Reduction in Delayed Gastric Emptying Following Non-Pylorus Preserving Pancreaticoduodenectomy by Addition of a Braun Enteroenterostomy

  • Mehrdad Nikfarjam Department of Surgery, University of Melbourne, Austin Health. Heidelberg, Victoria, Australia
  • Nezor Houli Department of Surgery, University of Melbourne, Austin Health. Heidelberg, Victoria, Australia
  • Farrukh Tufail Department of Surgery, University of Melbourne, Austin Health. Heidelberg, Victoria, Australia
  • Laurence Weinberg Department of Anaesthesia, University of Melbourne, Austin Health. Heidelberg, Victoria, Australia
  • Vijayaragavan Muralidharan Department of Surgery, University of Melbourne, Austin Health. Heidelberg, Victoria, Australia
  • Christopher Christophi Department of Surgery, University of Melbourne, Austin Health. Heidelberg, Victoria, Australia
Keywords: Gastroparesis, Pancreaticoduodenectomy, Pancreatic Fistula


Context Delayed gastric emptying is a major cause of morbidity following pancreaticoduodenectomy. Objective The impact of a Braun enteroenterostomy on delayed gastric emptying, used in reconstruction following classic pancreaticoduodenectomy, was assessed. Patients Forty-four consecutive patients undergoing non-pylorus preserving pancreaticoduodenectomy from 2009 to 2011 by a single surgeon were included in this study. Interventions The first 20 patients had a standard antecolic gastroenterostomy and the subsequent 24 had the addition of a Braun enteroenterostomy. Results Patient characteristics, the extent of surgery, surgical findings and tumor characteristics were similar between the two groups. The delayed gastric emptying rate in the Braun enteroenterostomy (1/24, 4.2%) was significantly lower (P=0.008) than the standard reconstruction group (7/20, 35.0%). In the standard group, 6 of 7 cases (85.7%) of delayed gastric emptying were class C in nature. After exclusion of 8 total pancreatectomy patients, the pancreatic fistula rate in the Braun enteroenterostomy group (4/19, 21.1%) was similar (0.706) to the standard reconstruction group (5/17, 29.4%) as was the median length of hospital stay (10 days vs. 15 days; P=0.291). Braun enteroenterostomy technique was the only significant independent factor associated with reduced delayed gastric emptying with an odds ratio of 0.08 (95% confidence interval: 0.01-0.73; P=0.025). Conclusion The use of Braun enteroenterostomy following non-pylorus preserving pancreaticoduodenectomy appears to result in a significant reduction in delayed gastric emptying.

Image: Reconstruction with the addition of Braun enteroenterostomy.


Download data is not yet available.


Pratt W, Joseph S, Callery MP, Vollmer CM, Jr. POSSUM accurately predicts morbidity for pancreatic resection. Surgery 2008;143(1): 8-19.

Lowy AM, Lee JE, Pisters PW, Davidson BS, Fenoglio CJ, Stanford P, Jinnah R, Evans DB. Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreatico-duodenectomy for malignant disease. Ann Surg 1997;226(5): 632-641.

DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, Clavien PA. Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244(6): 931-937; discussion 937-939.

Grobmyer SR, Pieracci FM, Allen PJ, Brennan MF, Jaques DP. Defining morbidity after pancreaticoduodenectomy: use of a prospective complication grading system. J Am Coll Surg 2007;204(3): 356-364.

Balcom JHt, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001;136(4): 391-398.

Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Buchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142(5): 761-768.

Malleo G, Crippa S, Butturini G, Salvia R, Partelli S, Rossini R, Bacchion M, Pederzoli P, Bassi C. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: validation of International Study Group of Pancreatic Surgery classification and analysis of risk factors. HPB (Oxford) 2010;12(9): 610-618.

Tan WJ, Kow AW, Liau KH. Moving towards the New International Study Group for Pancreatic Surgery (ISGPS) definitions in pancreaticoduodenectomy: a comparison between the old and new. HPB (Oxford) 2011;13(8): 566-572.

Welsch T, Borm M, Degrate L, Hinz U, Buchler MW, Wente MN. Evaluation of the International Study Group of Pancreatic Surgery definition of delayed gastric emptying after pancreatoduodenectomy in a high-volume centre. Br J Surg 2010;97(7): 1043-1050.

Miedema BW, Sarr MG, van Heerden JA, Nagorney DM, McIlrath DC, Ilstrup D. Complications following pancreaticoduodenectomy. Current management. Arch Surg 1992;127(8): 945-949; discussion 949-950.

Hocking MP, Harrison WD, Sninsky CA. Gastric dysrhythmias following pylorus-preserving pancreaticoduodenectomy. Possible mechanism for early delayed gastric emptying. Dig Dis Sci 1990;35(10): 1226-1230.

Braasch JW, Deziel DJ, Rossi RL, Watkins E, Jr., Winter PF. Pyloric and gastric preserving pancreatic resection. Experience with 87 patients. Ann Surg 1986;204(4): 411-418.

Liberski SM, Koch KL, Atnip RG, Stern RM. Ischemic gastroparesis: resolution after revascularization. Gastroenterology 1990;99(1): 252-257.

Martignoni ME, Friess H, Sell F, Ricken L, Shrikhande S, Kulli C, Buchler MW. Enteral nutrition prolongs delayed gastric emptying in patients after Whipple resection. Am J Surg 2000;180(1): 18-23.

Tanaka M, Sarr MG. Role of the duodenum in the control of canine gastrointestinal motility. Gastroenterology 1988;94(3): 622-629.

Nikfarjam M, Kimchi ET, Gusani NJ, Shah SM, Sehmbey M, Shereef S, Staveley-O'Carroll KF. A reduction in delayed gastric emptying by classic pancreaticoduodenectomy with an antecolic gastrojejunal anastomosis and a retrogastric omental patch. J Gastrointest Surg 2009;13(9): 1674-1682.

Lytras D, Paraskevas KI, Avgerinos C, Manes C, Touloumis Z, Paraskeva KD, Dervenis C. Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection. Langenbecks Arch Surg 2007;392(1): 1-12.

Kawai M, Tani M, Hirono S, Miyazawa M, Shimizu A, Uchiyama K, Yamaue H. Pylorus ring resection reduces delayed gastric emptying in patients undergoing pancreatoduodenectomy: a prospective, randomized, controlled trial of pylorus-resecting versus pylorus-preserving pancreatoduodenectomy. Ann Surg 2011;253(3): 495-501.

Raty S, Sand J, Lantto E, Nordback I. Postoperative acute pancreatitis as a major determinant of postoperative delayed gastric emptying after pancreaticoduodenectomy. J Gastrointest Surg 2006;10(8): 1131-1139.

Traverso LW, Hashimoto Y. Delayed gastric emptying: the state of the highest level of evidence. J Hepatobiliary Pancreat Surg 2008;15(3): 262-269.

Masui T, Doi R, Kawaguchi Y, Uemoto S. Delayed gastric emptying improved by straight stomach reconstruction with twisted anastomosis to the jejunum after pylorus-preserving pancreaticoduodenectomy (PPPD) in 118 consecutive patients at a single institution. Surg Today 2011.

Tani M, Terasawa H, Kawai M, Ina S, Hirono S, Uchiyama K, Yamaue H. Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy: results of a prospective, randomized, controlled trial. Ann Surg 2006;243(3): 316-320.

Braun H. Ueber die Gasto-enteostomie und gleichzeutig ausgefuhrte Entero-anastomose. Arch Klin Chir 1893;45: 361.

Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM, Jr. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007;245(3): 443-451.

Bassi C, Falconi M, Molinari E, Salvia R, Butturini G, Sartori N, Mantovani W, Pederzoli P. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg 2005;242(6): 767-771, discussion 771-763.

Itani KM, Coleman RE, Meyers WC, Akwari OE. Pylorus-preserving pancreatoduodenectomy. A clinical and physiologic appraisal. Ann Surg 1986;204(6): 655-664.

Kurosaki I, Hatakeyama K. Preservation of the left gastric vein in delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy. J Gastrointest Surg 2005;9(6): 846-852.

Haddad O, Porcu-Buisson G, Sakr R, Guidicelli B, Letreut YP, Gamerre M. Diagnosis and management of adenocarcinoma of the ampulla of Vater during pregnancy. Eur J Obstet Gynecol Reprod Biol 2005;119(2): 246-249.

Horstmann O, Becker H, Post S, Nustede R. Is delayed gastric emptying following pancreaticoduodenectomy related to pylorus preservation? Langenbecks Arch Surg 1999;384(4): 354-359.

Horstmann O, Markus PM, Ghadimi MB, Becker H. Pylorus preservation has no impact on delayed gastric emptying after pancreatic head resection. Pancreas 2004;28(1): 69-74.

Riediger H, Makowiec F, Schareck WD, Hopt UT, Adam U. Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications. J Gastrointest Surg 2003;7(6): 758-765.

Hunt DR, McLean R. Pylorus-preserving pancreatectomy: functional results. Br J Surg 1989;76(2): 173-176.

Lin PW, Lin YJ. Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy. Br J Surg 1999;86(5): 603-607.

Meyer BM, Werth BA, Beglinger C, Hildebrand P, Jansen JB, Zach D, Rovati LC, Stalder GA. Role of cholecystokinin in regulation of gastrointestinal motor functions. Lancet 1989;2(8653): 12-15.

Fox JE, Daniel EE, Jury J, Robotham H. The mechanism of motilin excitation of the canine small intestine. Life Sci 1984;34(10): 1001-1006.

Naritomi G, Tanaka M, Matsunaga H, Yokohata K, Ogawa Y, Chijiiwa K, Yamaguchi K. Pancreatic head resection with and without preservation of the duodenum: different postoperative gastric motility. Surgery 1996;120(5): 831-837.

Tait IS. Whipple's resection-proximal pancreaticoduodenectomy (PD). J R Coll Surg Edinb 2002;47(3): 528-540.

Tanaka M, Sarr MG. Total duodenectomy: effect on canine gastrointestinal motility. J Surg Res 1987;42(5): 483-493.

Kim HC, Suzuki T, Kajiwara T, Miyashita T, Imamura M, Tobe T. Exocrine and endocrine stomach after gastrobulbar preserving pancreatoduodenectomy. Ann Surg 1987;206(6): 717-727.

Kim DK, Hindenburg AA, Sharma SK, Suk CH, Gress FG, Staszewski H, Grendell JH, Reed WP. Is pylorospasm a cause of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy? Ann Surg Oncol 2005;12(3): 222-227.

Ueno T, Tanaka A, Hamanaka Y, Tsurumi M, Suzuki T. A proposal mechanism of early delayed gastric emptying after pylorus preserving pancreatoduodenectomy. Hepatogastroenterology 1995;42(3): 269-274.

Traverso LW, Longmire WP, Jr. Preservation of the pylorus in pancreaticoduodenectomy a follow-up evaluation. Ann Surg 1980;192(3): 306-310.

Pitt HA, Grace PA. Cancer of the pancreas. Pylorus-preserving resection of the pancreas. Baillieres Clin Gastroenterol 1990;4(4): 917-930.

Han SS, Kim SW, Jang JY, Park YH. A comparison of the long-term functional outcomes of standard pancreatoduodenectomy and pylorus-preserving pancreatoduodenectomy. Hepatogastroenterology 2007;54(78): 1831-1835.

van Berge Henegouwen MI, van Gulik TM, DeWit LT, Allema JH, Rauws EA, Obertop H, Gouma DJ. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. J Am Coll Surg 1997;185(4): 373-379.

Patel AG, Toyama MT, Kusske AM, Alexander P, Ashley SW, Reber HA. Pylorus-preserving Whipple resection for pancreatic cancer. Is it any better? Arch Surg 1995;130(8): 838-842; discussion 842-833.

Lin PW, Shan YS, Lin YJ, Hung CJ. Pancreaticoduodenectomy for pancreatic head cancer: PPPD versus Whipple procedure. Hepatogastroenterology 2005;52(65): 1601-1604.

Alsaif F. Pylorus preserving pancreaticoduodenectomy for peri-ampullary carcinoma, is it a good option? Saudi J Gastroenterol 2010;16(2): 75-78.

Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW, Terpstra OT, Zijlstra JA, Klinkert P, Jeekel H. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 2004;240(5): 738-745.

Hardacre JM. Is there a learning curve for pancreaticoduodenectomy after fellowship training? HPB Surg 2010;2010: 230287.

Tu BN, Sarr MG, Kelly KA. Early clinical results with the uncut Roux reconstruction after gastrectomy: limitations of the stapling technique. Am J Surg 1995;170(3): 262-264.

Hochwald SN, Grobmyer SR, Hemming AW, Curran E, Bloom DA, Delano M, Behrns KE, Copeland EM, Vogel SB. Braun enteroenterostomy is associated with reduced delayed gastric emptying and early resumption of oral feeding following pancreaticoduodenectomy. J Surg Oncol 2010;101(5): 351-355.

Wayne MG, Jorge IA, Cooperman AM. Alternative reconstruction after pancreaticoduodenectomy. World J Surg Oncol 2008;6: 9.

Reconstruction with the addition of Braun enteroenterostomy
How to Cite
NikfarjamM., HouliN., TufailF., WeinbergL., MuralidharanV., & ChristophiC. (2012). Reduction in Delayed Gastric Emptying Following Non-Pylorus Preserving Pancreaticoduodenectomy by Addition of a Braun Enteroenterostomy. JOP. Journal of the Pancreas, 13(5), 488-496.

Most read articles by the same author(s)