Obstructed pancreaticojejunostomy partly explains exocrine insufficiency after pancreatic head resection.
OBJECTIVE
The majority of patients with long-term survival after pancreatic head resection suffer from pancreatic exocrine insufficiency. The objective of this study was to investigate whether this is due to glandular malfunction or obstructed pancreaticojejunal anastomosis.


METHODS
Twenty-six patients (10 M, 16 F, mean age 61 years, range 34-81 years) were re-examined a median of 52 months (range 3-76 months) after pancreatic head resection and end-to-end invaginated pancreaticojejunostomy. Pancreatic exocrine function was measured by fecal elastase-1 assay. The size of the pancreatic remnant, glandular secretion and the flow through the anastomosis were analyzed with secretin-stimulated dynamic magnetic resonance pancreatography (D-MRP).


RESULTS
All patients had pancreatic exocrine insufficiency, 24 (92%) of them having severe insufficiency. Eighteen patients (69%) reported moderate to severe diarrhea. Lowest fecal elastase-1 concentrations were associated with the initial diagnosis of chronic pancreatitis or ductal adenocarcinoma, suggesting preoperative primary or secondary chronic pancreatitis as important determinants. The size of the remnant gland did not correlate with the fecal elastase-1 concentrations. D-MRP failed in three patients. Severe glandular malfunctions were found in 7 (30%) of the 23 successful D-MRP examinations. The anastomosis was totally obstructed in 5 patients (22%) or partially obstructed in 6 (26%) but remained perfectly open in 5 patients (22%). The five patients with perfect anastomoses had the highest measured median fecal elastase-1 activity.


CONCLUSIONS
Although late diarrhea and pancreatic exocrine insufficiency may be partly induced already by the disease treated with resection, at least half may be explained by obstructed anastomosis. To obtain better late functional results, improvements may be required in the surgical techniques.
Nordback
Isto
I
Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland. isto.nordback@pshp.fi
Parviainen
Mickael
M
Piironen
Anneli
A
Räty
Sari
S
Sand
Juhani
J
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D049448:Cholangiopancreatography, Magnetic Resonance; D010188:Exocrine Pancreatic Insufficiency / Q000175:diagnosis / Q000196:embryology / Q000209:etiology*; D005243:Feces / Q000201:enzymology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods*; D010196:Pancreatic Elastase / Q000378:metabolism; D010193:Pancreaticojejunostomy / Q000009:adverse effects*; D011183:Postoperative Complications; D011379:Prognosis; D013997:Time Factors
D010196:Pancreatic Elastase