Abstract
Introduction
The natural history of radiographic strictures of the pancreaticojejunostomy (PJ) after pancreatoduodenectomy (PD) is difficult to characterize. The purpose of this study was to identify the indications for operative revision of PJ strictures after PD for benign and malignant disease and to evaluate its safety and clinical efficacy.
Methods
A retrospective review of all patients undergoing operative revision of PJ strictures following PD at a single academic institution over an 8-year period (2006–2014) was performed.
Results
Twenty-seven patients underwent revision of a symptomatic radiographically detectable PJ stricture. The median time from PD to PJ stricture diagnosis was 46 months. The median increase in the main pancreatic duct diameter between the time of PD and PJ revision was 2 mm. The overall morbidity after PJ revision was 26 %. No postoperative mortality occurred. Twenty-one (78 %) patients experienced resolution of symptoms without recurrent acute pancreatitis after PJ revision during a median follow-up of 30 months. Durable symptom resolution was reported among 60 % of patients with chronic pancreatitis.
Conclusions
Surgical revision of pancreaticojejunostomy strictures is technically safe and clinically effective for selected patients who experience recurrent acute pancreatitis after pancreatoduodenectomy for either benign or malignant disease.
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Primary Discussant
Mark S. Talamonti, M.D. (Evanston, IL)
I would like to thank the program committee for the opportunity to review and discuss this important presentation and manuscript, and I would like to congratulate Dr. Cioffi and her co-authors on an important and significant contribution. The incidence of pancreaticojejunostomy stricture after a Whipple procedure is not well described in reports of short-term or long-term outcomes after surgical resection of the head of the pancreas. The indications for revision of the anastomosis are similarly poorly defined, and a critical assessment of the morbidity and quality of life after an obviously formidable undertaking are not available in the literature. So all of that makes this an important contribution to the surgical literature. Even more significant is the fact that some institutions now report that over 30–50 % of resections are being done for benign disease, and as the authors point out, the majority of patients in this series had benign indications for surgery, i.e., IPMN or head dominant chronic pancreatitis.
The incidence of a symptomatic stricture requiring surgical revision was rare, 2 %, and the index indication for the first procedure was benign disease in 75 % of patients; with IPMN (32 %) and chronic pancreatitis (19 %) being the two most frequent benign indications. Importantly, the authors only undertook revision of a strictured anastomosis with radiographic evidence of upstream main duct dilation if the patients had symptomatic recurring acute pancreatitis or persistent abdominal pain with no other identifiable cause. This then allows for a rather straightforward assessment of the safety and the efficacy of the revision procedure: could such an operation be undertaken with acceptable morbidity and low mortality and did their pancreatitis and abdominal pain get better? The postoperative complication rate was an acceptable 26 %, the average LOS was 6 days, and there were no deaths in their patients, proving the safety of the procedure; but I would emphasize that these outcomes were achieved by experienced surgeons at a high-volume center, and in your subsequent manuscript, I think you need to better emphasize that this is not a procedure for low-volume surgeons at a low-volume institution. In terms of efficacy, the revision was successful in relieving the patients’ complaints for pain in 80 % of all patients and in 60 % of those with a diagnosis of chronic pancreatitis. What the procedure did not do was cure pancreatic exocrine insufficiency or diabetes which developed after the first Whipple procedure. So you have shown that PJ revision can be done safely when performed by experienced surgeons but that the indications for this operation really need to be restricted to patients with acute recurring pancreatitis whose pain can perhaps best be addressed by surgical intervention. Patients with asymptomatic main duct dilation found incidentally on routine postoperative surveillance imaging are probably best off left alone, which leads me to the first of my three questions for the authors:
1.) The mean time interval between the Whipple procedure and the revision was 46 months, but do you know the time to diagnosis of a dilated main duct to the onset of symptoms? Many of us follow our patients, particularly with IPMN, with periodic MRI or CT scans and the finding of a progressively dilating main duct is not uncommon but it would be interesting to know how many of your patients were followed for an asymptomatic radiographic finding of main duct dilation and then over what time period went on to develop pancreatitis or pain indicating the need for surgical intervention?
2.) In the manuscript, over a third of your patients required a concomitant revision of the hepaticojejunostomy and/or GI anastomosis. I was really surprised to see that number and wonder if we are missing some other risk factor for a PJ stricture. Was there some associated vascular misadventure in the first procedure, or perhaps those patients underwent more aggressive lymphadenectomies or are you missing some primary systemic risk factor such as an extreme smoking history or history of connective tissue diseases?
3.) Finally, I would like more information about your patients with IPMN and how you choose between a revision of the PJ versus completion pancreatectomy in a patient who has undergone a Whipple procedure for main duct disease and who now has abdominal pain, a dilated main duct on MRI but no diabetes? You excluded those patients who underwent completion pancreatectomy in your manuscript and your presentation but we need to understand which patients with IPMN could be candidates for an islet cell sparing procedure such as PJ revision or should we be doing completion pancreatectomies on all of those patients, knowingly rendering them permanently diabetic. Please offer us some guidance on these patients based on your recent review of your database.
Closing Discussant
Dr. Cioffi
Thank you, Dr. Talamonti for reviewing our manuscript. I would agree that our morbidity rate of 26 % and mortality rate of 0 % were acceptable and demonstrate that revision of PJ anastomosis is safe in the hands of an experienced HPB surgeon at a high-volume center.
1.) In response to your first question, the mean time interval between the Whipple procedure and the diagnosis of the PJ stricture in a symptomatic patient was 46 months. These strictures were diagnosed radiographically in patients with a clinical history of acute pancreatitis. The time to revision of the stricture was slightly longer than 46 months, allowing for adequate preoperative preparation. Only 1 of our patients whose indication for the index operation was IPMN was diagnosed with an asymptomatic finding of a dilated main pancreatic duct on imaging who then went on to develop symptoms of acute pancreatitis. The time interval between main duct dilation and symptoms for this patient was 20 months, and his PJ stricture was revised a short time later.
2.) A third of our patients required a concomitant revision of the biliary enteric or duodenal/gastric anastomosis at the time of PJ revision. When comparing these patients to those who did not require such anastomotic revision, there were no differences between the two groups. Specifically, there was no vascular misadventure reported in the index operation, all lymphadenectomies were similar and there was no difference in primary systemic risk factors between the groups, e.g., vascular disease or autoimmune disease.
Patients with IPMN who underwent revision of PJ anastomosis as opposed to completion pancreatectomy were selected based upon preoperative imaging studies. All of these patients underwent biannual or annual imaging with MRCP as well as intermittent endoscopic ultrasound surveillance of the remnant gland. If there were any areas of concern for IPMN in the remnant gland in the setting of a dilated main pancreatic duct, these patients were selected to undergo completion pancreatectomy. The patients who underwent revision of PJ stricture did not have any cystic lesions on the remnant pancreas nor any concern for recurrence of IPMN; thus, we felt it was safe to proceed with an islet cell sparing procedure.
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Cioffi, J.L., McDuffie, L.A., Roch, A.M. et al. Pancreaticojejunostomy Stricture After Pancreatoduodenectomy: Outcomes After Operative Revision. J Gastrointest Surg 20, 293–299 (2016). https://doi.org/10.1007/s11605-015-3012-z
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DOI: https://doi.org/10.1007/s11605-015-3012-z