Association of preoperative symptoms of gastric outlet obstruction with delayed gastric emptying after pancreatoduodenectomy Jasper J. Atema, MD, Wietse J. Eshuis, MD, Olivier R. C. Busch, MD, PhD, Thomas M. van Gulik, MD, PhD, and Dirk J. Gouma, MD, PhD, Amsterdam, The Netherlands Background. Delayed gastric emptying (DGE) is among the most common complications after pancreatoduodenectomy (PD) and might demand postoperative nutritional support. The aim of this study was to investigate the association between preoperative symptoms of gastric outlet obstruction and DGE after PD in an attempt to identify patients in whom placement of a feeding tube at time of operation might be beneficial. Methods. We analyzed a consecutive series of 401 patients undergoing PD from a prospective database. Preoperative symptoms of nausea, vomiting, loss of appetite, weight loss, postprandial complaints, and dysphagia were retrospectively determined. Primary outcome was clinically relevant DGE according to the International Study Group of Pancreatic Surgery classification and the necessity of postoperative insertion of a nasojejunal feeding tube. Results. The incidence of clinically relevant DGE was 33.2% (133/401 patients). A nasojejunal feeding tube was inserted in 119 patients (29.7%). Patients having $2 symptoms of gastric outlet obstruction except weight loss (50 patients; 12.5%), were at a greater risk of developing both DGE (21.1% vs 8.2%; P < .001) and the need for insertion of a feeding tube (21.8% vs 8.5%; P < .001). In multivariable logistic regression analysis, the presence of $2 symptoms of gastric outlet obstruction other than weight loss remained a significant predictor of DGE (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.7–5.8) and the need for insertion of a nasojejunal feeding tube (OR, 3.1; 95% CI, 1.7–5.7). Conclusion. The preoperative presence of $2 symptoms of gastric outlet obstruction is a significant predictor of postoperative DGE after PD. By applying this risk factor, patients in whom placement of a feeding tube during surgery should be considered can be identified. (Surgery 2013;154:583-8.) From the Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands DESPITE A REDUCTION OF MORTALITY after pancreatoduo- denectomy (PD) to <5% in high-volume centers, postoperative morbidity rate remains high (approx- imately 50%). 1,2 Delayed gastric emptying (DGE) is among the most common complications after PD with an incidence varying from 19 to 57%. 1,3 Al- though not life threatening, DGE is associated with prolonged hospital stay, a decreased quality of life, and increases healthcare costs. The pathogene- sis of DGE after PD remains unclear; denervation of antropyloric region, pyloric and antral ischemia, and decreased levels of motilin are suggested to be involved. 4-8 Furthermore, the association between DGE and other postoperative intra-abdominal com- plications, such as pancreatic fistulae and abscesses, has been reported in several studies. 9-13 DGE is a condition of gastroparesis without mechanical obstruction. It is usually determined on the basis of 2 clinical parameters: Number of days that nasogastric drainage is required and number of days until solid food is tolerated. Because of the lack of a generally accepted defini- tion, the International Study Group of Pancreatic Surgery (ISGPS) developed an objective and gen- erally applicable definition in 2006 based on these 2 clinical parameters. 14 In cases of DGE, additional nutritional support is warranted. Early nutrition has become a vital part of postoperative care and fast recovery. For this purpose, enteral feeding has proven to be superior to parenteral support. 15 With gastropare- sis, feeding must be administered directly into Accepted for publication April 3, 2013. Reprint requests: Prof. Dr Dirk J. Gouma, MD, PhD, Depart- ment of Surgery, Academic Medical Center, Meibergdreef 9, PO Box 22660, 1105 AZ Amsterdam, The Netherlands. E-mail: d.j.gouma@amc.uva.nl. 0039-6060/$ - see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2013.04.006 SURGERY 583