The inconsistent nature of symptomatic pancreatico-jejunostomy anastomotic strictures.
BACKGROUND
Pancreatico-jejunostomy strictures (PJS) after pancreatiocoduodenectomy (PD) are poorly understood.


METHODS
Patients treated for PJS were identified from all PDs (n = 357) performed for all indications in our practice (2002 to 2009). Technical aspects of the original operation, as well as the presentation, management and outcomes of the resultant stricture were assessed.


RESULTS
Seven patients developed a symptomatic PJS for an incidence of 2%. 'Soft' glands and small ducts (</=3 mm) were each present in 3/7 of the original anastomoses. Pancreatic fistula occurred in 6/7. The latency period to stricture presentation averaged 41 months. Diagnosis of PJS was confirmed by secretin magnetic resonance cholangio-pancreatography (MRCP). Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) was attempted--each unsuccessfully--in four patients. All patients required operative correction of their PJS by takedown/revision of the original pancreatico-jejunal anastomoses (PJA) (n= 4) +/- a modified Puestow (n= 2). One patient's PJS was completely inaccessible due to dense adhesions. Another patient's stricture recurred and was successfully revised with a stricturoplasty. At a mean follow-up of 25 months, all are alive, but only 4/7 are pain free.


CONCLUSIONS
A symptomatic PJS appears to be independent of original pathological, glandular or technical features but pancreatic fistulae may contribute. Secretin MRCP is diagnostically useful, whereas ERCP has been proven to be therapeutically ineffective. Durable resolution of symptoms after surgical revision is unpredictable.
Demirjian
Aram N
AN
Division of General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
Kent
Tara S
TS
Callery
Mark P
MP
Vollmer
Charles M
CM
D001900:Boston; D002760:Cholangiopancreatography, Endoscopic Retrograde; D049448:Cholangiopancreatography, Magnetic Resonance; D003251:Constriction, Pathologic; D006801:Humans; D010183:Pancreatic Ducts / Q000473:pathology* / Q000601:surgery; D010185:Pancreatic Fistula / Q000209:etiology; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D010193:Pancreaticojejunostomy / Q000009:adverse effects*; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D011237:Predictive Value of Tests; D012086:Reoperation; D013997:Time Factors
Arch Surg. 2009 Dec;144(12):1163-6
20026836
J Gastrointest Surg. 2007 Aug;11(8):949-59; discussion 959-60
17534689
Ann Surg. 2006 Jul;244(1):10-5
16794383
J Am Coll Surg. 2007 Oct;205(4):546-57
17903728
Pancreas. 2010 Jan;39(1):115-6
20019572
Dig Endosc. 2009 Jul;21 Suppl 1:S87-91
19691745
J Hepatobiliary Pancreat Surg. 2007;14(5):514-7
17909723
Int Surg. 2008 May-Jun;93(3):155-7
18828270
Dig Surg. 2004;21(1):54-9
14707394
Arch Surg. 2001 Apr;136(4):391-8
11296108
World J Surg. 2008 Mar;32(3):419-28
18175170
HPB (Oxford). 2010 Apr;12(3):211-6
20590889
Ann Surg. 2003 Apr;237(4):509-14
12677147
J Gastrointest Surg. 2007 Dec;11(12):1704-11
17929105
J Gastrointest Surg. 2009 Jan;13(1):163-73
18496727
Ann Surg. 1993 May;217(5):430-5; discussion 435-8
8098202
Pancreatology. 2009;9(6):729-37
20090394
Dig Surg. 2009;26(3):222-8
19468232
J Gastrointest Surg. 2009 Jul;13(7):1321-7
19415402
Am J Surg. 1998 Sep;176(3):279-82
9776159
J Gastrointest Surg. 2009 Jul;13(7):1182-3
19333663
Arch Surg. 2007 Apr;142(4):371-80
17438173
Ann Surg. 2006 May;243(5):571-6; discussion 576-8
16632990
J Gastrointest Surg. 2006 Jul-Aug;10(7):1072-80
16983793
Surgery. 1999 Aug;126(2):178-83
10455881
Ann Surg. 1997 Sep;226(3):248-57; discussion 257-60
9339931