Impact of posterior wall gastrojejunostomy versus anterior wall gastrojejunostomy in pancreaticoduodenectomy on delayed gastric emptying and enhanced recovery: a prospective study

Background
Pancreaticoduodenectomy (Whipple operation) is considered the main surgical management for duodenal, pancreatic head, and lower end common bile duct neoplasm. Gastrojejunostomy orientation has a direct impact on enteral feeding and delayed gastric emptying (DGE).
Aim
The primary outcomes were reviewing the effect of changing the orientation of gastrojejunostomy either anterior wall vertical gastrojejunostomy versus posterior wall vertical gastrojejunostomy on DGE, early enteral feeding, leakage, and overall enhanced recovery with early start of chemotherapy.
Patients and methods
A prospective randomized trial 55 patients total number of patients after substraction of lost follow up was 50 patients and were divided into two group; group A: 27 patients underwent posterior wall gastrojejunostomy and group B: 23 patients underwent anterior wall gastrojejunostomy both techniques done in antecolic vertical manner.
Results
Operative time, postoperative bleeding, and leakage was not significantly different between the two groups. The total incidence of DGE was significantly lower in group A (posterior wall vertical) than group B (anterior wall vertical), regarding grades of DGE grade a was significantly lower in group A while the incidence in grades B and C was not significantly different regarding the number of patients. Ryle removal and starting oral intake was earlier and statistically significant in posterior wall vertical gastrojejunostomy when compared to anterior wall vertical gastrojejunostomy. Readmission, the actual use of prokinetics and need for nutritional support was higher in group B (anterior wall vertical gastrojejunostomy) than group A (posterior wall vertical gastrojejunostomy) but was not statistically significant.
Conclusions
Posterior wall vertical gastrojejunostomy has a better overall significant better outcome regarding early enteral feeding and DGE over anterior wall vertical gastrojejunostomy group also has better enhanced recovery and earlier time of starting chemotherapy. This topic should be evaluated in depth in a large-volume studies.