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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 51-54

Transgastric pancreaticogastrostomy: A novel technique for the management of pancreatico-enteric stenosis after pancreaticoduodenectomy


1 SIMS Institute of Gastroenterology, Hepatology and Transplantation, SIMS Hospital, Chennai, Tamil Nadu, India
2 Department of Imaging Sciences, SIMS Hospital, Chennai, Tamil Nadu, India

Date of Submission07-Dec-2021
Date of Decision03-Feb-2022
Date of Acceptance07-Feb-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Gautham Krishnamurthy
No. 1, Jawaharlal Nehru Salai, Vadapalani, Chennai . 26, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_46_21

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  Abstract 


Pancreatico-enteric stenosis (PES) is a long-term complication following pancreaticoduodenectomy (PD). The incidence of clinically relevant PES is likely to improve with better outcomes following PD for benign and neoplasms with favorable prognosis. Endoscopy and surgical techniques have been described addressing PES with revision of pancreatico-enteric anastomosis (PEA) being the most common performed surgery. Dense adhesions in the lesser sac especially after postoperative pancreatic fistula can be prohibitive to access the PEA. We describe a technique for postPD PES, transgastric pancreaticogastrostomy, that avoids lesser sac dissection and enables performing a wide anastomosis. Thus, it has the potential to reduce postoperative morbidity.

Keywords: Bilioenteric anastomotic stenosis, hepaticojejunostomy, Pancreaticoduodenectomy, pancreatico-enteric anastomotic stenosis, postoperative complications


How to cite this article:
Krishnamurthy G, Radhakrishna P, Vinish DB, Damodaran K. Transgastric pancreaticogastrostomy: A novel technique for the management of pancreatico-enteric stenosis after pancreaticoduodenectomy. Gastroenterol Hepatol Endosc Pract 2022;2:51-4

How to cite this URL:
Krishnamurthy G, Radhakrishna P, Vinish DB, Damodaran K. Transgastric pancreaticogastrostomy: A novel technique for the management of pancreatico-enteric stenosis after pancreaticoduodenectomy. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Aug 18];2:51-4. Available from: http://www.ghepjournal.com/text.asp?2022/2/2/51/340393




  Introduction Top


Pancreatico-enteric stenosis (PES) is a long-term complication following pancreaticoduodenectomy (PD).[1] The longer survival of patients with PD performed for chronic pancreatitis or neoplasms with favorable prognosis makes this complication common among these subgroups of patients.[2],[3] Despite availability of having numerous techniques, endoscopic and surgical, no standard management approach has been formulated yet.[3]


  Case Report Top


A 67-year-old male presented with upper abdominal pain and weight loss of 5 kilograms over 2 months. The patient had undergone classical PD with duct to mucosa pancreaticogastrostomy 15 months back. Preoperative suspicion was distal cholangiocarcinoma. Intraoperatively, pancreas was firm and pancreatic duct diameter was 4 mm. Postoperatively, he had pancreatic fistula (Grade B) and delayed gastric emptying (Grade C), which were managed conservatively. Histopathology showed benign biliary stricture with no specific etiology. During follow-up, he was diagnosed with diabetes mellitus and started on insulin at 8 months. There was no history of steatorrhea. Clinical examination was unremarkable. Imaging was suggestive of pancreaticogastrostomy stenosis. Endo-ultrasound (EUS) guided main pancreatic duct (MPD) drainage failed due to slippage of guidewire before stent placement. The pancreaticogastrostomy site could not be identified during endoscopy. After a month, pancreaticogastrostomy was done in the residual MPD using 5Fr straight plastic stent EUS guidance via transgastric route. Four months later, he presented again with abdominal pain. Magnetic resonance cholangiopancreatography showed pancreaticogastrostomy stenosis with diffuse dilatation of the MPD (12 mm) up to the gastric wall and dilated side branches [Figure 1]a. Multiple parenchymal calcifications were noted. Displaced stent was found to be within stomach with thickening noted at PES [Figure 1]b. In addition, moderate central and peripheral intrahepatic biliary radical dilatation with pneumobilia was noted up to hepaticojejunostomy (HJ) site [Figure 1]c. There was also evidence of evolving cholangitic abscess involving both lobes of the liver [Figure 1]a. Liver function tests showed elevated alkaline phosphatase and gamma-glutamyl transpeptidase. Review of previous cross-sectional imaging did not show biliary obstruction. The patient was offered surgery in view of failed endotherapy (twice) and to provide long-term results for PES and HJ stricture. We decided to approach the pancreatic duct via transgastric route. Anterior gastrotomy was made [Figure 2]a. The pancreaticogastrostomy site could not be identified. The posterior gastric wall was then palpated for the dilated pancreatic duct and the same was confirmed by needle aspiration [Figure 2]b and [Figure 2]c. Using the needle as a marker, posterior gastric wall and pancreatic duct opened in the same plane. Pancreaticogastrostomy was performed with intermittent 3-0 polyglactin [Figure 2]d and [Figure 2]e. Anterior gastrostomy was closed in a single layer. On exploring HJ, 10mm stone was found obstructing HJ [Figure 3]. Revision HJ was performed using 4-0 polyglactin single layer interrupted. The patient had an uneventful postoperative period and discharged on 7th postoperative day. Bile sent for culture did not show any growth. At 1 year of follow-up, the patient is doing fine with no pain, stable glycemic status, and weight gain of 3 kilograms.
Figure 1: Magnetic resonance cholangiopancreaticography. (a) T2– weighted axial section showing dilated main pancreatic measuring (MPD) 12 mm (solid red arrow) and dilated side branches upto the pancreaticogastrostomy site. Pancreatic parenchymal atrophy is also noted. (b) T2– weighted coronal section showing the thickening of the pancreaticogastrostomy site (solid yellow arrow). The section also shows T2 hyperintense lesion in segment 8 of the liver suggestive of cholangitic abscess (broken red arrow). (c) Magnetic resonance cholangiopancreatography image showing dilated intrahepatic biliary radicals and common hepatic duct upto hepaticojejunostomy (broken red arrow). The image also shows dilated MPD with side duct dilation. There is no stricture elsewhere in the pancreatic duct

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Figure 2: Transgastric pancreatico-gastrostomy (Intraoperative images). (a) Site of anterior gastrotomy held with stay sutures. (b) After anterior gastrotomy, the posterior gastric wall exposed with help of retractors and palpated for the main pancreatic duct. (c) Localisation of the main pancreatic duct confirmed by needle aspiration. (d) Pancreatico-gastrostomy performed using 3-0 polyglactin interrupted. Displaced stent with in the stomach noted. (e) Completed pancreatico-gastrostomy anastomosis

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Figure 3: (a) Calculus of size 10 mm found obstructing the hepaticojejunostomy. (b) Revision hepaticojejunostomy done

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  Discussion Top


Pancreatico-enteric anastomotic stricture (PES) is one of the long-term complications following pancreaticoduodenectomy.[1] Clinically relevant stenosis is lower, with nearly 77%–100% of radiologically diagnosed PES being asymptomatic.[1] Moreover, only 2%–11.4% require intervention.[2],[4],[5] The common presenting symptoms include pain and recurrent episodes of acute pancreatitis.[1],[4] Risk factors of PES include postoperative pancreatic fistula after index surgery and chronic pancreatitis being the etiology for primary surgery.[1] Although small duct diameter at primary surgery has been proposed as a risk factor for developing PES, it has not been proven unequivocally.

Magnetic resonance cholangiopancreatography with or without secretin enhancement is the investigation of the choice.[1],[3] Apart from good delineation of the PES evidenced by narrowing of PD at the anastomosis and upstream dilatation, features of new onset or progression of chronic pancreatitis can also be identified.

Endoscopic or surgical intervention is contemplated for persistent pain or recurrent acute pancreatitis.[2],[3],[6] In view of a paucity of evidence, intervention at present is not recommended for pancreatic insufficiency.[1] Endotherapy is the preferred choice and can be either endoscopic retrograde cholangiopancreatography (ERCP) guided or EUS guided. Using the ERCP, it might be possible to directly cannulate PEA or by rendezvous technique using EUS.[3] EUS-guided cannulation and transgastric drainage of MPD can also be performed. While the primary failure of endotherapy to drain the MPD is usually for technical reasons (inaccessible PES, failure of progression through intestinal loop), secondary failure results from stent dislodgement and stent blockage.[1] Kikuyuma et al. had reported that 6 out of 14 PES patients could not have their PEA identified during the first endoscopic intervention.[7] Similarly, we could not identify the pancreaticogastrostomy site during endoscopy and surgery. The overall success rate of endotherapy is 75% with pain relief achieved in only 37.5% of patients.[3]

The most common surgical technique involves revision of PEA.[1],[2],[5] Extended drainage of MPD can be performed using the same jejunal limb or a different segment of intestine to fashion lateral pancreaticojejunostomy.[2] In contrast to PEA performed during PD, complications following revision surgery for PES are lower.[1] This is likely resultant of hard pancreas and dilated duct.[1] The overall long-term success rate ranges from 26% to 100%.[3]

Dense adhesions in the lesser sac requiring abandoning of the proposed procedure, using ERCP guidance or changing to lateral PEA, are known.[2],[3] These adhesions are most likely the major cause of postoperative morbidity. After anterior gastrostomy, nonidentification of the pancreaticogastrostomy site precluded revision of PEA. Hence, we decided to approach pancreas through transgastric route. Given the imaging showing gross dilatation of the MPD, we felt that MPD should be palpable via posterior gastric wall.

Addition of lateral drainage of MPD with stomach without dismantling the pancreato-enteric anastomosis has also been described.[3] However, exposure of PD has been performed by accessing through lesser sac. In our technique, pancreas is approached through the posterior wall of stomach via anterior gastrotomy.

Advantages of our technique include avoidance of dense adhesion near PEA, especially after pancreatic fistula following index surgery. The size of PEA is not limited by the MPD diameter as in the case of revision duct to mucosa PEA. In case of lateral PEA being planned for better drainage, Roux-en-Y configuration might be required. This leads to increasing number of anastomosis and operative time. Moreover, Roux-en-Y configuration could reduce the effective bowel available for digestion since length of jejunum could have been used during index surgery for reconstruction. When stomach is used, the above problem is mitigated, and extended drainage can also be performed. Our technique also facilitates future endoscopic screening of MPD.[3]

When revision of PES is not possible, the options for performing pancreatico-enteric anastomosis (PEA) includes jejunum and stomach. PEA performed for chronic pancreatitis usually involves jejunum. Factors such as long segment of intestine available to bypass the entire duct when multiple strictures are present could have made jejunum the preferred choice. In general, in PES, after PD, the obstruction of MPD is likely to be at PEA site, rather than at multiple sites. Thus, a single-point drainage of dilated MPD is sufficient, rather than performing drainage along the entire length of MPD. In case of pancreatic pseudocyst or reconstruction following PD, there is no difference in the long-term outcome between stomach or jejunum being used for anastomosis.[8],[9] Similarly, various endoscopic techniques described for PES, stomach, and jejunum have been used with no definite difference in the outcome being reported.[1],[3] Given these factors, we felt that the pancreaticogastrostomy could provide equivalent outcomes with respect to pancreaticojejunostomy.

The technique has prerequisites which include sufficient remnant stomach to overly the pancreas. Distended MPD permitting transgastric palpation and appropriate lie of the posterior gastric incision with pancreatic duct is essential to perform a long lateral pancreaticogastrostomy. In our case, pancreaticogastrostomy was performed during the index surgery. Performing our technique in patients having pancreaticojejunostomy during index surgery might still be feasible since the lie of the stomach and pancreas are likely to be similar. Use of intraoperative ultrasound could facilitate identification of MPD in case MPD is not palpable through the posterior gastric wall and PG site is not identifiable.


  Conclusion Top


We describe a technique for postPD PES, transgastric pancreaticogastrostomy, that avoids lesser sac dissection and enables performing a wide anastomosis. Thus, it has the potential to reduce postoperative morbidity and improve long-term outcomes.

Clinical significance

Pancreatico-enteric anastomotic stenosis is a long-term complication in patients undergoing PD for benign or low-grade malignant disease. After failure of endotherapy, surgery remains the only viable option. Transgastric pancreaticogastrostomy avoids lesser sac dissection and has the potential to reduce the postoperative morbidity in comparison the conventional techniques described.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vanbrugghe C, Campanile M, Caamaño A, Pol B. Management of delayed stenosis of pancreatico-enteric anastomosis following pancreatoduodenectomy. J Visc Surg 2019;156:30-6.  Back to cited text no. 1
    
2.
Demirjian AN, Kent TS, Callery MP, Vollmer CM. The inconsistent nature of symptomatic pancreatico-jejunostomy anastomotic strictures. HPB (Oxford) 2010;12:482-7.  Back to cited text no. 2
    
3.
Zarzavadjian Le Bian A, Cesaretti M, Tabchouri N, Wind P, Fuks D. Late pancreatic anastomosis stricture following pancreaticoduodenectomy: A systematic review. J Gastrointest Surg 2018;22:2021-8.  Back to cited text no. 3
    
4.
Reid-Lombardo KM, Ramos-De la Medina A, Thomsen K, Harmsen WS, Farnell MB. Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases. J Gastrointest Surg 2007;11:1704-11.  Back to cited text no. 4
    
5.
Morgan KA, Fontenot BB, Harvey NR, Adams DB. Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: Is it futile? HPB (Oxford) 2010;12:211-6.  Back to cited text no. 5
    
6.
Wagle P, Yadav KS, Sali PA, Garg R, Varty P. Is revision surgery justified for symptomatic pancreatico-enteric anastomotic stenosis in long-term survivors following pancreaticoduodenectomy for malignancy? J Gastrointest Surg 2017;21:339-43.  Back to cited text no. 6
    
7.
Kikuyama M, Itoi T, Ota Y, Matsumura K, Tsuchiya T, Itokawa F, et al. Therapeutic endoscopy for stenotic pancreatodigestive tract anastomosis after pancreatoduodenectomy (with videos). Gastrointest Endosc 2011;73:376-82.  Back to cited text no. 7
    
8.
Keck T, Wellner UF, Bahra M, Klein F, Sick O, Niedergethmann M, et al. Pancreatogastrostomy versus pancreatojejunostomy for RECOnstruction after PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and long-term results of a multicenter randomized controlled trial. Ann Surg 2016;263:440-9.  Back to cited text no. 8
    
9.
Ye J, Wang L, Lu S, Yang D, Hu W, Lu H, et al. Clinical study on cystogastrostomy and Roux-en-Y-type cystojejunostomy in the treatment of pancreatic pseudocyst: A single-center experience. Medicine (Baltimore) 2021;100:e25029.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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