Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases

Effectiveness of direct needle puncture for complete hepaticojejunostomy anastomotic stricture after pancreaticoduodenectomy (with video)

A 79-year-old Japanese woman, who had undergone pancreaticoduodenectomy 6 months prior to presentation owing to pancreatic cancer, complained of jaundice with high fever. Computed tomography revealed proximal bile duct dilatation with complete hepaticojejunostomy anastomotic stricture (HJAS). We performed a single-balloon endoscopy for biliary drainage. The presence of a scar-like feature surrounding the anastomosis was identified as the HJAS. White-light imaging during single-balloon endoscopy revealed that the HJAS contained a milky whitish area (MWA), suggesting that a membranous and fibrosis layer affected continuous inflammation around the center of the anastomosis (within a scar-like feature). Endoscopic dilatation was performed using an endoscopic injection needle, with the MWA used as an indicator. A 23-gauge endoscopic injection needle was used to penetrate the center of the blind lumen within the MWA, and a pinhole was created in the stricture. After confirming the position of the proximal bile duct using a contrast medium with the needle, an endoscopic guidewire with a cannula was inserted into the pinhole. A through-the-scope sequential balloon dilator was used to dilate the stricture, and a plastic stent was inserted into the proximal bile duct. This endoscopic intervention led to positive outcomes. In cases of complete HJAS occlusion, an endoscopic approach to the bile duct is difficult because the anastomotic opening of the HJAS is not visible. Thus, puncturing within the MWA, which can be used as a scar-like landmark within a complete membranous HJAS, is considered a useful endoscopic strategy.

Needle Knife Stricturoplasty for Hepaticojejunostomy Stricture After Whipple Procedure

Hepaticojejunostomy anastomotic stricture is a relatively uncommon postoperative complication after a Whipple procedure. However, they are increasingly being observed because of advancements in operative mortality rates and the widening of operative indications to include benign diseases such as chronic pancreatitis and intraductal papillary mucinous neoplasm. In this article, we describe a patient diagnosed with intraductal papillary mucinous neoplasm and another with pancreatic cancer, both of whom developed jaundice after undergoing the Whipple procedure. Subsequent investigation revealed a benign hepaticojejunostomy anastomotic stricture, successfully treated with stricturoplasty using a needle knife.

Long-Term Oncologic Outcome following Duodenum-Preserving Pancreatic Head Resection for Benign Tumors, Cystic Neoplasms, and Neuroendocrine Tumors: Systematic Review and Meta-analysis

BACKGROUND

Pancreatoduodenectomy (PD) has a considerable surgical risk for complications and late metabolic morbidity. Parenchyma-sparing resection of benign tumors has the potential to cure patients associated with reduced procedure-related short- and long-term complications.

MATERIALS AND METHODS

Pubmed, Embase, and Cochrane libraries were searched for studies reporting surgery-related complications following PD and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. A total of 38 cohort studies that included data from 1262 patients were analyzed. In total, 729 patients underwent DPPHR and 533 PD.

RESULTS

Concordance between preoperative diagnosis of benign tumors and final histopathology was 90.57% for DPPHR. Cystic and neuroendocrine neoplasms (PNETs) and periampullary tumors (PATs) were observed in 497, 89, and 31 patients, respectively. In total, 34 of 161 (21.1%) patients with intraepithelial papillar mucinous neoplasm exhibited severe dysplasia in the final histopathology. The meta-analysis, when comparing DPPHRt and PD, revealed in-hospital mortality of 1/362 (0.26%) and 8/547 (1.46%) patients, respectively [OR 0.48 (95% CI 0.15-1.58); p = 0.21], and frequency of reoperation of 3.26 % and 6.75%, respectively [OR 0.52 (95% CI 0.28-0.96); p = 0.04]. After a follow-up of 45.8 ± 26.6 months, 14/340 patients with intraductal papillary mucinous neoplasms/mucinous cystic neoplasms (IPMN/MCN, 4.11%) and 2/89 patients with PNET (2.24%) exhibited tumor recurrence. Local recurrence at the resection margin and reoccurrence of tumor growth in the remnant pancreas was comparable after DPPHR or PD [OR 0.94 (95% CI 0.178-5.34); p = 0.96].

CONCLUSIONS

DPPHR for benign, premalignant neoplasms provides a cure for patients with low risk of tumor recurrence and significantly fewer early surgery-related complications compared with PD. DPPHR has the potential to replace PD for benign, premalignant cystic and neuroendocrine neoplasms.

[Premalignant cystic neoplasms and neuroendocrine tumors of the pancreatic head-Is the Kausch-Whipple resection an adequate treatment?]

Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is a multiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure a new onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, a mortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.

Treatment of delayed pancreatic fistula associated with anastomosis breakdown after pancreaticoduodenectomy using percutaneous interventions

We here present a rare case of development of a postoperative pancreatic fistula and breakdown of the pancreaticojejunal anastomosis 8 months after pancreaticoduodenectomy. A 70-year-old man underwent pancreaticoduodenectomy for distal cholangiocarcinoma and initially recovered well. However, 8 months later, he developed abdominal pain and distention and was admitted to our institution with suspected pancreatitis. On the 17th day of hospitalization, he suddenly bled from the jejunal loop and a fluid collection was detected near the pancreaticojejunal anastomosis site. The fluid collection was drained percutaneously. Subsequent fistulography confirmed breakdown of the pancreaticojejunal anastomosis. Considering the patient's overall condition and the presence of postoperative adhesions, we decided to manage him conservatively. An additional drain tube was placed percutaneously from the site of the anastomotic breakdown into the lumen of the jejunum, along with the tube draining the fluid collection, creating a completely new fistula. This facilitated the flow of pancreatic fluid into the jejunum and was removed 192 days after placement. During a 6-month follow-up, there were no recurrences of pancreatitis or a pancreatic fistula. This case highlights the efficacy of percutaneous drainage and creation of an internal fistula as a management strategy for delayed pancreatic fistula and anastomotic breakdown following pancreaticoduodenectomy.

Impact of preoperative self-expandable metal stent on benign hepaticojejunostomy anastomotic stricture after pancreaticoduodenectomy

Objectives

Hepaticojejunostomy anastomotic stricture (HJAS) is a serious adverse event of pancreaticoduodenectomy. Preoperative biliary drainage with a self-expandable metal stent (SEMS) is often performed before pancreaticoduodenectomy. The purpose of this study is to evaluate the risk factors and impact of preoperative SEMS placement on developing benign HJAS after pancreaticoduodenectomy.

Methods

We retrospectively analyzed consecutive patients who underwent pancreatoduodenectomy at our institution between July 2014 and June 2020. Risk factors for benign HJAS were identified using univariate and multivariate logistic regression analysis. We also compared outcomes of preoperative biliary drainage using SEMS and non-SEMS.

Results

Of the 626 included patients, benign HJAS occurred in 36 patients (5.8%). The median follow-up time was 36.7 months (interquartile range, 25.4-57.4 months). Multivariate logistic regression analysis revealed that lack of preoperative biliary drainage, preoperative bile duct diameter <5 mm, and former or current smoking were independent predictors of benign HJAS. In the preoperative biliary drainage group, the rate of preoperative bile duct diameter <5 mm was significantly lower in the SEMS group than in the non-SEMS group (2.0% vs. 12.8%, p = 0.04).

Conclusions

Preoperative biliary drainage with SEMS may be useful to maintain bile duct diameter ≥5 mm and to reduce benign HJAS as a result.

Risk factors for recurrent stenosis after balloon dilation for benign hepaticojejunostomy anastomotic stricture

BACKGROUND/AIMS

Hepaticojejunostomy anastomotic stricture (HJAS) is a feared adverse event associated with hepatopancreatobiliary surgery. Although balloon dilation for benign HJAS during endoscopic retrograde cholangiopancreatography with balloon-assisted enteroscopy has been reported to be useful, the treatment strategy remains controversial. Therefore, we evaluated the outcomes and risk factors of recurrent stenosis after balloon dilation alone for benign HJAS.

METHODS

We retrospectively analyzed consecutive patients who underwent balloon-assisted enteroscopy-endoscopic retrograde cholangiopancreatography for benign HJAS at our institution between July 2014 and December 2020.

RESULTS

Forty-six patients were included, 16 of whom had recurrent HJAS after balloon dilation. The patency rates at 1 and 2 years after balloon dilation were 76.8% and 64.2%, respectively. Presence of a residual balloon notch during balloon dilation was an independent predictor of recurrence (hazard ratio, 2.80; 95% confidence interval, 1.01-7.78; p=0.048), whereas HJAS within postoperative 1 year tended to be associated with recurrence (hazard ratio, 2.43; 95% confidence interval, 0.85-6.89; p=0.096). The patency rates in patients without a residual balloon notch were 82.1% and 73.1% after 1 and 2 years, respectively.

CONCLUSION

Balloon dilation alone may be a viable option for patients with benign HJAS without residual balloon notches on fluoroscopy.

Clinical utility of the forward-viewing echoendoscope in patients after pancreatoduodenectomy: A prospective study

Background and Objectives

Endoscopic treatment of obstructive jaundice and pancreatitis due to hepaticojejunostomy (H-J), pancreatojejunostomy (P-J) strictures, and tumor recurrence after pancreatoduodenectomy (PD) is technically challenging. Treatment of P-J strictures results in poor outcomes. Although conventional EUS that has an oblique view is not suitable for such patients, forward-viewing EUS (FV-EUS) may become a useful option. This study aimed to evaluate the feasibility and efficacy of FV-EUS in patients who have undergone PD.

Methods

Patients with PD who were scheduled to undergo diagnosis and treatment using FV-EUS for H-J or P-J lesions were enrolled in this single-center prospective study. After observation of the P-J and H-J using FV-EUS according to a predetermined protocol, treatment using FV-EUS was performed as needed.

Results

A total of 30 patients were enrolled, and FV-EUS was used to observe P-J and H-J in 24 and 28 patients, respectively. The detection rates of P-J and H-J by endoscopy were 50% (12/24) and 96.4% (27/28), respectively, and by EUS were 70.8% (17/24) and 100% (28/28), respectively. Of these, P-J and H-J were found by endoscopy only after EUS observation in 3 and 1 patient, respectively. The success rates of endoscopic treatment using FV-EUS were 66.7% (2/3), 95.2% (20/21), and 25% (1/4) for benign P-J strictures, benign H-J strictures, and tumor recurrence, respectively.

Conclusions

Endoscopic treatment using FV-EUS is feasible and effective for patients after PD. Moreover, FV-EUS increases the P-J lesion detection rate by adding EUS observation.

Study protocol for a prospective, multicentre, phase II trial on endoscopic treatment using two fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy

INTRODUCTION

The current endoscopic treatment for postoperative benign hepaticojejunostomy anastomotic stricture (HJAS) has a high technical success rate and is highly effective in the short term. However, long-term results have shown a high rate of stenosis recurrence, which indicates an insufficient response to treatment. Three prospective studies on fully covered self-expandable metallic stent (FC-SEMS) treatment for benign HJAS used the stenosis resolution rate as the primary endpoint, and no study has yet used the long-term non-stenosis rate (at 12 months) as the primary endpoint.

METHODS AND ANALYSIS

We launched the 'saddle-cross study', which will be conducted as a multicentre, prospective intervention of endoscopic treatment using two modified FC-SEMSs (BONASTENT️ M-Intraductal) that have been improved for benign stenosis in patients with benign HJAS, with the long-term non-restenosis rate (at 12 months) as the primary endpoint. This study aims to evaluate the long-term non-restenosis rate (at 12 months) and safety of the saddle-cross technique for benign HJAS. We plan to enrol 50 participants.

ETHICS AND DISSEMINATION

This study has been approved by the Certified Review Board of the National Cancer Center, Japan (CRB3180009). The results will be reported at various conferences and published in international peer-reviewed journals.

Duodenum-Preserving Pancreatic Head Resection for Benign and Premalignant Tumors-a Systematic Review and Meta-analysis of Surgery-Associated Morbidity

BACKGROUND

Pancreatic benign, cystic, and neuroendocrine neoplasms are increasingly detected and recommended for surgical treatment. In multiorgan resection pancreatoduodenectomy or parenchyma-sparing, local extirpation is a challenge for decision-making regarding surgery-related early and late postoperative morbidity.

METHODS

PubMed, Embase, and Cochrane Libraries were searched for studies reporting early surgery-related complications following pancreatoduodenectomy (PD) and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. Thirty-four cohort studies comprising data from 1099 patients were analyzed. In total, 654 patients underwent DPPHR and 445 patients PD for benign tumors. This review and meta-analysis does not need ethical approval.

RESULTS

Comparing DPPHRt and PD, the need for blood transfusion (OR 0.20, 95% CI 0.10-0.41, p<0.01), re-intervention for serious surgery-related complications (OR 0.48, 95% CI 0.31-0.73, p<0.001), and re-operation for severe complications (OR 0.50, 95% CI 0.26-0.95, p=0.04) were significantly less frequent following DPPHRt. Pancreatic fistula B+C (19.0 to 15.3%, p=0.99) and biliary fistula (6.3 to 4.3%; p=0.33) were in the same range following PD and DPPHRt. In-hospital mortality after DPPHRt was one of 350 patients (0.28%) and after PD eight of 445 patients (1.79%) (OR 0.32, 95% CI 0.10-1.09, p=0.07). Following DPPHRp, there was no mortality among the 192 patients.

CONCLUSION

DPPHR for benign pancreatic tumors is associated with significantly fewer surgery-related, serious, and severe postoperative complications and lower in-hospital mortality compared to PD. Tailored use of DPPHRt or DPPHRp contributes to a reduction of surgery-related complications. DPPHR has the potential to replace PD for benign tumors and premalignant cystic and neuroendocrine neoplasms of the pancreatic head.

Clinical outcome of endoscopic treatment of symptomatic Hepaticojejunal anastomotic strictures after pancreatoduodenectomy

BACKGROUND

Hepaticojejunostomy anastomotic stricture (HJAS) is an adverse event after pancreatoduodenectomy (PD) which can result in jaundice and/or cholangitis. With endoscopy, HJAS can be managed. However, few studies report the specific success and adverse event rates of endoscopic therapy after PD.

METHODS

Patients with symptomatic HJAS, who underwent an endoscopic retrograde cholangiopancreatography at the Erasmus MC between 2004-2020, were retrospectively included. Primary outcomes were short-term clinical success defined as no need for re-intervention <3 months and long-term <12 months. Secondary outcome measures were cannulation success and adverse events. Recurrence was defined as symptoms with radiological/endoscopic confirmation.

RESULTS

A total of 62 patients were included. The hepaticojejunostomy was reached in 49/62 (79%) of the patients, subsequently cannulated in 42/49 (86%) and in 35/42 patients (83%) an intervention was performed. Recurrence of symptomatic HJAS after technically successful intervention occurred in 20 (57%) patients after median time to recurrence of 7.5 months [95%CI, 7.2-NA]. Adverse events were reported in 4% of the procedures (8% of patients), mostly concerning cholangitis.

DISCUSSION

Endoscopic treatment for symptomatic HJAS after PD has a moderate technical success rate and a high recurrence rate. Future studies should optimize endoscopic treatment protocols and compare percutaneous versus endoscopic treatment.

Antegrade stenting for pancreaticojejunostomy stricture following successful guidewire placement through the pancreaticogastrostomy facilitated by peroral pancreatoscopy

Watch a video of this article.

Laparoscopic revision of duct-to-mucosa pancreaticojejunostomy anastomotic stricture after laparoscopic pancreaticoduodenectomy

PURPOSE

Pancreaticojejunostomy stricture (PJS) is an uncommon late complication of laparoscopic pancreaticoduodenectomy (LPD). The incidence, clinical characteristics, and managements of PJS after LPD are still unreported.

METHODS

All patients undergoing LPD between January 2015 and December 2019 were identified from an institutional database. All pancreaticojejunostomies were performed using Bing's duct-to-mucosa anastomosis. PJS was diagnosed by computed tomography or magnetic resonance cholangio-pancreatography with secretin administration. Re-operation was performed in those patients with persistent abdominal pain and/or recurrent pancreatitis. Patients' demographic characteristics, perioperative outcomes, and follow-up outcomes were retrospectively collected.

RESULTS

During the 5-year study period, 506 cases of LPD were performed. Among these patients, 13 patients (2.6%) were diagnosed with PJS. Only seven patients presented with abdominal pain and/or recurrent pancreatitis and underwent re-operation. The interval between the diagnosis of PJS and the original operation was 23 months. The median operative time was 140 min (range 90 to 210 min). The estimated blood loss was 40 ml (range 10 to 100 ml). The post-operative outcomes were favorable. Only one patient suffered from biochemical fistula. Six of these 7 patients (85.7%) reported complete pain resolution after the re-operation. The other patient reported partial resolution after surgery. All patients did not need to take analgesic drugs after the operation.

CONCLUSION

PJS following LPD is a late complication that was underestimated. It is technically safe and clinically effective to perform laparoscopic revision of the PJS after LPD.

Interrupted versus continuous suture technique for biliary-enteric anastomosis: randomized clinical trial

BACKGROUND

Biliary-enteric anastomosis (BEA) can be performed using continuous or interrupted suture techniques, but high-quality evidence regarding superiority of either technique is lacking. The aim of this study was to compare the suture techniques for patients undergoing BEA by evaluating the suture time as well as short- and long-term biliary complications.

METHODS

In this single-centre randomized clinical trial, patients scheduled for elective open procedure with a BEA between 21 January 2016 and 20 September 2017 were randomly allocated in a 1:1 ratio to have the BEA performed with continuous suture (CSG) or interrupted suture technique (ISG). The primary outcome was the time required to complete the anastomosis. Secondary outcomes were BEA-associated postoperative complications with and without operative revision of the BEA, including bile leakage, cholestasis, and cholangitis, as well as morbidity and mortality up to day 30 after the intervention and survival.

RESULTS

Altogether, 82 patients were randomized of which 80 patients received the allocated intervention (39 in ISG and 41 in CSG). Suture time was longer in the ISG compared with the CSG (median (interquartile range), 22.4 (15.0-28.0) min versus 12.0 (10.0-17.0) min, OR 1.26, 95 per cent c.i. 1.13 to 1.40; unit of increase of 1 min; P < 0.001). Short-term and long-term biliary complications were similar between groups. The incidence of bile leakage (6 (14.6 per cent) versus 4 (10.3 per cent), P = 0.738) was comparable between groups. No anastomotic stenosis occurred in either group.

CONCLUSION

Continuous suture of BEA is equally safe, but faster compared with interrupted suture.

REGISTRATION NUMBER

NCT02658643 (http://www.clinicaltrials.gov).

Outcomes of patients with hepaticojejunostomy anastomotic strictures undergoing endoscopic and percutaneous treatment

Background and study aims  The increase in hepaticojejunostomies has led to an increase in benign strictures of the anastomosis. Double balloon enteroscopy-assisted ERCP (DBE-ERCP) and percutaneous transhepatic biliary drainage (PTBD) are treatment options; however, there is lack of long-term outcomes, with no consensus on management. We performed a retrospective study assessing the outcomes of patients referred for endoscopic management of hepaticojejunostomy anastomotic strictures (HJAS). Patients and methods  All consecutive patients at a tertiary institution underwent endoscopic intervention for suspected HJAS between 2009 and 2021 were enrolled. Results  Eighty-two subjects underwent DBE-ERCP for suspected HJAS. The technical success rate was 77 % (63/82). HJAS was confirmed in 41 patients. The clinical success rate for DBE-ERCP ± PTBD was 71 % (29/41). DBE-ERCP alone achieved clinical success in 49 % of patients (20/41). PTBD was required in 49 % (20/41). Dual therapy was required in 22 % (9/41). Those with liver transplant had less technical success compared to other surgeries (72.1 % vs 82.1 % P  = 0.29), less clinical success with DBE-ERCP alone (40 % vs 62.5 % P  = 0.16) and required more PTBD (56 % vs 37.5 % P  = 0.25). All those with ischemic biliopathy (n = 9) required PTBD for clinical success, required more DBE-ERCP (4.4 vs 2.0, P = 0.004), more PTBD (4.7 vs 0.3, P  < 0.0001), longer treatment duration (181.6 vs 99.5 days P  = 0.12), and had higher rates of recurrence (55.6 % vs 30.3 % P  = 0.18) compared to those with HJAS alone. Liver transplant was the leading cause of ischemic biliopathy (89 %). The overall adverse event rate was 7 %. Conclusions  DBE-ERCP is an effective diagnostic and therapeutic tool in those with altered gastrointestinal anatomy and is associated with low complication rates.

Pancreatic fistula and biliary fistula after laparoscopic pancreatoduodenectomy: 500 patients at a single institution

Background

Pancreatic fistula (PF) and biliary fistula (BF) are two major leakage complications after pancreatoduodenectomy (PD). The aim of this study is to investigate the risk factors of PF and BF after laparoscopic PD (LPD).

Materials and Methods

We conducted a retrospective analysis of 500 patients who underwent LPD from 1 April 2015 to 31 March 2020. Clinical data from patients were analysed using multivariate logistic regression analysis.

Results

PF occurred in 86 (17.2%) patients. Univariate and multivariate analysis indicated that the soft texture of the pancreas (P = 0.001) was the independent risk factor for PF. BF occurred in 32 (6.4%) patients. Univariate and multivariate analysis indicated that history of cardiovascular disease (P < 0.001), surgical time (P = 0.005), pre-operative CA125 (P = 0.036) and pre-operative total bilirubin (P = 0.044) were independent risk factors for BF.

Conclusion

The texture of the pancreas was an independent risk factor for PF after LPD, which was consistent with the literatures. In addition, history of cardiovascular disease, surgical time, pre-operative CA125 and pre-operative total bilirubin were new independent risk factors for BF after LPD. Therefore, patients with high-risk factors of BF should be informed that they are at a high risk for this complication.

A novel endoscopic technique using fully covered self-expandable metallic stents for benign strictures after hepaticojejunostomy: the saddle-cross technique (with video)

BACKGROUND

In recent years, the number of patients with hepaticojejunostomy anastomotic strictures has increased. Balloon dilation and placement of multiple plastic stents have proven effective for hepaticojejunostomy anastomotic strictures. However, for refractory strictures, there is often a need for repeated endoscopic procedures within a short period. This study aimed to assess the efficacy and safety of the new saddle-cross technique, which uses two fully covered self-expandable metallic stents.

METHODS

This was a retrospective analysis of 20 patients with benign hepaticojejunostomy anastomotic strictures who underwent placement of two fully covered self-expandable metallic stents at the National Cancer Center, Japan, from November 2017 to June 2021.

RESULTS

The technical and clinical success rates were 100% (20/20). The median time of the procedure was 61 (range 25-122) min. The scheduled stent removal rate was 70% (14/20). Spontaneous dislodgement of the stent was observed on computed tomography in five patients (25.0%). The non-restenosis rate 12 months after the saddle-cross technique was 88.2% (15/17). Procedure-related early adverse events included mild ascending cholangitis in three patients (15.0%) and sepsis in one patient (5.0%). Procedure-related late adverse events included mild ascending cholangitis in three patients (15.0%) and bile duct hyperplasia in one patient (5.0%).

CONCLUSIONS

The saddle-cross technique performed using two fully covered self-expandable metallic stents resulted in promising long-term stricture resolution with a high technical success rate. Based on these findings, the saddle-cross method can be considered an option for the standard procedure for benign hepaticojejunostomy anastomotic strictures.

Surgical revision for pancreatojejunostomy stricture: a case series of 14 patients

Background

Pancreatojejunostomy stricture (PJS) is a rare long-term complication of pancreaticojejunal anastomosis. This study aimed to investigate the role of surgery in the management of pancreatojejunostomy strictures.

Methods

The database of the Pancreas Center of Nanjing Medical University was retrospectively screened for patients who underwent a surgical revision for PJS between June 2012 and August 2019, and their clinical characteristics and management modalities were reviewed.

Results

Fourteen consecutive cases were retrieved, the median age at index operation was 41.1 years (19–71). The average time between the two operations was 70.6 months (8–270 months). Index procedures included pancreaticoduodenectomy (PD) (7/14, 50%), pylorus-preserving PD (4/14, 28.6%), Berger procedure (2/14, 14.3%), and middle pancreatectomy (1/14, 7.1%). The diameter of the main pancreatic duct was < 4 mm in all 14 cases, and nine underwent pancreaticojejunostomy (PJ) stenting during the index operation. The most frequent complaints were abdominal pain (6/14, 42.9%), recurrent acute pancreatitis (6/14, 42.9%), pancreatic fistula (1/14, 7.1%), and abdominal distention (1/14, 7.1%). The diagnosis of PJ stricture was confirmed by computed tomography or magnetic resonance imaging in all cases. All patients had a main duct diameter > 5 mm before surgical revision. All patients underwent wedge excision with interrupted one-layer suturing with absorbable sutures and without stent placement. In this series, only one patient required reoperation. Upon follow-up, 11 of 12 patients had complete resolution of the PJ stricture.

Conclusion

PJS is a long-term complication of pancreatojejunostomy. Surgical revision of the anastomosis is a safe and effective treatment modality.

Longitudinal Pancreaticojejunostomy for Pancreaticodigestive Tract Anastomotic Stricture After Pancreaticoduodenectomy

Aim

Pancreaticodigestive tract anastomotic stricture is a long-term complication of pancreticoduodenectomy (PD). However, optimal treatment has not yet been defined. We conducted longitudinal pancreaticojejunostomy (LPJ) in symptomatic patients with anastomotic stricture after PD. This study aimed to evaluate the efficacy of this procedure.

Methods

Pancreticoduodenectomy was performed in 605 patients at our institution between January 2005 and April 2020. Of these, 15 patients (2.5%) developed symptomatic pancreaticodigestive tract anastomotic stricture after PD. Three patients were referred to our institution owing to recurrent pancreatitis with anastomotic stricture after PD. LPJ was indicated for these 18 patients, and they were enrolled in this study.

Results

The median time from the initial operation to LPJ was 2.0 y. Preoperative clinical presentations included obstructive pancreatitis in 10 patients, a rapid deterioration of glucose tolerance in nine, and severe steatorrhea in two. Surgical morbidity ≥grade III defined by the Clavien-Dindo classification was not observed. After LPJ, preoperative symptoms improved in 16 patients (89%) during a median follow-up of 39 mo. Nine of the 10 patients with obstructive pancreatitis achieved complete pain relief. All nine patients with a rapid deterioration of glucose tolerance showed improved endocrine function. Daily insulin requirement was significantly decreased after LPJ (11.6 ± 3.3 vs 3.4 ± 4.3 units, P = .0239). Four of the seven patients who required insulin injections were free of insulin after LPJ.

Conclusion

LPJ is a safe and effective surgical procedure for symptomatic patients with stricture of the pancreaticodigestive tract anastomosis after PD.

Symptomatic Pancreaticojejunal Anastomotic Stricture After Pancreaticoduodenectomy Managed by Longitudinal Pancreaticogastrostomy: A Report of Two Cases

Symptomatic pancreaticojejunal anastomotic stricture is a rare complication following pancreaticoduodenectomy. Literature for the management of pancreaticojejunal anastomotic strictures is limited. Revision of pancreaticojejunostomy anastomosis, endoscopic dilation, stenting of pancreaticojejunal stricture, and modified Puestow procedure have all been described with variable outcomes. We present a report of two patients who developed symptomatic pancreaticojejunal anastomotic stricture following a pancreaticoduodenectomy, managed by longitudinal pancreaticogastrostomy with no complications, and resolution of symptoms with an average follow-up interval of 45 months.

Application analysis of omental flap isolation and modified pancreaticojejunostomy in pancreaticoduodenectomy (175 cases)

Background

To explore the application value of free omental wrapping and modified pancreaticojejunostomy in pancreaticoduodenectomy (PD).

Methods

The clinical data of 175 patients who underwent pancreaticoduodenectomy from January 2015 to December 2020 were retrospectively analysed. In total, 86 cases were divided into Group A (omental wrapping and modified pancreaticojejunostomy) and 89 cases were divided into Group B (control group). The incidences of postoperative pancreatic fistula and other complications were compared between the two groups, and univariate and multivariate logistic regression analyses were used to determine the potential risk factors for postoperative pancreatic fistula. Risk factors associated with postoperative overall survival were identified using Cox regression.

Results

The incidences of grade B/C pancreatic fistula, bile leakage, delayed bleeding, and reoperation in Group A were lower than those in Group B, and the differences were statistically significant (P < 0.05). Group A had an earlier drainage tube extubation time, earlier return to normal diet time and shorter postoperative hospital stay than the control group (P < 0.05). The levels of C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) inflammatory factors 1, 3 and 7 days after surgery also showed significant. Univariate and multivariate logistic regression analyses showed that a body mass index (BMI) ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap and modified pancreaticojejunostomy were independent risk factors for pancreatic fistula (P < 0.05). Cox regression analysis showed that age ≥ 65 years old, body mass index ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap isolation and modified pancreaticojejunostomy, and malignant postoperative pathology were independent risk factors associated with postoperative overall survival (P < 0.05).

Conclusions

Wrapping and isolating the modified pancreaticojejunostomy with free greater omentum can significantly reduce the incidence of postoperative pancreatic fistula and related complications, inhibit the development of inflammation, and favourably affect prognosis.

Transjejunal endoscopic ultrasound‐guided pancreatic drainage for pancreatic jejunostomy stricture using a forward‐viewing echoendoscope in a patient with altered anatomy

Pancreatic jejunostomy stricture (PJS) is one of the major late complications after pancreaticoduodenectomy. Endoscopic ultrasound‐guided pancreatic drainage (EUS‐PD) is considered a salvage treatment for symptomatic PJS after endoscopic retrograde pancreatography failure; however, the technical success rate of the endoscopic treatment of PJS remains unsatisfactory, mainly due to surgically altered anatomy. Herein, we describe a case of PJS successfully treated with transjejunal EUS‐PD using a forward‐viewing echoendoscope. A 62‐year‐old man who suffered from repetitive severe back pain due to PJS was referred to our hospital. Since transgastric EUS‐PD was difficult, we attempted transjejunal EUS‐PD using a forward‐viewing echoendoscope. To facilitate scope insertion, we first straightened the afferent jejunal loop and placed a stiff guidewire. With this scheme, we successfully performed transjejunal EUS‐PD and placed a 5‐Fr plastic stent. In conclusion, this technique is useful for treating patients with PJS when transgastric EUS‐PD is difficult.

The Utility of Biliary Manometry in Assessing Early Catheter Removal After Percutaneous Balloon Dilatation of Hepaticojejunostomy Strictures

Background and objective

Percutaneous balloon dilatation followed by long-term internal-external biliary catheter (IEBC) placement is the standard radiological management for postoperative hepaticojejunostomy (HJ) strictures. The treatment is considered successful when cholangiography shows a free flow of contrast across the anastomosis and the patient passes a "clinical test". However, these tests may not be suitable predictors of long-term successful treatment outcomes. The purpose of this study was to assess the utility of biliary manometry in the evaluation of successful treatment outcomes after HJ stricture dilatation and IEBC placement and its efficacy as a tool for early catheter removal.

Patients and methods

A total of 14 patients underwent percutaneous balloon dilatation of HJ strictures with IEBC placement. A two-to-three-month interval was maintained between sessions of exchanging or upsizing IEBCs. Biliary manometry was performed after a mean duration of 6.3 months. Intra-biliary pressure of <15 mmHg was considered as the success threshold.

Results

Among the 14 patients, 11 patients passed initial manometry and had their IEBCs removed and were followed up for a mean duration of 47.8 months. Of these, one patient developed biliary obstruction after six months and underwent repeat HJ stricture dilatation and long-term IEBC placement. Three patients failed manometry and underwent re-dilatation of HJ strictures with IEBC placement. Using Kaplan-Meier survival analysis, the probability of patients remaining stricture-free after HJ stricture dilatation was found to be 100% at three months and 91% at six, 12, 18, 24, 36, and 47.8 months.

Conclusion

Biliary manometry prevents subjective variations in determining treatment endpoints and helps to assess early catheter removal after percutaneous balloon dilatation of HJ strictures.

Efficacy of double-balloon enteroscopy-assisted endoscopic balloon dilatation combined with stent deployment for hepaticojejunostomy anastomotic stricture

BACKGROUND

Hepaticojejunostomy anastomotic stricture (HJAS) is a significant complication of biliary reconstruction surgery. Endoscopic management of HJAS using double-balloon enteroscopy has expanded; however, retrospective reports in this setting are limited. This study aimed to evaluate the efficacy of endoscopic balloon dilatation combined with stent deployment for HJAS.

METHODS

This was a single-arm prospective clinical trial involving 40 patients with treatment-naïve HJAS enrolled between March 2016 and August 2019 at four endoscopy units in Japan. For HJAS, plastic stents combined with balloon dilatation were placed for 6 months after initial stenting. The primary outcome was HJ anastomosis patency 12 months after stent removal.

RESULTS

The technical success rate was 97.5% (39/40). The failed case required percutaneous transhepatic biliary drainage using the rendezvous technique. All cases achieved successful endoscopic treatment. During the treatment period, four of 40 patients (10%) ended the study protocol due to unrelated causes and were excluded from the primary analysis. Among the 36 patients, clinical success was achieved in 34 (94.4%) patients. The remaining two patients achieved HJAS resolution after an additional 3 months. All 36 patients achieved HJAS resolution. Adverse events were observed in two patients (5.0%) who developed moderate cholangitis. During a median follow-up of 21.3 months, HJAS recurrence was observed in 8.3% (3/36) with a median time to recurrence of 4.3 months and HJ anastomosis patency at 12 months was 94.4%.

CONCLUSIONS

Endoscopic balloon dilatation combined with plastic stent deployment for 6 months was a safe and effective strategy for HJAS. (Clinical Trial Registry no. UMIN000020613).

Risk factors and treatment strategy for clinical hepatico-jejunostomy stenosis defined with intrahepatic bile duct dilatation after pancreaticoduodenectomy: a retrospective study

BACKGROUNDS/PURPOSE

The purpose of this study was to identify risk factors and establish a treatment strategy for clinical hepatico-jejunostomy stenosis defined with intrahepatic bile duct dilatation after pancreaticoduodenectomy.

METHODS

The 443 patients who underwent PD from April 2006 to December 2015 were analyzed. Clinical characteristics were compared between patients with and without clinical HJ stenosis, and risk factors for clinical HJ stenosis were analyzed. In addition, the treatment and clinical course of patients with clinical HJ stenosis were retrospectively reviewed.

RESULTS

Clinical HJ stenosis defined with intrahepatic bile duct dilatation was identified in 40 patients (9.0%). Multivariate analysis revealed that the independent risk factor for clinical HJ stenosis was the hepatic duct at surgery ≤ 8 mm. Endoscopic HJ stenosis was identified in 36 patients, and 31 patients were treated successfully with double balloon endoscopic retrograde cholangiography; 5 patients required re-anastomosis (n=3) and percutaneous transhepatic biliary drainage (n=2). Complete obstruction of HJ was found in 5 patients, and treatment with DB-ERC was successful in only one patient.

CONCLUSION

The independent risk factor for clinical HJ stenosis was hepatic duct diameter ≤8 mm. Most cases of endoscopic HJ stenosis were treated successfully with DB-ERC, except in patients with complete obstruction.

Safety and efficacy of EUS-guided pancreatic duct drainage in symptomatic main pancreatic duct obstruction: Is there still a place for surgery?

Background and study aims In patients with symptomatic dilation of the main pancreatic duct (MPD) for whom endoscopic retrograde cholangiopancreatography (ERCP) is impossible, surgery has long been the only available treatment. EUS-PD is described as a minimally invasive alternative for ductal decompression surgery. We describe the results of our experience with it.

Patients and methods This was a retrospective single-center study over 9 years. Twenty-seven patients, median age 61.8 years (range 36 to 85) who underwent EUS-PD for symptomatic MPD dilatation were included. The main objective was to evaluate the technical success (placement of a plastic stent between the stomach and the MPD). Secondary objectives were to document clinical success based on pain and quality of life (visual analogic scales and treatments) and complication rates, and to define a standardized management algorithm.

Results The technical success rate was 92.5 %. The rate of minor adverse events was 21 % (4 cases of non-specific postoperative pain and two cases of delayed benign edematous pancreatitis). The clinical success rate was 88 %, and half of patients in whom the procedure was successful had "complete regression" of pain and half "partial regression." Median follow-up was 34.2 months (range 4 to 108). During follow-up, 74 % of patients reported improvement in quality of life and no patients required secondary surgery.

Conclusion Provided it is performed in an expert center, EUS-PD is a minimally invasive, effective, and safe alternative to pancreatic surgical drainage in patients with symptomatic MPD dilatation with failure or in whom ERCP is impossible.

Endoscopic management of pancreatic diseases in patients with surgically altered anatomy: clinical outcomes of combination of double-balloon endoscopy- and endoscopic ultrasound-guided interventions

OBJECTIVES

In patients with surgically altered anatomy, endoscopic treatment of pancreatic diseases is technically challenging. We aimed to evaluate the feasibility, effectiveness, and safety of an interchangeable combination of double-balloon endoscope-assisted ERP (DB-ERP) and endoscopic ultrasonography-guided pancreatic duct drainage (EUS-PD) in this clinical setting.

METHODS

Consecutive patients with surgically altered anatomy undergoing endoscopic treatment (DB-ERP, EUS-PD, or both) for pancreatic diseases were studied. The primary outcome was technical success; secondary outcomes were clinical success and adverse events.

RESULTS

Forty patients who underwent DB-ERP (38) and EUS-PD (2) as an initial intervention were retrospectively studied. Indications for intervention included 18 pancreaticojejunostomy anastomotic stricture (PJAS), four pancreatic duct stone (PDS), four pancreatic fistula (PF), 11 PJAS with PDS, and three PJAS with PF. Prior surgical reconstruction was 26 Billroth-II, 13 Roux-en-Y, and one Imanaga reconstruction. Along with salvage procedures including three DB-ERP and seven EUS-PD, the overall technical success rates of DB-ERP and EUS-PD were 70.7% (29/41) and 100% (9/9), respectively. Clinical success was achieved in 85.0% (34/40) by combination of DB-ERP and EUS-PD; successful drainage for PJAS, complete removal of PDS, and resolution of PF were achieved in 90.6%, 80.0%, and 71.4%, respectively. Adverse event rates were 12.2% (5/41; one perforation, and four pancreatitis) in DB-ERP and 55.6% (5/9; three pancreatic leakage, and two abdominal pain) in EUS-PD.

CONCLUSIONS

A combination of DB-ERP and EUS-PD can achieve high technical and clinical success for pancreatic diseases in surgically altered anatomy patients. A prospective multicenter study to investigate an appropriate treatment algorithm is warranted.

Video review reveals technical factors predictive of biliary stricture and cholangitis after robotic pancreaticoduodenectomy

BACKGROUND

Cholangitis due to anastomotic stricture of the hepaticojejunostomy (HJ) following pancreaticoduodenectomy (PD), while uncommon, adversely affects postoperative quality-of-life. While prior studies have identified patient-related risk factors for these biliary complications, technical risk factors have not been systematically examined. Video review of surgical procedures has helped define technical details predictive of postoperative complications in bariatric and hepato-pancreato-biliary (HPB) surgery. Similarly, the present study utilized video review to identify technical factors associated with cholangitis and anastomotic biliary stricture following robotic PD.

METHODS

This was an observational study. A blinded experienced HPB surgeon reviewed videos of post-learning-curve HJs performed during robotic PD and extracted 20 technical variables. Other demographic and clinical variables were collected from a prospectively maintained database.

RESULTS

241 robotic PD videos were reviewed. 29 (12.0%) developed cholangitis and/or biliary stricture, with a median time-to-event of 189 (IQR 78-365) days. Several clinical and technical factors were independently predictive of cholangitis and/or biliary stricture: preoperative radiotherapy, small duct size (<10 mm diameter), increased distance of the HJ (>10 mm) from the hilar plate, and continuous suturing technique.

CONCLUSION

Post-hoc video review of HJ is a powerful method to predict biliary complications. Moreover, altering specific technical factors might enable surgeons to improve postoperative outcomes.

Long-Term Surgical Complications After Pancreatoduodenectomy: Incidence, Outcomes, and Risk Factors

BACKGROUND

Long-term complications following pancreatoduodenectomy (PD) can significantly impact quality of life and healthcare utilization. Most reports focus on short-term (within 90 days) PD outcomes; however, the incidence and risk factors for long-term complications (> 90 days) remain to be evaluated. We sought to identify the incidence, outcomes, and risk factors for long-term complications post-PD.

METHODS

All PD survivors between 2010 and 2017 were identified from a single-institutional database. Long-term complications (> 90 days post-PD and not resulting from cancer recurrence), including biliary stricture, cholangitis, pancreatitis, peptic ulcer, small bowel obstruction, and incisional hernia, were identified. Logistic regression was used to identify perioperative predictors of long-term complications.

RESULTS

Of 906 PDs, 628 long-term survivors met criteria for analysis (mean age of 65.3 years, 47% female). Median follow-up and overall survival were 51.1 months (95% CI 47.6, 55.7) and 68.5 months (95% CI 57.9, 81.4), respectively. A total of 198 (31.5%) experienced at least one long-term complication. Complications included incisional hernia (17.7%), biliary stricture or cholangitis (8.0%), pancreatitis (5.7%), small bowel obstruction (4.3%), and peptic ulcer (3.2%). In total, 108 (17.2%) of the complications required an intervention, nearly half of which were surgical. On multivariable analysis, several predictors of long-term complications were identified: obesity (BMI ≥ 30 kg/m²), postoperative wound infection, prolonged index length of stay, readmission (< 90 days), operative approach (open vs. robotic), and pylorus-preservation.

CONCLUSION

Long-term complications occur in nearly a third of PDs and nearly one-fifth of all PDs require re-intervention. Several modifiable predictors of long-term complications were identified.

Cholangitis following biliary-enteric anastomosis: A systematic review and meta-analysis

BACKGROUND

Cholangitis is a serious biliary complication following biliary-enteric anastomosis (BEA). However, the rate of cholangitis in the postoperative period and its associated risk factors are inconclusive. The objective of this systematic review and meta-analysis was to assess the onset and risk factors of cholangitis after biliary-enteric reconstruction in literature.

METHODS

MEDLINE, EMBASE, and Cochrane databases were searched systematically to identify studies reporting about cholangitis following biliary-enteric anastomosis. Meta-analyses were performed for risk factors using random effects model with odds ratio (OR) and 95% confidence interval (95 %CI) as effect measures. Study quality was assessed by the MINORS (methodological index for non-randomized studies) criteria.

RESULTS

28 studies involving 6904 patients were included in the study. The pooled rate for postoperative cholangitis (POC) was 10% (95 %CI: 8 %-13%) with studies reporting about an early- and late-onset of cholangitis. Male sex (OR 2.08; 95 %CI: 1.33-3.24; P = 0.001), postoperative hepatolithiasis (OR 137.19; 95 %CI: 29.00-648.97; P < 0.001) and postoperative anastomotic stricture (OR 178.29; 95 %CI: 68.64-463.11; P < 0.001) were associated with a higher risk of a late-onset of POC with a pooled rate of 8% (95 %CI: 6 %-11%) after a median time interval of 12 months. The quality of the included studies was low to moderate.

CONCLUSION

Cholangitis is a frequent complication after BEA. Consensus definition and prospective trials are required to assess optimal therapeutic strategies. We proposed a standardized definition and grading of POC to enable comparisons between future studies.

Endoscopic Balloon Dilation for Benign Bilioenteric Stricture: Outcomes and Factors Affecting Recurrence

BACKGROUND

Balloon dilation (BD) is a simple, effective procedure for postoperative benign bilioenteric strictures (BBESs). Factors associated with BBES recurrence after endoscopic BD have not been studied adequately. This study examined the outcomes and 1-year recurrence factors in patients with BBES who underwent endoscopic BD.

METHODS

Patients who underwent endoscopic BD as an initial treatment between April 2008 and March 2017 were retrospectively assessed. The median time to recurrence of BBES (RBBES) and recurrence factors were evaluated.

RESULTS

The study group comprised 55 patients (median age 72 years). The rate of RBBES was 52.7% (29/55), and the median time to RBBES was 2.78 years (95% confidence interval [CI] 1.17-4.40). RBBES was observed in 32.7% (18/55) within 1 year after endoscopic BD. The significant factors associated with recurrence within 1 year, revealed by multivariate analysis, were: postoperative bile leak (p = 0.001; hazard ratio [HR] 10.94; 95% CI 2.47-48.39); BBES onset within 6 months, postoperatively (p = 0.013; HR 6.18; 95% CI 1.46-26.21); no intrahepatic stones (p = 0.049; HR 3.05; 95% CI 1.01-9.22); and remaining balloon waist (p = 0.005; HR 5.71; 95% CI 1.69-19.31). The median time to RBBES was significantly shorter in patients with these recurrence factors (0.88 years vs. not reached, p = 0.004). Patients exhibiting at least two recurrence factors were significantly more likely to experience recurrence (p < 0.001).

CONCLUSION

Endoscopic BD is effective for BBES, especially for patients with no recurrence factors. Consideration of endoscopic BD and additional treatment may be necessary for patients with recurrence factors.

Design of an immunohistochemistry biomarker panel for diagnosis of pancreatic adenocarcinoma

BACKGROUND

Challenges still exist in differentiating pancreatic adenocarcinoma from benign disease. The use of adjuvant testing of tissue biopsies has demonstrated potential diagnostic value. We designed a proof of concept study to first validate four individual immunohistochemistry biomarkers and then combine them into a panel to boost overall diagnostic sensitivity.

METHODS

Malignant and benign pancreas from 27 pancreaticoduodenectomy specimens underwent immunohistochemistry staining with VHL, IMP3, S100A4, S100P. Using ROC curve analysis, threshold criteria for number of cells staining were chosen for each biomarker. Biomarkers were then evaluated as a panel for their ability to discriminate malignant from benign specimens.

RESULTS

Diagnostic sensitivity of VHL, IMP3, S100A4, and S100P were 75.0%, 79.2%, 45.8%, and 0%. When VHL, IMP3, and S100A4 were grouped into a panel, they were able to distinguish cancer from normal tissue with a sensitivity of 100% and a specificity of 96%.

CONCLUSIONS

The high diagnostic value of an IHC panel consisting of VHL, IMP3, and S100A4 on surgical specimens suggests the need for future prospective studies of these biomarkers on biopsy specimens.

The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant After Proximal Pancreatectomy for IPMN

OBJECTIVE(S)

A dilated main pancreatic duct in the distal remnant after proximal pancreatectomy for intraductal papillary mucinous neoplasms (IPMN) poses a diagnostic dilemma. We sought to determine parameters predictive of remnant main-duct IPMN and malignancy during surveillance.

METHODS

Three hundred seventeen patients underwent proximal pancreatectomy for IPMN (Indiana University, 1991-2016). Main-duct dilation included those ≥ 5 mm or "dilated" on radiographic reports. Statistics compared groups using Student's T/Mann-Whitney U tests for continuous variables or chi-square/Fisher's exact test for categorical variables with P < 0.05 considered significant.

RESULTS

High-grade/invasive IPMN or adenocarcinoma at proximal pancreatectomy predicted malignant outcomes (100.0% malignant outcomes; P < 0.001) in remnant surveillance. Low/moderate-grade lesions revealed benign outcomes at last surveillance regardless of duct diameter. Twenty of 21 patients undergoing distal remnant reoperation had a dilated main duct. Seven had main-duct IPMN on remnant pathology; these patients had greater mean maximum main-duct diameter prior to reoperation (9.5 vs 6.2 mm, P = 0.072), but this did not reach statistical significance. Several features showed high sensitivity/specificity for remnant main-duct IPMN.

CONCLUSIONS

Remnant main-duct dilation after proximal pancreatectomy for IPMN remains a diagnostic dilemma. Several parameters show a promise in accurately diagnosing main-duct IPMN in the remnant.

Anterograde Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: A Technical Review

The advancement of pancreatic endotherapy has increased the availability of minimally invasive endoscopic pancreatic ductal drainage techniques. In this regard, familiarity with endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is critical for treatment of obstructed pancreatic ductal systems, especially in nonsurgical candidates and in patients desiring a minimally invasive approach. Two distinct forms of EUS-PDD exist, viz. rendezvous-assisted endoscopic retrograde pancreatography (rendezvous-assisted ERP) and anterograde EUS-PDD. Anterograde EUS-PDD refers to transmural anterograde passage of a pancreatic drainage catheter or stent directly into the main pancreatic duct, through either the gastric or enteral wall. Rendezvous-assisted ERP should be attempted after failed conventional ERP, and anterograde EUS-PDD should be considered if rendezvous-assisted ERP fails or is not technically feasible. Common clinical scenarios that fulfil these conditions are chronic pancreatitis with high-grade main pancreatic duct obstruction, surgically altered anatomy with ductal/anastomotic obstruction, pancreas divisum, and disconnected pancreatic duct syndrome. The focus of this review article is anterograde EUS-PDD and its indications, technique, and outcomes. It also provides a summary of our own experience with this procedure, and a video demonstration of the technique.

Hospitalization Burden of Biliary Strictures and Cholangitis After Pancreaticoduodenectomy

BACKGROUND

Postsurgical biliary disease in Roux-en-y and cholecystectomies has been investigated, but less literature exists regarding biliary complications after Whipple procedure (pancreaticoduodenectomy [PD]). Moreover, the hospital burden incurred after this complication has not been previously examined. The aim of this study is to assess the trends in hospitalization for biliary strictures and cholangitis after PD.

MATERIALS AND METHODS

The National Inpatient Sample identified all cases with a PD and a primary diagnosis of biliary complication in 2014. Cases were identified using the International Classification of Diseases, Clinical Modification codes. Primary outcomes were association of biliary complications with mortality, cost of admission, and length of stay.

RESULTS

A total of 10,145 patients in 2014 were documented with a previous PD. Mortality was 50-fold greater without biliary complications (2.7% versus 0.05%), but a 95% increased length of stay (25.8 d versus 13.2 d, P = 0.014) and 70% increased cost of admission ($293,894 versus $165,862, P = 0.092) occurred with biliary complications. Regression analysis revealed increased length of stay in all cohorts (adjusted odds ratio: 14.3, P = 0.007) and increased cost of admission with cholangitis (adjusted odds: 458283, P = 0.00). Finally, there was increased biliary strictures, cost of hospitalization, and length of stay from 2011 to 2014.

CONCLUSIONS

Biliary disease due to the PD appears to longitudinally increase length of stay and cost of hospitalization. Compared with gastrointestinal bleed and delayed gastric emptying, biliary strictures and cholangitis are still very high acuity, requiring more extensive medical resources. Minimally invasive surgeries and robotics could play a vital role in minimizing biliary complications and the ensuing hospitalization burden.

Strengths, Weaknesses, Opportunities, and Threats of Centralized Pancreatic Surgery: a Single-Center Analysis of 3000 Consecutive Pancreatic Resections

BACKGROUND

Pancreatic surgery at high-volume centers has undergone major changes over the last decades. However, the quality of surgery remains to be considered as one important factor for achieving long-term survival especially in patients at advanced stages of disease.

METHODS

Between January 1990 and June 2017, 3000 consecutive patients have undergone pancreatic resections at our institution. Relevant postoperative data and histopathological findings as well as overall survival were analyzed. In addition, a SWOT (strengths, weaknesses, opportunities, threats) analysis of pancreatic surgery at high-volume centers was performed.

RESULTS

A total of 2218 pancreatic head resections (74%), 494 distal pancreatectomies (16%), 200 total pancreatectomies (7%), and 88 other resections (3%) were performed within our study period. Despite additional vascular resections in 265 patients (9%) and additional liver resections in 167 patients (6%), overall perioperative mortality did not exceed 3%. Overall survival strongly depended on the underlying disease, as well as on lymph node stage (p = < 0.001) and surgical radicality (p = < 0.001).

CONCLUSIONS

The decentralization of pancreatic surgery over the last decades has led to a focus on high-volume centers to perform extended procedures in complex patients. The present SWOT analysis underlines the significance of a centralization of pancreatic surgery for patient safety and to increase the chance of long-term survival.

Magnetic Anastomosis for Biliojejunostomy: First Prospective Clinical Trial

BACKGROUND

Magnetic compression anastomosis (magnamosis, MCA) has been verified safe and effective by us and others in animal bilioenteric anastomosis (BEA). The objective of the present study was to introduce clinical application of magnetic compression bilioenteric anastomosis (MC-BEA) with a unique device in series of patients.

METHODS

Patients with obstructive jaundice with an indication of BEA were prospectively enrolled from 2012 to 2015. After dissection of bile ducts, the mother ring and drainage tube were placed in the proximal bile duct and the purse-string suture was tightened over the drainage tube. The drainage tube was introduced into the jejunal lumen at the anastomotic site and used to guide the daughter ring to assemble with the mother ring. All the patients were routinely followed up for magnets discharge or any complications associated.

RESULTS

Forty-one patients were included. Thirty-four (82.9%) patients had a malignant primary disease, while seven (17.1%) had benign disease. The median time for MC-BEA was 10.5 min (interquartile range [IQR] 8.3-13.0 min). No perioperative morbidity or mortality associated with MC-BEA was observed. The median time for a patent bilioenteric anastomosis formation was 19.0 days (IQR 14.5-23.0 days), and the magnets were discharged with a median postoperative duration of 35.0 days (IQR 28.0-43.0 days). With a median follow-up of 547.5 days (range 223-1042 days), no patients had biliary fistula, while two (4.9%) developed anastomotic stricture at 4 months and 14 months after surgery, and underwent reoperation for reconstruction of BEA.

CONCLUSIONS

MCA is a safe, effective, and time-saving modality for biliojejunostomy.

Technical feasibility of EUS-guided antegrade dilation for hepaticojejunostomy anastomotic stricture using novel endoscopic device (with videos)

Background

A novel endoscopic dilation device (EZ Dilator; Zeon Medical Co, Tokyo, Japan) is now available in Japan that might affect dilation for biliary strictures under endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) guidance because it has good push ability. We evaluated the technical feasibility of this device under EUS guidance in a case series of patients with hepaticojejunostomy anastomotic stricture (HJAS) that led to further complications.

Method

We enrolled 14 patients with HJAS leading to obstructive jaundice or repeated cholangitis in this study. Technical success was defined as insertion of the EZ Dilator into the intestine across the stricture site without the need for other dilation devices. Deployed plastic stents were removed after three months to evaluate anastomosis sites.

Results

The median procedural duration was 25 minutes. Rates of technical and clinical success were 100% and 78.5%, respectively. One patient developed an adverse event of abdominal pain. Contrast medium flowed across the anastomosis site in 11 patients after stent removal, indicating a clinical success rate of 78.5% (11 of 14). Plastic stents were deployed again in the remaining three patients.

Conclusion

Although a prospective evaluation with long-term follow up is needed, the EZ Dilator shows clinical promise for treating benign biliary strictures under ERCP and EUS guidance.

Late acute pancreatitis after pancreaticoduodenectomy: incidence, outcome, and risk factors

BACKGROUND

The pancreatoenteric anastomotic stricture (PEAS) is a common long-term complication after pancreaticoduodenectomy (PD), some of which present as acute pancreatitis requiring emergency care. This important topic has never been reported. In this study, we focus on the incidence, radiological features, clinical outcome, and risk factors of late-occurring acute pancreatitis (LAP) after PD.

METHODS

We retrospectively reviewed a prospectively collected database of 539 patients who underwent PD at a single tertiary referral center between June 2005 and December 2014. Only patients with at least 3 years of follow-up and available pre- and post-operative images were included.

RESULTS

Of the 539 patients, 23 (15 [65%] with and eight [35%] without PEAS) were diagnosed with LAP after PD. The cumulative incidence of LAP was 3.6% (1-year), 4.4% (2-year), and 5.1% (5-year). The median time to the first LAP episode was 22 months (range 8-38 months) after PD. All the first and recurrent LAP events were mild in severity and resolved after conservative treatment. Multivariate analysis showed that a history of acute pancreatitis before PD (P = 0.001, HR 5.24, 95% CI 1.95-14.10) and PEAS (P = 0.047, HR 2.75, 95% CI 1.01-7.49) were two significant risk factors.

CONCLUSIONS

We propose using a more conservative treatment for patients who experience LAP after PD.

Long-term outcomes of EUS-guided transluminal stent deployment for benign biliary disease: Multicenter clinical experience (with videos)

Background and Objectives:

Biliary drainage (BD) under EUS guidance is usually indicated for malignant biliary obstruction. Recently, EUS-guided transluminal treatment has been applied to benign biliary disease (BBD). This multicenter retrospective study evaluated the clinical impact of EUS-guided transluminal stent deployment for BBD with long-term follow-up.

Patients and Methods:

This retrospective study investigated patients treated between September 2015 and October 2016 at participating hospitals in the therapeutic endoscopic group. The inclusion criteria comprised complications with BBD obstructive jaundice or cholangitis and failed endoscopic retrograde cholangiopancreatography or inaccessible ampulla of Vater.

Results:

Twenty-six patients underwent EUS-guided transluminal stent deployment. Indications for EUS-guided transluminal stent deployment comprised anastomotic biliary stricture (n = 17), bile duct stones (n = 5), inflammatory biliary stricture (n = 3), and acute pancreatitis prevention (n = 1). Thirteen of these 26 patients underwent scheduled reintervention, with technical success achieved in all 13 patients. None of the deployed stents became dysfunctional. Among the 13 patients who underwent reintervention on demand, stents had become dysfunctional in six patients (stent patency: 48, 90, 172, 288, 289, and 608 days). Reintervention was successfully performed in all patients. During follow-up (median, 749 days), severe adverse events were not seen in any patients.

Conclusion:

We concluded that EUS-guided transluminal stent deployment for BBD is feasible and safe. Because metal stent dysfunction was more frequent when deployed on demand, such stents should be exchanged for plastic stents in a scheduled manner if a metal stent is used.

Laparoscopic Magnetic Compression Biliojejunostomy: A Preliminary Clinical Study

BACKGROUND

Magnetic compression anastomosis is a feasible and effective method for bilioenteric anastomosis (BEA) in animal model. The objective of the present study was to report our initial clinical experience in laparoscopically magnetic compression bilioenteric anastomosis (LMC-BEA).

METHODS

Patients with obstructive jaundice who were candidates for LMC-BEA were prospectively enrolled from 2013 to 2015. All the procedures were performed laparoscopically. A mother magnet and drainage tube were placed in the proximal bile duct and tightened by a purse suture after dissection of the common bile duct. The drainage tube was introduced into the jejunal lumen at the anastomotic site and guided a daughter magnet to approximate the mother magnet. The two magnets mated at the anastomotic site. All the patients were routinely followed up for magnets discharge till the end of the study.

RESULTS

In total, four patients with malignant obstructive jaundice and one patient with benign biliary stricture were included. The median age was 70 y (range, 49-74 y). The median time for LMC-BEA was 12 min (range, 8-15 min). A complete anastomosis was confirmed after a median time of 21 d (range, 5-25 d) postoperatively by cholangiography via drainage tube. The magnets were expulsed around 41 d after surgery (range, 12-47 d) postoperatively. With a median follow-up of 313 d (range, 223-1042 d), no complications associated with magnetic anastomosis was documented, such as bile leakage or anastomotic stricture.

CONCLUSIONS

Magnetic compression is a promising alternate method for laparoscopic BEA. Among the five patients undergoing LMC-BEA, no one developed anastomotic complications.

Late Pancreatic Anastomosis Stricture Following Pancreaticoduodenectomy: a Systematic Review

BACKGROUND

With an increasing postoperative survival and prolonged follow-up, late complications following pancreaticoduodenectomy (PD) have yet to be thoroughly described and analyzed. Among those, pancreatic anastomosis stricture may lead to severe consequences.

METHODS

A systematic review focusing on pancreaticojejunostomy anastomosis (PJA) stricture.

RESULTS

PJA stricture incidence reached 1.4-11.4% with a median time interval of 34 months after PD. No risk factor was identified. PJA stricture repercussions were inconsistent but postprandial abdominal pain and recurrent acute pancreatitis were the most common symptoms, followed by impaired pancreatic function. To confirm diagnosis, secretin-enhanced magnetic resonance cholangiopancreatography (SMRCP) sensitivity reached 56-100%. As impaired pancreatic function is not improved by any procedure, only PJA stricture leading to abdominal pain or acute pancreatitis should be considered for treatment. Endoscopic techniques (mainly ultrasound-assisted "rendezvous") should be proposed prior to surgical repair, with a morbidity, an overall technical and clinical success reaching 16.5-33% and 28.6-100% and 33-100%, respectively. Regarding surgical repair, overall morbidity varied between 14.3 and 33%, with a clinical success reaching 26.1-100%. Finally, total pancreatectomy with islet auto-transplantation should be considered only for pain intractable to medical management and recurrent acute pancreatitis which has failed medical, endoscopic, and traditional surgical management strategies.

CONCLUSION

PJA stricture following PD is a late, unusual, and potentially serious complication. When there is currently no clear consensus, PJA stricture leading to abdominal pain or acute pancreatitis should be considered treatment. With increasing survival after PD, further studies should focus on late complications.

CORE TIP

Stricture of pancraticojejunostomy is a late and potentially serious complication after pancreaticoduodenectomy. Incidence reaches 1.4-11.4% and no risk factor is identified. Symptoms are inconsistent but postprandial abdominal pain, recurrent acute pancreatitis, and impaired pancreatic function are the most frequent. To confirm diagnosis, secretin-enhanced magnetic resonance cholangiopancreatography is the best modality. Only PJA stricture leading to abdominal pain or acute pancreatitis should be considered for treatment. Endoscopic techniques (mainly ultrasound-assisted "rendezvous") should be proposed prior to surgical repair. Finally, total pancreatectomy with islet auto-transplantation should be considered only for pain intractable to medical management and recurrent acute pancreatitis which has failed medical, endoscopic, and traditional surgical management strategies.

Management of delayed stenosis of pancreatico-enteric anastomosis following pancreatoduodenectomy

Stenosis of the pancreatico-enteric anastomosis following pancreatoduodenectomy (PD), a late post-operative complication that is seen mainly after PD for diseases with good prognosis, has been reported in less than 3% of cases in the literature. Most often asymptomatic, pancreatic-enteric anastomotic stenosis can lead to pancreatitis, pain or pancreatic insufficiency. Symptomatic stenosis is difficult to treat and its management is not standardized. Magnetic resonance cholangiopancreatography is the best investigation to confirm the diagnosis of stenosis. The Endoscopic UltraSonography (EUS) « rendezvous » technique, associating an endoscopic approach and EUS-guided puncture of the main pancreatic duct, has been available since 2010. Of note, however, the failure rate of the EUS series is as high as 25%, leading to repeat procedures. Surgical reconstruction of the anastomosis has been reported with good results in terms of morbidity. Surgical re-do of the pancreatico-enteric anastomosis for stenosis following PD carries a low risk of pancreatic fistula (around 5%) and an overall morbidity rate of around 20%.

Management of Biliary Stricture Following Emergent Pancreaticoduodenectomy for Trauma: Report of Two Cases

Stricturing of the biliary-enteric anastomosis is a known complication of emergent pancreaticoduodenectomy (PD) performed for trauma. Percutaneous techniques have become the first-line option for the management of these strictures. In cases where percutaneous intervention fails, surgical revision of the biliary enteric anastomosis is necessary. We present two cases of young males with penetrating injuries to the pancreatic head managed with PD and subsequently developed post-operative biliary strictures. The biliary stricture was managed successfully with percutaneous intervention for one of the patients. The other patient required surgical revision of the biliary anastomosis. Pancreaticoduodenectomy is typically performed in patients with malignant or benign biliary obstruction with associated ductal dilatation. In the setting of trauma, the bile duct is typically non-dilated, creating greater susceptibility for anastomotic stricture. Although such strictures may be amenable to percutaneous cholangioplasty, strictures involving distal anastomoses may require operative revision. Thus, we suggest creating the more proximal hepaticojejunostomy during the initial operation, as this may benefit the success of percutaneous management should a stricture develop. Operative revision is the definitive management of post-PD biliary stricture.

Enucleation of non-invasive tumors in the proximal pancreas: indications and outcomes compared with standard resections

OBJECTIVE

The aim of this study was to evaluate the safety and efficiency of enucleation (EU) for proximal pancreatic non-invasive neoplasms.

METHODS

Patients with solitary non-invasive neoplasms in the proximal pancreas from January 1998 to April 2014 at the Second Affiliated Hospital of Zhejiang University, Hangzhou, China were included. Different operations and outcomes were analyzed.

RESULTS

A total of 123 patients were enrolled. Forty patients (32.5%) underwent EU including 18 patients who had tumors close to the main pancreatic duct (MPD). Sixty-one patients (49.6%) had pancreaticoduodenectomy (PD) performed and 22 (17.9%) underwent central pancreatectomy (CP). Pathological outcomes included neuroendocrine tumors, cystic lesions, and solid pseudopapillary tumors. Operation time, intra-operative blood loss, and duration of hospital stay were significantly reduced in the EU group. PD was associated with the greatest complication rate (55.7%), followed by EU (50%) and CP (40.9%), though the pancreatic fistula rate after EU was the highest (50%), especially in patients with tumors larger than 3 cm and tumors close to the MPD. EU had advantages in the preservation of pancreatic parenchyma and endocrine and exocrine function.

CONCLUSIONS

EU can be carried out safely and effectively for tumors in the proximal pancreas with improved outcomes compared with standard resections, even if the tumor is larger than 3 cm and close to the MPD.