Braun enteroenterostomy during pancreaticoduodenectomy decreases postoperative delayed gastric emptying

doi:10.1016/j.amjsurg.2014.06.035

The American Journal of Surgery

Volume 209, Issue 6, June 2015, Pages 1036-1042

https://doi.org/10.1016/j.amjsurg.2014.06.035 Get rights and content

Abstract

Background

Modified digestive reconstruction during pancreaticoduodenectomy (PD) may affect the postoperative incidence of delayed gastric emptying (DGE). The purpose of this study is to investigate whether Braun enteroenterostomy following PD can reduce the incidence of DGE.

Methods

Four hundred seven patients who received PD with child reconstruction from June 2000 to March 2013 were divided into 2 groups: 206 patients with Braun enteroenterostomy (Child-Braun group) and 201 patients without Braun enteroenterostomy (Child-non-Braun group). Clinical data were retrospectively extracted; univariate and multivariate analyses were performed to investigate the association between Braun enteroenterostomy and DGE.

Results

DGE was less frequent in the Child-Braun group than in the Child-non-Braun group (6.7% vs 26.87%, P < .001). The multivariate logistic regression analysis showed that Braun enteroenterostomy was the only significant independent factor associated with the reduced DGE after PD with Child reconstruction, with an odds ratio of 4.485 (95% confidence interval: 2.372 to 8.482, P < .001).

Conclusion

Braun enteroenterostomy reduces the incidence of postoperative DGE associated with PD.

Section snippets

Clinical data

Data of 418 patients who had undergone PD between June 2000 and March 2013 were retrospectively retrieved by chart review. The first 217 patients, operated from June 2000 to March 2009, had a standard antecolic gastroenterostomy with PD. Those patients had a high incidence of DGE. By communication with other surgeons, we realized that the addition of Braun enteroenterostomy might decrease the incidence of postoperative DGE. We also retrospectively reviewed our data on Billroth Ⅱ reconstruction

Clinical results

A total of 418 patients underwent PD. Their mean age was 58 years (95% confidence interval [CI]: 56.96 to 59.08). Perioperative mortality, defined as death within 30 days after operation, was 1.20%. Intra-abdominal infections occurred in 33 patients (7.9%): 15 in none-DGE group and 18 in DGE group. The overall incidence of postoperative complications, excluding grade A DGE, was 41.6%; details of the postoperative complications are summarized in Table 1. Anastomotic leaks, DGE, wound infections,

References (30)

B. Topal et al.
Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial
Lancet Oncol
(2013)
Y. Sakamoto et al.
Analysis of risk factors for delayed gastric emptying (DGE) after 387 pancreaticoduodenectomies with usage of 70 stapled reconstructions
J Gastrointest Surg
(2011)
M. Rayar et al.
Enteral nutrition reduces delayed gastric emptying after standard pancreaticoduodenectomy with child reconstruction
J Gastrointest Surg
(2012)
M. Nikfarjam et al.
A reduction in delayed gastric emptying by classic pancreaticoduodenectomy with an antecolic gastrojejunal anastomosis and a retrogastric omental patch
J Gastrointest Surg
(2009)
H. Qu et al.
Clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a systematic review and meta-analysis
Eur J Surg Oncol
(2013)
G. Malleo et al.
Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors
HPB (Oxford)
(2010)
M. Sugiyama et al.
A new reconstruction method for preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy
Am J Surg
(2004)
C. Bassi et al.
Postoperative pancreatic fistula: an international study group (ISGPF) definition
Surgery
(2005)
M.N. Wente et al.
Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)
Surgery
(2007)
W.J. Tan et al.
Moving towards the New International Study Group for Pancreatic Surgery (ISGPS) definitions in pancreaticoduodenectomy: a comparison between the old and new
HPB (Oxford)
(2011)

I. Kurosaki et al.

Preservation of the left gastric vein in delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy

J Gastrointest Surg

(2005)

H. Riediger et al.

Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications

J Gastrointest Surg

(2003)

S. Raty et al.

Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy

J Gastrointest Surg

(2006)

J.G. Greene et al.

Delayed gastric emptying and enteric nervous system dysfunction in the rotenone model of Parkinson's disease

Exp Neurol

(2009)

T. Hackert et al.

Pylorus resection or pylorus preservation in partial pancreatico-duodenectomy (PROPP study): study protocol for a randomized controlled trial

Trials

(2013)

Cited by (23)

Surgical techniques to prevent delayed gastric emptying after pancreaticoduodenectomy
2023, Hepatobiliary and Pancreatic Diseases International
Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). DGE represents impaired gastric motility without significant mechanical obstruction and is associated with an increased length of hospital stay, increased healthcare costs, and a high readmission rate. We reviewed published studies on various technical modifications to reduce the incidence of DGE.
Studies were identified by searching PubMed for relevant articles published up to December 2022. The following search terms were used: “pancreaticoduodenectomy”, “pancreaticojejunostomy”, “pancreaticogastrostomy”, “gastric emptying”, “gastroparesis” and “postoperative complications”. The search was limited to English publications. Additional articles were identified by a manual search of references from key articles.
In recent years, various surgical procedures and techniques have been explored to reduce the incidence of DGE. Pyloric resection, Billroth II reconstruction, Braun's enteroenterostomy, and antecolic reconstruction may be associated with a decreased incidence of DGE, but more high-powered studies are needed in the future. Neither laparoscopic nor robotic surgery has demonstrated superiority in preventing DGE, and the use of staplers is controversial regarding whether they can reduce the incidence of DGE.
Despite many innovations in surgical techniques, there is no surgical procedure that is superior to others to reduce DGE. Further larger prospective randomized studies are needed.
An invaginated pancreaticogastrostomy following subtotal stomach-preserving pancreaticoduodenectomy: A prospective observational study
2021, Asian Journal of Surgery
Citation Excerpt :
Second, side-to-side stapled gastrojejunostomy can hold the anastomotic lumen open uniformly, prevents anastomotic edema or stenosis efficiently, and avoids disturbance of the blood supply to the anastomotic site.27,28 Third, ante-colic reconstruction with Braun jejunojejunostomy is thought to be an important procedure for reducing the risk of DGE.29,30 The present study possesses some limitations.
Postoperative pancreatic fistula (POPF) leads to life-threatening complications after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) often adopted as a reconstruction technique after PD to prevent POPF. Delayed gastric emptying (DGE) following PD is the most common complication that compromises the quality of life. Subtotal stomach-preserving PD (SSPPD) preserves the pooling ability of the stomach and minimize the occurrence of DGE. This study aimed to describe our PG technique following SSPPD and evaluate the perioperative outcomes.
The study included patients who underwent PG following SSPPD from August 2013 to July 2020 at our institution. An invaginated PG was performed by one-layer eight interrupted sutures with a lost stent. Patients’ demographics and perioperative outcomes were documented.
This technique was applied in 72 patients with a median age of 75 years. The median operative time was 342 min. The clinically relevant POPF, DGE and post-pancreatectomy hemorrhage was 4 (5.6%), 5 (6.9%), and 10 (13.9%), respectively. Although the drain fluid amylase concentration on postoperative day 3 was significantly higher in clinically relevant POPF (CR-POPF) positive group (median, 2006 U/L vs. 74 U/L in CR-POPF negative group, p = 0.002), none of the risk factors including disease pathology, pancreatic duct diameter, texture of pancreas and excessive blood loss were significantly associated with CR-POPF. Other morbidity ≥ Clavien-Dindo classification II occurred in 29 patients (40.3%). The 90-days operative mortality was two (2.8%).
This novel method of one-layer invaginated PG following SSPPD is safe and dependable procedure with acceptable morbidity and mortality.
Gastric stricture following corrosive agent ingestion: A case report
2020, International Journal of Surgery Case Reports
Citation Excerpt :
Our case underwent gastrojejunostomy and Braun anastomosis because of severe stricture of the gastric antrum and pylorus approximately one month after the incident of accidental caustic agent ingestion and showed good outcome. We performed Braun anastomosis in addition to gastrojejunostomy because of several advantages as follows: it decreases the incidence of delayed gastric emptying, prevents the possibility of twisting, angulation, kinking and edema of gastrojejunostomy, enables the route of the food, reduces the possibility of gastric mucosa exposure from bile and pancreatic juice reflux, and decreases the incidence of loop obstruction [10]. In addition, we performed the surgery in patients with malnourished nutritional status.
Gastric stricture due to corrosive ingestion is a rare cause of obstruction in the upper gastrointestinal tract in children. However, only a few reports highlight the management of the stricture of the gastric antrum and pylorus, i.e. gastric outlet obstruction (GOO) due to corrosive ingestion, particularly in children.
We report a 1-year-old male who presented with chief complaints of upper abdominal pain and profuse vomiting after accidentally ingesting sulfuric acid one month prior. On physical examination, minimal epigastric distension was found. Endoscopic examination showed oesophagitis, erosive gastritis, multiple gastric ulcers and suspicion of pyloric stricture. We decided to perform an exploratory laparotomy and found severe strictures from the major curvature to the gastric pylorus. Subsequently, we conducted gastrojejunostomy and Braun anastomosis. The patient was discharged on the eighth postoperative day uneventfully.
Endoscopy is a reliable technique for assessing upper digestive tract mucous membranes after caustic agent ingestion because it helps in making a definitive diagnosis, especially to define the anatomic location and injury severity. The timing and type of surgery for GOO is controversial. We performed Braun anastomosis in addition to gastrojejunostomy because of several advantages over other surgical methods.
We recommend choosing an appropriate supporting examination to precisely diagnose gastric stricture due to corrosive ingestion. Gastojejunostomy and Braun anastomosis show a good outcome for gastric stricture due to corrosive ingestion, particularly in children.
The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy
2017, Hepatobiliary and Pancreatic Diseases International
A number of definitions have been used for delayed gastric emptying (DGE) after pancreatoduodenectomy and the reported rates varied widely. The International Study Group of Pancreatic Surgery (ISGPS) definition is the current standard but it is not used universally. In this comprehensive review, we aimed to determine the acceptance rate of ISGPS definition of DGE, the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence.
We searched PubMed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition, DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles.
Out of 435 search results, 178 were selected for data extraction. The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7% (range: 0–100%; median: 18.7%) and 14.3% (range: 1.8%–58.2%; median: 13.6%), respectively. Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates. Although pyloric dilatation, Braun's entero-enterostomy and Billroth II reconstruction were associated with significantly lower DGE rates, pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies.
ISGPS definition of DGE has been used in majority of studies published after 2010. Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications. Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.
Braun enteroenterostomy reduces delayed gastric emptying: A systematic review and meta-analysis
2015, International Journal of Surgery
Citation Excerpt :
Pooled analysis revealed no significant difference in the rate of pancreatic fistula (7 studies [10,12,13,18–21]: OR, 0.70; 95%CI, 0.35 to 1.40; P = 0.31; I2 = 69%), bile leakage (6 studies [10,12,18–21]: OR, 0.61; 95%CI, 0.34 to 1.08; P = 0.09; I2 = 0%) and intra-abdominal abscess (5 studies [10,12,18,19,21]: OR, 0.92; 95%CI, 0.58 to 1.45; P = 0.71; I2 = 0%) between Braun group and Non-Braun group. Five studies [12,13,18,20,21] provided data on the LOS. However, only two articles [18,20] provide the standard deviation.
It remains controversial whether the additional Braun enteroenterostomy (BEE) is necessary in decreasing delayed gastric emptying (DGE) following pancreaticoduodenectomy (PD). This meta-analysis aims to assess the efficacy of the additional BEE in reducing DGE after PD.
PubMed, EMBASE, Science Citation Index and The Cochrane Library were searched to identify relevant studies. Articles published before May 15, 2015 comparing BEE with traditional gastrojejunostomy during PD were selected. The evaluated end points consist of intro-operative outcomes as well as postoperative complications.
Seven observational clinical studies that recruited 1401 patients were included. This meta-analysis indicated that the occurrence of DGE was lower in Braun group (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.15 to 0.60; P = 0.0007). Overall morbidity (OR, 0.61; 95%CI, 0.47 to 0.80; P = 0.0003) and the length of hospital stay (LOS) (weighted mean difference [WMD], −1.80; 95%CI, −3.4 to −0.18; p = 0.03) were also in favor of the Braun group. However, Braun group had no advantage over Non-Braun group in terms of intra-operative blood loss, mortality, pancreatic fistula, bile Leakage and intra-abdominal abscess.
The additional of BEE plays an important role in reducing DGE, overall morbidity and LOS.
The Effect of Braun’s Enteroenterostomy on Delayed Gastric Emptying in Binding Pancreaticogastrostomy Following Pancreaticoduodenectomy: a Comparative Study and Review of Literature
2022, Indian Journal of Surgery

View all citing articles on Scopus

: The authors declare no conflicts of interest.

: Supported by the National Natural Science Foundation of China (81001007) and the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry (SRF for ROCS, SEM).

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Clinical ScienceBraun enteroenterostomy during pancreaticoduodenectomy decreases postoperative delayed gastric emptying

Abstract

Background

Methods

Results

Conclusion

Section snippets

Clinical data

Clinical results

Lancet Oncol

J Gastrointest Surg

J Gastrointest Surg

J Gastrointest Surg

Eur J Surg Oncol

HPB (Oxford)

Am J Surg

Surgery

Surgery

HPB (Oxford)

J Gastrointest Surg

J Gastrointest Surg

J Gastrointest Surg

Exp Neurol

Pylorus resection or pylorus preservation in partial pancreatico-duodenectomy (PROPP study): study protocol for a randomized controlled trial

Trials

Clinical Science
Braun enteroenterostomy during pancreaticoduodenectomy decreases postoperative delayed gastric emptying