Delayed gastric emptying
Delayed gastric emptying consists in a functional gastroparesis, and it is one of the most common complications after pancreatic resection (especially after pancreaticoduodenectomy). Its incidence varies widely across surgical institutions (5-25%).The definition of delayed gastric emptying encompasses different clinical items, including:
- Prolonged naso-gastric tube or necrssity of naso-gastric tube reinsertion
- Inability to tolerate a solid diet
- Vomit and gastric distension
- Use of prokinetic drugs
The causes for delayed gastric emptying are still unclear and are probably multifactorial, involving disruption of pylorus innervation, motilin deficiency due to duodenum resection, and technical aspects. Several studies have suggested a greater incidence of delayed gastric emptying after pylorus-preserving than after Whipple pancreaticoduodenectomy, whereas others found the opposite effect. Another operative factors that may impact the rate delayed gastric emptying is method of reconstruction of gastric drainage (antecolic versus retrocolic). Finally, delayed gastric emptying is often secondary to pancreatic fistula, biliary fistula and abdominal collections.
When a delayed gastric emptying is suspected, it may be necessary to exclude a gastric outlet obstruction. This can be done by a gastrografin swallow X-ray (that allows the radiologist to see the movement of the dye through the digestive anastomosis), or an upper endoscopy (that allows visualization of the digestive anastomosis and of associated problems, such as anastomotic ulcers).
Three different grades (A, B, and C) were defined based on the impact on the clinical course and on postoperative management:
- Delayed gastric emptying grade A usually does not lead to a marked change in management other than by minor disturbances in the return to intake of solid food or reinsertion of nasogastric tube for a brief period.
- Delayed gastric emptying grade B requires treatment with prokinetic drugs and parenteral or enteral nutritional support, and usually a prolonged reinsertion of the nasogastric tube.
- Delayed gastric emptying grade C necessitates a major change in clinical management, and possibly treatment of associated postoperative complications, such as pancreatic fistula or intra-abdominal abscesses. Consequently, further diagnostic workup and radiologic or operative interventions are often needed.
Delayed gastric emptying may lead to significant patient discomfort, and its treatment may be difficult. A multidisciplinary team including experienced gastroenterologists and dietitians is necessary to provide the best care.
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