Distal Subtotal Gastric Resection for Prevention of Delayed Gastric Emptying Following Pancreaticoduodenectomy

Rationale: Delayed gastric emptying is one of the leading causes of morbidity following pancreatico-dudenectomy occurring in nearly one third of patients. Literature reports indicate that the incidence of delayed gastric emptying (DGE) is higher after Pylorus-preserving pancreaticodudenectomy (PPPD) than after conventional pancreatico-dudenectomy (CPD). Delayed Gastric emptying is traditionally diagnosed from patient report subjective sensations.In order to improve gastric emptying, distal subtotal gastrectomy with resection of nearly 60% of the stomach converting it from a reservoir into a conduit is undertaken to prevent gastric stasis and shortens transient time.Study design: Over a period of five years from 2001-2006, a total of twenty patients with operable pancreatic lesions underwent extended gastric resection in the form of distal subtotal gastric resection concomitant with pancreaticodudenectomy. The male-female ratio was 14/6, the mean age was 55 years with 15.5 standard deviation (SD). This group was compared prospectively with a matched control group of patients who underwent conventional pancreaticodudenectomy regarding the development of delayed gastric emptying. We sought to quantify the rates of subjective DGE (sDGE) based on patient complaint versus objective DGE (oDGE) based on gastrograffin study in the tenth post operative day post Extended distal subtotal gasric resection with pancreatico-dudenectomy group (EPD) and the control retrospective group post conventional pancreatico-dudenectomy (CPD).Result: For the 20 patients in the EPD group and the other 20 patients in the CPD control group sDGE and oDGE data were collected on the postoperative day 14, and 6 months postoperatively. The incidence of sDGE was higher for the CPD (42%) than for EPD (15%) at 14 days, (33%) and (6%) at 6 months. The oDGE was higher for CPD (91%) than for EPD (67%) at 14 days, with a 6-months incidence of (37%) in CPD and (4.7%) for EPD.The proximal gastric function detected by the Liquid phase gastric emptying test (normal control reference=23 minutes) was prolonged for the CPD group (73 minutes) compared to (38 minutes) for the ECP in the first 14 days. At 6-months interval the LGE was (48 minutes) for CPD and (12.7 minutes) for ECP.Conclusion:1-The concept of DGE should distinguish between subjective and objective symptoms.2-The loss of distal stomach mechanoreceptors in EPD reduces patient sensation of oDGE producing silent DGE.3-The EPD contributed greatly in preventing the early delayed gastric emptying, resulting in short hospital stay and decrease cost with minimal associated surgical morbidity.