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Original Investigation
October 2018

Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy

Author Affiliations
  • 1Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Department of Surgery, State University of New York Upstate Medical University, Syracuse
  • 3Division of Surgical Research, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA Surg. 2018;153(10):918-927. doi:10.1001/jamasurg.2018.2089
Key Points

Question  Can assessment of intraoperative video identify modifiable technical factors that prevent postoperative delayed gastric emptying in addition to identifying patient variables that prevent postoperative delayed gastric emptying?

Findings  During video review of 192 robotic pancreaticoduodenectomies, the angle of the gastrojejunal anastomosis, gastrostomy size, and surgical device style of gastrojejunal anastomosis were technical variables that were associated with postoperative delayed gastric emptying.

Meaning  Video assessment of technical factors is a powerful, yet underused, tool to assess perioperative outcomes, particularly delayed gastric emptying; targeting specific technical factors during surgery can potentially improve postoperative outcomes.


Importance  Technical proficiency at robotic pancreaticoduodenectomy (RPD) and video assessment are promising tools for understanding postoperative outcomes. Delayed gastric emptying (DGE) remains a major driver of cost and morbidity after pancreaticoduodenectomy.

Objective  To determine if technical variables during RPD are associated with postoperative DGE.

Design, Setting, and Participants  A retrospective study was conducted of technical assessment performed in all available videos (n = 192) of consecutive RPDs performed at a single academic institution from October 3, 2008, through September 27, 2016.

Exposures  Video review of gastrojejunal anastomosis during RPD.

Main Outcomes and Measures  Delayed gastric emptying was classified according to International Study Group of Pancreatic Surgery criteria. Video analysis reviewed technical variables specific in the construction of the gastrojejunal anastomosis. Using multivariate analysis, DGE was correlated with known patient variables and technical variables, individually and combined.

Results  Of 410 RPDs performed, video was available for 192 RPDs (80 women and 112 men; mean [SD] age, 65.7 [11.1] years). Delayed gastric emptying occurred in 41 patients (21.4%; grade A, 15; grade B, 14; and grade C, 12). Patient variables contributing to DGE on multivariate analysis were advanced age (odds ratio [OR] 1.11; 95% CI, 1.05-1.16; P < .001), small pancreatic duct size (OR, 0.84; 95% CI, 0.72-0.98; P = .03), and postoperative pseudoaneurysm (OR, 17.29; 95% CI, 2.34-127.78; P = .005). However, technical variables contributing to decreased DGE on multivariate analysis included the flow angle (within 30° of vertical) between the stomach and efferent jejunal limb (OR, 0.25; 95% CI, 0.08-0.79; P = .02), greater length of the gastrojejunal anastomosis (OR, 0.40; 95% CI, 0.20-0.77; P = .006), and a robotic-sewn anastomosis (robotic suture vs stapler: OR, 0.30; 95% CI, 0.09-0.95; P = .04).

Conclusions and Relevance  This study examines modifiable technical factors through the use of review of video obtained at the time of operation and suggests ways by which the surgical construction of the gastrojejunal anastomosis during RPD may reduce the incidence of DGE as a framework for prospective quality improvement.

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