Several techniques for reducing the incidence of DGE after PD have been advocated [11–14], but no definitive conclusions have been reached and the optimal treatment strategy for DGE remains to be clarified. A straight alignment of the stomach following PPPD has recently been reported to reduce the incidence of DGE [13, 14]. However, previous groups transposed the stomach over the left transverse colon and simply mobilized it downward in a straight line, without any anchoring suture or fixation of the stomach to the parietes. In contrast, we anchored the stomach to the parietes in the left lower quadrant of the abdomen, making use of a feeding jejunostomy tube in our technique. This anchoring contributed to straight placement of the anastomosed duodenum and stomach to allow smoother flow of food into the efferent jejunum by gravity when the patient was upright, regardless of stasis. In the present study, although the incidence of PPPD was more frequent in the ASSR group, the incidence of significant DGE in that group was only 5%, being lower than the incidence reported previously (range, 17–46%) [1–3]. As to placement of the feeding jejunostomy tube (FJT) at the time of PD, previous authors have suggested that it increases perioperative morbidity [15]. Contrarily, Sun et al. also reported that FJT placement did not appear to be associated with increased perioperative morbidity or mortality among 2980 patients who underwent gastrectomy [16]. In this study, our technique was simple and safe, with no complications related to jejunostomy, such as bowel occlusion, bowel perforation, or volvulus. Accordingly, this technique was considered acceptable in patients undergoing PD.
Conventionally, DGE is not considered a life-threatening complication. Recently, Futagawa et al. have demonstrated that severe DGE, especially grade C, negatively impacts survival, and is an independent risk factor for cancer-specific survival [7]. In the present study, survival was found to be significantly better in the ASSR group, the type of reconstruction was an independent factor affecting post-PD prognosis, and thus our results were consistent with their findings. Although the reasons why DGE may affect survival are not fully understood, it can be speculated that preservation of almost the whole stomach led to more favorable surgical outcomes, and may have contributed to improved oral intake. This in turn would have led to a more favorable nutritional status, possibly resulting in better survival through an improvement in immune status and compliance with adjuvant chemotherapy [7]. We compared the postoperative nutritional status between the two groups. This showed that ASSR facilitated better recovery in terms of BW and serum albumin level. We consider that, in the ASSR group, earlier resumption of oral feeding may have improved the protein supply, thus contributing to BW gain and an increase in the albumin level. Kawai et al. have suggested that DGE is associated with weight loss and poor nutritional status [17]. They also demonstrated that the incidence of > grade 2 weight loss (10–20% from the baseline) at 6 and 12 months after surgery in PPPD patients was 41.1% and 43.0%, respectively. In our series, on the other hand, the corresponding incidence at 6 and 12 months in the ASSR group was 32.7% and 31.7%, respectively. Further recovery of the serum albumin level in the ASSR group was also better than that observed in their study. Fujii et al. also reported that approximately 12% of BW was lost at 6 months after the surgery, and that the serum albumin level was also decreased at 6 months after surgery [3]. In our series, patients in the ASSR group at 6 months after surgery showed a BW loss of 7% and an increased albumin level. Consequently, ASSR in the present study might have facilitated prompter recovery of postoperative nutritional status in comparison with previous reports. Poor nutrition can delay recovery and is correlated with a higher incidence of complications and a poorer quality of life. Regarding with correlation between postoperative nutritional status and survival, there is mounting evidence that sarcopenia is associated with poorer prognosis after multiple abdominal operations, including gastric, liver, and pancreatic surgery [18–20]. Our results are consistent with those findings, and indicate shed new light on the relationship between DGE, nutritional status, and survival in patients with PD, particularly the degree to which DGE leads to poorer postoperative nutritional status, and its impact on long-term survival. To our knowledge, this is the first study to have investigated the reasons why DGE can impact survival in patients after PD.
Several limitations of this study must be acknowledged. This was a retrospective observational study with a non-randomized design, the number of patients included was relatively small, and thus potential bias could not be excluded. Although further studies with larger numbers of patients are warranted, the cases included were all assessed using acceptable standardized methods, as mentioned previously. Additionally, in this study, a nutritional advantage in patients with ASSR was apparent in comparison with previous reports.