A comparative study between Roux-en-Y reconstruction with isolated biliary limb and single loop after pancreaticoduodenectomy: a solution for delayed gastric emptying

Background
Whipple’s operation is the primary treatment for periampullary and pancreatic tumors. The rates of morbidity and mortality have gone down to approach 50 and 1%, respectively. The incidence of delayed gastric emptying (DGE) is reported in 25–70% of patients, making it a significant morbidity. In this study, we described the use of an isolated biliary limb in Roux-en-Y hepaticojejunostomy (HJ) for biliary reconstruction and analyzed its effect on the incidence and severity of the DGE as a primary end point as well as postoperative morbidity and mortality and length of hospital stay as secondary end points.
Patients and methods
A before-and-after prospective study was conducted between January 2019 and December 2021 in the hepatopancreaticobiliary and liver transplantation unit of Air Force Specialized Hospital. We included 39 patients who underwent pancreaticoduodenectomy with resectable or borderline resectable preampullary tumors and were divided into two groups: group A included 17 patients who underwent standard pancreaticoduodenectomy, and group B included 22 patients with Roux-en-Y HJ with an isolated biliary limb.
Results
The overall incidence of DGE in the study group was 33% (13/39 patients). It was lower in group B and showed significant statistical values in all grades A, B, and C, with values of 0.015, 0.000, and 0.023, respectively. After the use of isolated biliary limb in group B, the incidence had decreased significantly to 13% (3/22 patients), with significant prolongation of the mean hospital stay by a mean of 6.34 days longer in group A (=0.016). The prolonged need for nasogastric tube was recorded in three (17.64%) of 17 cases in group A, two-thirds of which were grade A and one-third were grade B, with values of 0.022 and 0.041, respectively, when compared with only 4.55% of patients in group B. The mean time needed until the removal of the nasogastric tube was significantly lower in group B (2.1±0.43 vs. 3.9±1.65 days), with value of 0.037, with no incidence of reinsertion on both groups. When considering the solid oral intake tolerance, group B patients developed at a faster rate, with a mean of 3.33±2.88 days, whereas group A needed 8.46±2.81 days to reach tolerance (=0.055).
Conclusion
The technique of reconstruction with isolated biliary loop away from both HJ and gastrojejunostomy in pancreaticoduodenal resection markedly reduced the postoperative incidence and severity of DGE reflected in a lesser duration of hospital stay.