In our RCT comparing the antecolic route with the retrocolic route for duodenojejunostomy after PpPD, DGE occurred Dasatinib
in 5% of patients treated using the antecolic route, compared with 50% of those treated using the retrocolic route (P = 0.0014) . An interim analysis using Bonferroni's method and involving 20 patients per arm was planned, although the adequate sample size for this RCT was calculated to be a total of 116 patients (58 per arm). This interim analysis clearly indicated a significant benefit of the antecolic route over the retrocolic route with regard to the incidence of DGE, resulting in a decision to terminate the RCT, based on statistical and ethical factors. The antecolic route for duodenojejunostomy during PpPD significantly reduced the incidence of DGE. The antecolic route for duodenojejunostomy during PpPD may be superior to the retrocolic route with regard to the incidence of DGE for several reasons. For example, the antecolic route may reduce the incidence of DGE by changing the anastomosis position, such as by causing transient torsion or angulation of the anastomosis, by setting the stomach vertically in the left Dasatinib
abdomen . Several studies have suggested that gastric dysrhythmia secondary to other abdominal complications, such as a pancreatic fistula or intra-abdominal abscess, increased the incidence of DGE [11, 12, [41-43]]. The use of the antecolic route for an anastomosis may avoid clinical inflammation associated with pancreatic fistula or intra-abdominal abscess better than the retrocolic route. On the other hand, Chijiiwa et al.  reported that DGE occurred in 6% of patients operated on using the antecolic route, compared with 22% of those operated on using the vertical Afatinib nmr
retrocolic route (P = 0.34); the difference between the antecolic route and the vertical retrocolic route concerning the incidence of DGE was not significant. For the vertical retrocolic route, the left side of the transverse mesocolon (left side of the middle colic vessels) was opened, and the duodenum was brought down together with the gastric antrum in a straight, vertical manner. As a result of the above findings, Chijiiwa et al. therefore suggested that the two routes after PpPD were similar concerning DGE. Kim et al.  suggested that DGE may be caused by pylorospasms secondary to inadvertent surgical injuries to the branches of the vagus nerve innervating the pyloric region. Two reports describe surgical techniques to manage pylorospasms due to denervation after PpPD, including mechanical dilatation of the pyloric ring and pyloromyotomy [38, 39]. One of these studies suggested that the addition of pyloric dilatation to the PpPD procedure reduced the incidence of DGE from 26 to 6.5% (P < 0.05) compared with conventional PpPD .