Two Case Reports of Symptomatic Pancreaticojejunal Anastomotic Stricture after Pancreaticoduodenectomy Managed by Longitudinal Pancreaticogastrostomy

Abstract

Introduction: The management of symptomatic pancreaticojejunal anastomotic stricture has not been well established. Revision of pancreaticojejunostomy anastomosis, endoscopic dilation and stenting, modified Puestow procedure have all been described with variable outcomes. We present a case report of 2 patients of symptomatic pancreaticojejunal anastomotic stricture who were managed by longitudinal pancreaticogastrostomy without any complications and symptom resolution. Method: This is a case report of two patients who underwent pancreaticoduodenectomy, one for pancreatic ductal adenocarcinoma and the other for periampullary tubullovillous adenoma, and developed symptomatic pancreaticojejunal stricture after 21 months and 48 months respectively from the index operation. One patient developed recurrent pancreatitis with progressive dilation of main pancreatic duct distal to the pancreaticojejunostomy identified on CT. The other patient had worsening abdominal pain with progressive dilation of pancreatic duct and formation of pancreaticolith just distal to the pancreaticojejunostomy anastomosis. Both patients were managed with longitudinal pancreaticogastrostomy. The post op course was uneventful and patients developed resolution of symptoms. Results: The two patients who underwent longitudinal pancreaticogastrostomy have remained symptom free since their last surgery with a follow up period of 44 and 46 months respectively. Conclusions: Longitudinal pancreaticogastrostomy, as a management strategy for symptomatic pancreaticojejunal anastomotic stricture, provides a theoretical advantage in terms of favorable anatomy and less adhesions. Moreover, a pancreaticogastric anastomosis is accessible via endoscopy for any intervention that may be needed in the long run. We need more case reports/series and long term outcome data after pancreaticogastrostomy to make definitive conclusions.