Shifting emphasis in pancreatic surgery: Pre-, intra-, and postoperative determinants of outcome

This thesis studies factors influencing the outcome of pancreatic surgery. Resultss from multicenter randomized controlled trials, and from studies in the Academic Medical Center’s (AMC) pancreatic surgery database are described. The core of the thesis focusses on the most prevalent complication after pancreatoduodenectomy, delayed gastric emptying (DGE).
DGE requires prolonged nasogastric drainage and delays return to solid food intake. In the thesis, a multicenter randomized controlled trial is described, that randomized patients who underwent pancreatoduodenectomy between a retrocolic and antecolic gastroenteric anastomosis. Small studies suggested that an antecolic route led to lower DGE incidences, however, as one can read in this thesis, these results were not confirmed in the AMC population. In the trial, in which 246 patients from ten hospitals participated, it was shown that the route of gastroenteric reconstruction in pancreatoduodenectomy does not influence DGE, other clinical outcomes, and quality of life.
Some other causative factors of DGE are identified in this thesis, such as preoperative gastric outlet obstruction and early postoperative hyperglycemia.
Furthermore, the thesis describes the longterm results of a multicenter trial that randomized operable icteric patients with a pancreatic head tumor, between preoperative biliary drainage followed by surgery, and early surgery without biliary drainage. This trial showed that biliary drainage led to more complications, and early surgery is preferred. The longterm results show that survival is not compromised in patients who undergo biliary drainage. Whenever preoperative biliary drainage is necessary, due to logistic or clinical reasons, it can be performed without affecting survival.