Management of a stenotic pancreatico-digestive tract anastomosis following pancreatoduodenectomy

Abstract

Early postoperative complications of pancreatico-digestive anastomosis following pancreatoduodenectomy are pancreatic fistula and pancreatitis affecting the pancreatic tail. Stenosis of the anastomosis is a later complication. Symptomatic and painful presentations are difficult to treat, and the optimal treatment is not currently defined. The aim of this work was to retrospectively report two cases of pancreaticogastrostomy stenosis. In both patients, the complication was diagnosed, with pancreatitis that developed following pancreatoduodenectomy. These patients were treated surgically, by fashioning a new anastomosis. Pancreaticogastrostomy has been viewed as a simpler and more secure reconstruction technique, with a lower occurrence rate of pancreatic fistula, than that of pancreaticojejunostomy. One complication of this surgery, however, is stenosis of the anastomosis. Following pancreatoduodenectomy, stenosis of the pancreaticogastrostomy may not occur until many years later. In a significant percentage of patients it is without clinical signs. It may be discovered after systematic explorations of patients following pancreaticogastrostomy or pancreaticojejunostomy. There is no study regarding the optimal treatment of postoperative stenosis of a pancreatico-gastric anastomosis. We believe that the optimal treatment is surgical. The intervention involves resection of the stenosis, and the formation of a new anastomosis.

The inconsistent nature of symptomatic pancreatico-jejunostomy anastomotic strictures

“…In each circumstance, the pancreatic tissue and duct was obscured by overgrowth of the gastric mucosa. Literature about rates of this complication after PG is lacking, however, there are papers describing both endoscopic 24 and surgical 22,25 solutions to this dilemma. Another series of 61 PGs indicates that stricture is a significant factor in the development of post-operative pancreatic exocrine insufficiency.…”

The Postoperative Pancreas Imaging

“…Strictures: These are the most common delayed complications of PD, and mostly occur at both the PJ or HJ anastomoses with incidence of 4.6% and 8.2%, respectively, at 5 years. 57,58 Patients of HJ strictures usually presents with jaundice and cholangitis, while PJ strictures commonly manifests with abdominal pain, diarrhea, steatorrhea, pancreatic insufficiency, and recurrent pancreatitis with pseudocysts on imaging 56 . Contrast enhanced-CT plays a vital role in diagnosing anastomotic strictures during postoperative follow-up (►Fig.…”

Endoscopic ultrasonography‐guided pancreatic duct access: Techniques and literature review of pancreatography, transmural drainage and rendezvous techniques

“…Apart from patients with normal anatomy, stenosis of the pancreaticoenterostomy after pancreaticoduodenectomy, which is observed in approximately 30%, 20 is the most complex late adverse event. 21 In addition to pancreaticoenterostomy stenosis, pancreatic fistula frequently accompanying stenotic pancreaticojejunal anastomosis is also observed in 10-20% of these patients. [22][23][24][25] Consequently, in 2-3% of such patients, acute recurrent pancreatitis, which requires further treatment, frequently occurs.…”

“…[22][23][24][25] Consequently, in 2-3% of such patients, acute recurrent pancreatitis, which requires further treatment, frequently occurs. 22,23 Additional surgical intervention 21 is one option and has also been carried out to treat these stenoses. However, in general, surgeons sometimes hesitate to carry out additional surgery due to the risk of possible postoperative re-stenosis, postoperative adhesions or the additional physical burden on the patients.…”