Association of pylorus preservation with outcomes of pancreaticoduodenectomy across the United States - PubMed (original) (raw)

Association of pylorus preservation with outcomes of pancreaticoduodenectomy across the United States

Sona Mahrokhi et al. Surg Open Sci. 2025.

Abstract

Background: Pylorus-preserving pancreaticoduodenectomy (PPPD) was developed to improve postoperative gastrointestinal function while maintaining oncologic adequacy. However, conflicting evidence and concerns persist regarding increased delayed gastric emptying, warranting a national-level investigation.

Methods: This retrospective cohort study analyzed 40,063 adult pancreaticoduodenectomy procedures from the ACS NSQIP database (2014-2023). Patients were stratified into pylorus-preserving and non-pylorus-preserving groups. Multivariable regression models evaluated independent associations between pylorus-preserving status and clinical outcomes including infectious complications, blood transfusions, delayed gastric emptying, and length of stay.

Results: Of 40,063 pancreaticoduodenectomy procedures, 13,882 (34.6 %) were pylorus-preserving. PPPD was associated with lower rates of infectious complications (25.9 vs 27.5 %, P = 0.01) and blood transfusions (13.6 vs 16.4 %, P < 0.001), but higher delayed gastric emptying rates (17.1 vs 16.1 %, P = 0.02) and shorter length of stay (7 vs 8 days, P = 0.01). Readmission rates were similar (17.4 vs 17.9 %, P = 0.16). Following risk adjustment, PPPD remained associated with reduced infectious complications (AOR 0.94, 95 % CI 0.89-0.99) and blood transfusions (AOR 0.88, 95 % CI 0.82-0.95), but increased delayed gastric emptying (AOR 1.12, 95 % CI 1.04-1.21).

Conclusion: Despite declining utilization over the study period, PPPD offers significant advantages in reducing infectious complications and blood transfusion requirements while shortening operative times and hospital stay. However, the trade-off of increased delayed gastric emptying requires careful consideration in surgical decision-making. These findings support individualized approach selection based on patient complexity and surgeon expertise to optimize perioperative outcomes.

© 2025 The Authors.

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Conflict of interest statement

PB reports receiving proctoring fees from AtriCure, Inc. TRD reports serving as a shareholder and executive board member of Trethera Corp. This manuscript does not discuss any related products or services. All other authors declare no conflicts of interest.

Figures

Fig. 1

Fig. 1

Consort Diagram.

Fig. 2

Fig. 2

Proportion of Pylorus Preserving vs Non-Pylorus Preserving Procedures Over Time. Across the study period, the proportion of patients undergone pylorus preserving operation significantly decreased, from 42 % in 2014 to 29 % in 2023 while the proportion of non-pylorus preserving patients undergoing minimally invasive surgery increased from 9 % in 2014 to 13 % in 2023 (NPtrend<0.001). *Indicates statistical significance, P < 0.001.

Fig. 3

Fig. 3

Cumulative risk of readmission within 30 days of discharge comparing PPPD and Non-PPPD. CI, confidence interval; PPPD, pylorus preserving pancreaticoduodenectomy.

Fig. 4

Fig. 4

Risk-Adjusted Rates of Postoperative Complications by Pylorus Preservation. * Indicates statistical significance, P < 0.001. ‡ End Organ Damage: Sepsis, Septic Shock, Renal Complications, Reintubation.

Fig. 5

Fig. 5

Association of Pylorus preservation with outcomes of interest stratified by the presence of Malignancy. Following risk adjustment, pylorus preserving remained associated with greater odds of delayed gastric emptying but lower odds of blood transfusions and infectious complications among malignant. End Organ Damage: Sepsis, Septic Shock, Renal Complications, Reintubation. Reference: Non-pylorus preserving. Error bars represent 95 % confidence intervals. * Indicates statistical significance, P < 0.001

Supplementary Fig. 1

Supplementary Fig. 1

Distribution of total length of stay by pylorus preservation status and DGE occurrence. PPPD demonstrates shorter hospital stays among DGE patients. PPPD, pylorus preserving pancreaticoduodenectomy; DGE, delayed gastric emptying.

Supplementary Fig. 2

Supplementary Fig. 2

Association of Pylorus preservation with outcomes of interest. Following risk adjustment, pylorus preserving remained associated with greater odds of delayed gastric emptying and end organ damage but lower odds of blood transfusion and infectious complications. End Organ Damage: Sepsis, Septic Shock, Renal Complications, Reintubation.

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