Late benign biliary complications after pancreatoduodenectomy

Upper gastrointestinal endoscopy in the surgically altered patient

As management of upper gastrointestinal malignancies improves, and with popularization of bariatric surgery, endoscopists are likely to meet patients with altered upper gastrointestinal anatomy. Short-term, the surgery can cause complications like bleeding, leaks, and fistulas, and longer-term problems such as intestinal or biliary anastomotic strictures or biliary stones can arise, all necessitating endoscopy. In addition, the usual upper gastrointestinal pathologies can also still occur. These patients pose unique challenges. To proceed, understanding the new layout of the upper gastrointestinal tract is essential. The endoscopist, armed with a clear plan for navigation, can readily diagnose and manage most commonly occurring conditions, such as marginal ulcers and proximal anastomotic strictures with standard endoscopic instruments. With complex reconstructions involving long segments of small bowel, such as Roux-en-Y gastric bypass, utilization of balloon-assisted enteroscopy may be necessary, mandating modification of procedures such as endoscopic retrograde cholangiopancreatography. Successful endoscopic management of patients with altered anatomy will require prior planning and preparation to ensure the appropriate equipment, setting, and skill set is provided.

Benign hepaticojejunostomy strictures after pancreatoduodenectomy

PURPOSE

To determine the causes of benign hepaticojejunostomy strictures (BHSs) after pancreaticoduodenectomy (PD) and the outcome of endoscopic retrograde cholangiography (ERC) treatment for BHSs.

METHODS

A total of 175 patients who underwent PD between January 2013 and December 2020 and who were followed up for at least 1 year were included. Preoperative data, operative outcomes, and postoperative courses were compared between the BHS group and the group of patients who did not develop stenosis during follow-up (non-BHS group). The course of treatment in the BHS group was also examined.

RESULTS

BHS occurred in 13 of 175 patients (7.4%). Multivariate analysis of the BHS and non-BHS groups revealed that male sex (OR; 3.753, 95% CI; 1.029-18.003, P = 0.0448) and a preoperative bile duct diameter less than 8.8 mm (OR; 7.51, 95% CI; 1.75-52.40, P = 0.0053) were independent risk factors for the development of BHS. In the BHS group, all patients underwent ERC using enteroscopy. The success rate of the ERC approach to the bile duct was 92.3%. Plastic stents were inserted in 6 patients, and metallic stents were inserted in 3 patients. The median observation period since the last ERC was 17.9 months, and there was no recurrence of stenosis in any of the 13 patients.

CONCLUSIONS

Patients with narrow bile ducts are at greater risk of BHS after PD. Recently, BHS after PD has been treated with ERC-related procedures, which may reduce the burden on patients.

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.

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.

Meta-analysis of interrupted versus continuous suturing for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy

AIMS

To compare outcomes of interrupted (IS) and continuous (CS) suturing techniques for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy.

METHODS

The study protocol was prospectively registered in PROSPERO (registration number: CRD42021286294). A systematic search of MEDLINE, CENTRAL, and Web of Science and bibliographic reference lists were conducted (last search: 14th March 2022). All comparative studies reporting outcomes of IS and CS in hepaticojejunostomy and choledochocholedochostomy were included and their risk of bias was assessed using ROBINS-I tool. Overall biliary complications, bile leak, biliary stricture, cholangitis, liver abscess, and anastomosis time were the evaluated outcome parameters.

RESULTS

Ten comparative studies (2 prospective and 8 retrospective) were included which reported 1617 patients of whom 1186 patients underwent Roux-en-Y hepaticojejunostomy (IS: 789, CS: 397) and the remaining 431 patients underwent duct-to-duct choledochocholedochostomy (IS: 168, CS: 263). Although use of IS for hepaticojejunostomy was associated with significantly longer anastomosis time (MD: 14.15 min, p=0.0002) compared to CS, there was no significant difference in overall biliary complications (OR: 1.34, p=0.11), bile leak (OR: 1.64, p=0.14), biliary stricture (OR: 0.84, p=0.65), cholangitis (OR: 1.54, p=0.35), or liver abscess (OR: 0.58, p=0.40) between two groups. Similarly, use of IS for choledochocholedochostomy was associated with no significant difference in risk of overall biliary complications (OR: 0.92, p=0.90), bile leak (OR: 1.70, p=0.28), or biliary stricture (OR: 1.07, p=0.92) compared to CS.

CONCLUSIONS

Interrupted and continuous suturing techniques for Roux-en-Y hepaticojejunostomy or duct-to-duct choledochocholedochostomy seem to have comparable clinical outcomes. The available evidence may be subject to confounding by indication with respect to diameter of bile duct. Future high-quality research is encouraged to report the outcomes with respect to duct diameter and suture material.

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.

Continuous suture is a risk factor for benign hepaticojejunostomy stenosis after pancreatoduodenectomy in patients with a non-dilated bile duct

BACKGROUND

It is unclear whether hepaticojejunostomy with a continuous suture is suitable for patients with a non-dilated bile duct.

METHODS

Medical records of patients who underwent pancreatoduodenectomy between 2003 and 2013 were retrospectively reviewed, focusing on the incidence of benign anastomotic stenosis and its relationship with suture method (continuous vs interrupted) and common hepatic duct size.

RESULTS

Among 336 patients, 172 had a non-dilated (<8 mm) duct, and the remaining 164 had a dilated duct. Benign stenosis occurred in 12.2% (21/172) in the former, but in only 0.6% (1/164) in the latter (p < 0.001; median follow-up period, 43.5 months). Thus, further analysis was conducted in the 172 patients with a non-dilated duct, among whom 116 received a continuous suture and 56 received an interrupted suture. The cumulative incidence of benign anastomotic stenosis was significantly higher in patients who received a continuous suture vs those who received an interrupted suture (15.6% vs 1.8%, respectively, at 3 years; p = 0.006). Multivariable analysis identified continuous suture, male gender, and cholangitis (within 3 months after surgery) as independent risk factors for benign stenosis.

CONCLUSIONS

In this observational study, the use of a continuous suture was associated with benign anastomotic stricture in patients with a non-dilated hepatic duct.

Transient Biliary Fistula After Pancreatoduodenectomy Increases Risk of Biliary Anastomotic Stricture

BACKGROUND

Biliary fistula after pancreatoduodenectomy (PD) is associated with significant morbidity and mortality. The aim of this study was to determine the risk of early postoperative biliary fistula for developing biliary anastomotic stricture after PD.

METHODS

Retrospective review of all PD performed for various indications at a single institution between 2013 and 2018. Postoperative biliary fistulae were graded according to the International Study Group of Liver Surgery (ISGLS) as grade A-C. Multivariable analysis was performed for all comparative patient subgroups.

RESULTS

A total of 843 patients underwent PD for malignant (68%) and benign (32%) indications. Postoperative biliary fistula developed in 66 (8%) patients; ISGLS grade A in 29 (3%), grade B in 32 (4%), and grade C in 5 (0.6%). Ninety-day mortality was 3% (25 patients). The remaining 818 patients were evaluated with a median follow-up of 16 months (IQR, 5-32 months). Biliary anastomotic stricture developed in 41 (5%) patients at a median of 10 months (IQR, 6-18 months) postoperatively. Strictures were managed with percutaneous (27 patients, 66%) or endoscopic (14 patients, 34%) stenting. No biliary stricture required operative anastomotic revision. Postoperative biliary fistula (HR, 4.4; 95% CI, 2.0-9.9; P = 0.0002) was associated with biliary anastomotic stricture; an increased risk for biliary anastomotic stricture was seen in patients with grade A (HR, 6.4; 95% CI, 2.4-16.9; P = 0.0002) and grade B (HR, 3.6; 95% CI, 1.2-10.9; P = 0.02) postoperative biliary fistula.

CONCLUSION

Postoperative biliary fistula after pancreatoduodenectomy, including clinically insignificant, transient biliary fistula, is associated with an increased risk of a late biliary anastomotic stricture requiring stenting.