Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA.
J Gastrointest Surg. 2021 Sep;25(9):2221-2230. doi: 10.1007/s11605-020-04877-z. Epub 2020 Nov 24.
Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD) that impairs recovery and quality of life. The purpose of this study was to assess the impact risk-stratified pancreatectomy clinical pathways (RSPCPs) had on delayed gastric emptying (DGE) and identify factors associated with DGE in a contemporary period.
A single-institution, prospective database was queried for consecutive PDs during July 2011-November 2019. Using international definitions, DGE rates were compared between periods before and after RSPCPs were implemented in 2016, classifying patients according to their postoperative pancreatic fistula (POPF) risk. Risk factors were analyzed to identify modifiable targets.
Among 724 elective PDs, 552 (76%) were for adenocarcinoma and 172 (24%) for other diagnoses. Of the 197 (27%) patients with DGE, 119 (16%) had type A, 41 (6%) type B, and 38 (5%) type C. In the overall cohort, DGE rates were higher with pylorus-preserving vs. classic hand-sewn reconstruction (odds ratio [OR] - 1.84; p < 0.001), postoperative abscess (OR - 2.54; p = 0.003), and non-white patients (p = 0.007), but lower after implementation of RSPCPs (OR - 0.34, p < 0.001). In the 374 patients treated with RSPCPs, only 17% (n = 65/374) developed DGE. Patients with protocol-compliant NGT removal ≤ 48 h were less likely to experience DGE (OR - 1.46, p = 0.042).
Our data suggest that implementation of preoperatively assigned RSPCPs as a care bundle was the most important factor in decreasing DGE. These gains were accentuated in patients who underwent early nasogastric tube removal and had a classic hand-sewn gastro-jejunostomy reconstruction. Application of these modifiable factors is generalizable with low implementation barriers.
延迟性胃排空（DGE）是胰十二指肠切除术（PD）后的常见并发症，会影响患者的恢复和生活质量。本研究旨在评估风险分层的胰腺切除术临床路径（RSPCP）对延迟性胃排空（DGE）的影响，并确定与 DGE 相关的因素在当代时期的情况。
对 2011 年 7 月至 2019 年 11 月连续进行的 PD 患者的单机构前瞻性数据库进行了查询。使用国际定义，比较了在 2016 年实施 RSPCP 前后两个时期的 DGE 发生率，并根据术后胰腺瘘（POPF）风险对患者进行分类。分析危险因素以确定可修改的目标。
在 724 例择期 PD 中，552 例（76%）为腺癌，172 例（24%）为其他诊断。在 197 例（27%）DGE 患者中，119 例（16%）为 A 型，41 例（6%）为 B 型，38 例（5%）为 C 型。在整个队列中，与经典手工缝合重建相比，保留幽门的重建（比值比 [OR] -1.84；p<0.001）、术后脓肿（OR -2.54；p=0.003）和非白人患者（p=0.007）的 DGE 发生率更高，但在实施 RSPCP 后（OR -0.34，p<0.001）则较低。在接受 RSPCP 治疗的 374 例患者中，仅 17%（n=65/374）发生 DGE。在遵循方案规定的 48 小时内拔除 NG 管的患者发生 DGE 的可能性较低（OR -1.46，p=0.042）。
我们的数据表明，术前分配的 RSPCP 作为护理方案的实施是降低 DGE 的最重要因素。在早期拔除鼻胃管且接受经典手工缝合胃肠吻合术重建的患者中，这一获益更为明显。这些可修改因素的应用具有较低的实施障碍，具有普遍适用性。
