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Antecolic Versus Retrocolic Route of the Gastroenteric Anastomosis After Pancreatoduodenectomy: A Randomized Controlled Trial

Eshuis, Wietse J. MD*; van Eijck, Casper H. J. MD, PhD§; Gerhards, Michael F. MD, PhD; Coene, Peter P. MD, PhD; de Hingh, Ignace H. J. T. MD, PhD**; Karsten, Thom M. MD, PhD; Bonsing, Bert A. MD, PhD‡‡; Gerritsen, Josephus J. G. M. MD, PhD§§; Bosscha, Koop MD, PhD¶¶; Spillenaar Bilgen, Ernst J. MD, PhD‖‖; Haverkamp, Jorien A. MSc; Busch, Olivier R. C. MD, PhD*; van Gulik, Thomas M. MD, PhD*,††; Reitsma, Johannes B. MD, PhD; Gouma, Dirk J. MD, PhD*

doi: 10.1097/SLA.0b013e3182a6f529
Randomized Controlled Trials

Objective: To investigate the relationship between the route of gastroenteric (GE) reconstruction after pancreatoduodenectomy (PD) and the postoperative incidence of delayed gastric emptying (DGE).

Background: DGE is one of the most common complications after PD. Recent studies suggest that an antecolic route of the GE reconstruction leads to a lower incidence of DGE, compared to a retrocolic route. In a nonrandomized comparison within our trial center, we found no difference in DGE after antecolic or retrocolic GE reconstruction.

Methods: Ten middle- to high-volume centers participated in the patient inclusion. Patients scheduled for PD who gave written informed consent were included and randomized during surgery after resection. Standard operation was a pylorus-preserving PD. Primary endpoint was DGE. Secondary endpoints included other complications and length of hospital stay.

Results: There were 125 patients in the retrocolic group, and 121 patients in the antecolic group. Baseline and treatment characteristics did not differ between the study groups. In the retrocolic group, 45 patients (36%) developed clinically relevant DGE compared with 41 (34%) in the antecolic group (absolute risk difference: 2.1%; 95% confidence interval: −9.8% to 14.0%). There were no differences in need for postoperative (par)enteral nutritional support, other complications, hospital mortality, and median length of hospital stay.

Conclusions: The route of GE reconstruction after PD does not influence the postoperative incidence of DGE or other complications. The etiology and treatment of DGE, which occurs frequently after both procedures, need further investigation. The GE reconstruction after PD should be routed according to the surgeon's preference.

This multicenter randomized controlled trial investigated the influence of the route of gastroenteric reconstruction (antecolic or retrocolic) on the incidence of delayed gastric emptying and other complications after pancreatoduodenectomy. No difference was found between an antecolic and a retrocolic gastroenteric reconstruction.

Departments of *Surgery

Dietetics and Nutrition

Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam

§Department of Surgery, Erasmus Medical Center, Rotterdam

Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam

Department of Surgery, Maasstad Hospital, Rotterdam

**Department of Surgery, Catharina Hospital, Eindhoven

††Department of Surgery, Reinier de Graaf Hospital, Delft

‡‡Department of Surgery, Leiden University Medical Center, Leiden

§§Department of Surgery, Medisch Spectrum Twente, Enschede

¶¶Department of Surgery, Jeroen Bosch Hospital, ‘s-Hertogenbosch; and

‖‖Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands. Dr Reitsma is now with Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands.

Reprints: Dirk J. Gouma, MD, PhD, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands. E-mail:

Disclosure: No financial support has been taken for the study. The authors declare no conflicts of interest.

This paper was presented at the 10th World Congress of the International HPB Association, Paris, 2012.

© 2014 by Lippincott Williams & Wilkins.