Prevention, Not Rescue, Should Be Emphasized for Delayed Gastric Emptying After Pancreatic Surgery

Montorsi RM, Strijbos BTM, Stommel MWJ, et al. Preventing and Treating Delayed Gastric Emptying After Pancreatic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Ann Surg. December 2025.

This systematic review pooled 152 randomized trials published from 2007 to 2023 that encompassed 22,260 patients undergoing pancreatic operations. Using International Study Group of Pancreatic Surgery (ISGPS) criteria, the pooled rate of clinically relevant delayed gastric emptying (DGE, grade B/C) was 11.9%, higher after pancreatoduodenectomy than after left pancreatectomy (~12.7% versus 4.2%). No randomized trial demonstrated an effective treatment once DGE occurred. 

Twelve preventive strategies each showed benefit in at least one trial, spanning anastomotic/reconstruction choices (pancreaticojejunostomy, antecolic gastrojejunostomy, Billroth II, pylorus resection, and modified Roux-en-Y), operative approach (minimally invasive pancreatoduodenectomy or left pancreatectomy), and perioperative care (prehabilitation, ERAS modifications, nasojejunal feeding, early oral intake, and selective drains for left pancreatectomy). In pooled analyses, only minimally invasive left pancreatectomy consistently reduced grade B/C DGE compared with open surgery.

For HPB surgeons, emphasis should be on prevention rather than rescue. Incorporate DGE mitigation into the operative plan and pathway, preferentially using minimally invasive left pancreatectomy when feasible. Consider antecolic reconstruction and Billroth II during pancreatoduodenectomy where local expertise supports these techniques and standardized supportive measures such as prehabilitation and early feeding. 

Treat DGE as a driver of prolonged hospitalization and delayed recovery and recognize that no randomized therapy has proven effective once grade B/C DGE is established—which underscores a prevention-first approach and the need for trials targeting treatment of established DGE.