Impact of Antecolic versus Transmesocolic Reconstruction on Delayed Gastric Emptying Following Pancreaticoduodenectomy

Background Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy. There remains an active debate over the impact of gastrointestinal reconstruction techniques, such as antecolic (AC) versus transmesocolic (TMC) reconstruction, on DGE rates. This study compared the rates of DGE between AC and TMC reconstruction following pylorus-preserving (PPPD) and classic pancreaticoduodenectomies (PD). Methods This was a retrospective analysis of a prospectively maintained pancreatic surgery database in a single, high-volume center. Demographic, perioperative, and surgical outcome data were recorded from patients who underwent a PD or PPPD between 2013 and 2021. DGE grades were classified using the International Study Group of Pancreatic Surgeons (ISGPS) criteria. Post-operatively, all patients were managed using an accelerated Whipple recovery protocol. Results A total of 824 patients were assessed, with 303 patients undergoing AC reconstruction and 521 undergoing TMC reconstruction. The risk of DGE was significantly greater in patients who received an AC reconstruction as compared to a TMC reconstruction (OR=1.51; 95%CI, 1.07-2.15; P<0.05). Notably, AC reconstruction was also shown to have a greater incidence of severe DGE (ISGPS grades B or C) compared to TMC reconstruction, with nearly a 2-fold increase in severe DGE (OR=1.94; 95%CI, 1.10-3.45; P<0.05). Logistic regression and propensity-score matching have found increased DGE incidence with AC reconstruction (OR=1.69, and OR=1.73, respectively. P<0.05). Conclusions Although the correlation between gastrointestinal reconstruction methods and DGE remains a subject of ongoing debate, our study indicates that TMC may be superior to AC reconstruction in minimizing the development and severity of DGE for patients post-pancreaticoduodenectomy.