicated in the pathogenesis of DGE. Among the various methods employed to reduce the incidence, recent reports have suggested that an antecolic reconstruction of gastro/duodenojejunostomy may decrease the incidence of DGE.
  
  
  METHODS
  Between Sep 2006 and Nov 2008, 95 patients requiring PD (for both malignant and benign conditions) were eligible for the study. Of these, 72 patients finally underwent a PD and were randomized to either a retrocolic or antecolic reconstruction of the gastro/duodenojejunostomy. All patients underwent the standard Whipple's or a pylorus preserving pancreaticoduodenectomy (PPPD), and the randomization was stratified according to the type of PD done. DGE was assessed clinically using the Johns Hopkins criteria (Yeo et al. in Ann Surg 218: 229-37, 1993). In patients suspected to have DGE, mechanical causes were excluded by imaging and/or endoscopy. Occurrence of DGE was the primary endpoint, whereas duration of hospital stay and occurrence of intra-abdominal complications were the secondary end points.
  
  
  RESULTS
  The antecolic and retrocolic groups were comparable with regard to patient demographics, diagnosis, and other preoperative, intraoperative, and postoperative factors. Overall, DGE occurred in 21 patients (30.9%). There was no significant difference in the incidence of DGE in the antecolic vs. the retrocolic group (34.4% vs. 27.8%; p = 0.6). On univariate analysis, older age, use of octreotide, and intra-abdominal complications were significantly associated with the occurrence of DGE; however, on a multivariate analysis, only age was found to be significant (p = 0.02). The mean postoperative stay was longer among patients who developed DGE (21.9 ± 9.3 days vs. 13 ± 6.9 days; p = 0.0001).
  
  
  CONCLUSIONS
  Delayed gastric emptying is a cause of significant morbidity and prolongs the duration of hospitalization following pancreaticoduodenectomy. The incidence of DGE does not appear to be related to the method of reconstruction (antecolic or retrocolic). Older age may be a risk factor for its occurrence.
authors.affiliation: Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, 1st Floor, P.C Block Ansari Nagar, New Delhi, 110029, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Gangavatiker
authors.forename: Sujoy
authors.initials: S
authors.lastname: Pal
authors.forename: Amit
authors.initials: A
authors.lastname: Javed
authors.forename: Nihar Ranjan
authors.initials: NR
authors.lastname: Dash
authors.forename: Peush
authors.initials: P
authors.lastname: Sahni
authors.forename: Tushar Kanti
authors.initials: TK
authors.lastname: Chattopadhyay
mesh_terms: D001649:Bile Duct Diseases / Q000601:surgery*; D004385:Duodenostomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000379:methods*; D005746:Gastric Emptying / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011446:Prospective Studies; D019651:Plastic Surgery Procedures / Q000379:methods*; D013272:Stomach Diseases / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome