S0925 The Endoscopic Management of Stricture in Patients With Pancreaticoduodenectomy

Abstract

INTRODUCTION: Stricture formation is a known post-pancreaticoduodenectomy (PD)-related adverse event (AE) and noted to be as high as 8.2% in the first 5 years. In this study, we assessed the safety and efficacy of ERCP for the treatment of choledochojejunostomy and pancreaticojejunostomy stricture. METHODS: We retrospectively evaluated patients with prior classic or pylorus-preserving PD who received ERCP from 01/13/06 to 01/16/19. ERCP reports were analyzed for stricture location, treatment for stricture, and stent characteristics. Outcomes included technical success rate—the ability to treat stricture with dilation or stent placement, and clinical success rate—a decrease in bilirubin to normal or 50% of peak value within 2 weeks. Statistical analysis was done using Stata/SE version 16.0. RESULTS: A total of 28 patients (75% male; median age 66 years, range 22–86 years) with prior PD received 66 ERCPs for biliary (25 patients received 63 ERCPs) and pancreatic (3 patients received 3 ERCPs) evaluation. All 3 ERCPs for pancreatic evaluation were unsuccessful. On hepatobiliary assessment, 16 patients had stricture on initial ERCP: choledochojejunostomy (n = 12), distal extrahepatic (n = 3) and hilar (n = 1). An additional 36 strictures were discovered on repeat ERCPs for a total of 52 strictures. Overall, the most common stricture location was at the choledochojejunostomy (n = 41), then the distal extrahepatic (n = 8), intrahepatic (n = 2), and hilar (n = 1). A total of 38 stents were placed: 33 plastic (86.8%), 3 uncovered metal (7.9%), and 2 covered metal (5.3%). More straight plastic stents (n = 23, 69.7%) were placed than double pigtail stents (n = 10, 30.3%), and the most common stent size was 10 Fr by 5 cm (n = 17, 44.7%). All strictures were treated with balloon dilation and subsequent stent placement when indicated. The technical success rate was 81.0% (51/63 ERCPs) and the clinical success rate was 76.2% (48/63 ERCPs). Procedure-related AEs occurred in 5/66 ERCPs (7.6%): 4 cases of self-resolving fever, 1 case of mild cholangitis. CONCLUSION: ERCP is a safe and effective modality for the management of post-PD-related stricture. The incidence of stricture formation was likely inflated in our population given the nature of a large tertiary cancer-center. Further technological advancements and improvements in technique are required for pancreatic intervention in post-PD patients.