Delayed Gastric Emptying After Major Upper GI Surgery: From Diagnosis to Prokinetic Algorithms

Background and Aims: Delayed gastric emptying (DGE) remains a common, costly source of morbidity after major upper gastrointestinal (GI) surgery, particularly after pancreaticoduodenectomy (PD) and oesophagectomy, despite advances in technique and enhanced recovery pathways. Objective: To synthesise contemporary evidence on definitions, diagnosis, risk stratification, prevention and treatment of postoperative DGE and to present a pragmatic, evidence-aligned prokinetic algorithm. Methods: Targeted narrative review of PubMed/PMC, focusing on consensus definitions, randomized controlled trial (RCT)s, meta-analyses and high-quality observational studies in PD, distal pancreatectomy (DP), gastrectomy and oesophagectomy. Results: The International Study Group of Pancreatic Surgery (ISGPS) criteria underpin DGE grading after pancreatic surgery; a 2020 international consensus exists for early DGE after oesophagectomy. Incidence after PD varies (≈10%–30%), influenced by technical and patient factors; risk increases with older age, preoperative biliary drainage, soft pancreas, postoperative pancreatic fistula (POPF) and high opioid exposure. Reconstruction route may affect DGE (inconclusively), while pylorus preservation versus resection shows no consistent benefit in RCTs. Enhanced recovery after surgery (ERAS) adherence reduces DGE-related sequelae. Prokinetics with the strongest footing are metoclopramide and domperidone; 5-HT4 agonists and ghrelin agonists (e.g., relamorelin) show promise in trials but are not yet standard postoperative care. Conclusions: Accurate phenotyping and structured care, excluding obstruction, optimise ERAS elements, treat contributors (POPF, infection, opioids) and deploy short, monitored prokinetic courses, can shorten DGE. We propose a stepwise algorithm integrating these elements.