IJHPD – International Journal of Hepatobil iary and Pancreatic Diseases, Vol. 3, 201 3. ISSN – [2230–901 2]

IJHPD 201 3;3:1 7–21 .www.ijhpd.com

Pancreaticoduodenectomy after Roux­en­Y gastric bypass:A single institution retrospective case seriesRyan Helmick, Ranjodh Singh, Jeffery Welshhans,Elliot J Fegelman, Hassan Shahid

ABSTRACTIntroduction: The unique challenges ofpancreaticoduodenectomy in a patient withaltered midgut anatomy secondary to Roux­en­Ygastric bypass are seldom discussed in surgicalliterature. We discuss two such cases at ourinstitution, in light of experiences of otherauthors. Case Series: The two cases reportedhere are different from the majority ofpreviously reported cases as remnantgastrectomy was not performed in eitherpatient. However, one patient did receive agastrostomy tube in the gastric remnant. Theessential differences in existing literature arethe removal of the gastric remnant in otherreports versus a gastrojejunal anastomosis forremnant drainage in our cases, without anyclear advantage in either case. Gastric remnantdissection increases operative time in contrastto gastrojejunal anastomosis, which is a nidusfor complications postoperatively. Withpreservation of gastric remnant however,enteral feeding tube can be placed without

manipulation of the altered anatomy, as theneed arises. Conculsion: Gastric remnantremoval is ideal in decreasing the complexity ofpancreaticoduodenectomy by reducing thenumber of required anastomoses. However,there is an increase in operative time requiredfor dissection of the remnant gastric pouch.Keywords: Gastric bypass, Gastric remnant,Pancreaticoduodenectomy

*********Helmick R, Singh R, Welshhans J, Fegelman EJ,Shahid H. Pancreaticoduodenectomy after Roux­en­Ygastric bypass: A single institution retrospective caseseries. International Journal of Hepatobiliary andPancreatic Diseases 2013;3:17–21.Article ID: 100012IJHPDRH2013

*********doi:10.5348/ijhpd­2013­12­CS­3

INTRODUCTIONIn the United States due to the growing problem ofobesity, many patients are seeking surgical solutions toaid weight loss [1]. Consequently, a growing populationof patients has undergone bariatric procedures and hasaltered foregut anatomy, especially after Roux­en­Ygastric bypass (RYGB). This anatomy poses a diagnosticand therapeutic challenge for foregut andbiliopancreatic diseases.Pancreaticoduodenectomy is a well reportedprocedure with ample data regarding differenttechniques and their complication rates. However,pancreaticoduodenectomy after RYGB is rare and onlyfew reports exist in surgical literature. The management

CASE SERIES OPEN ACCESS

Ryan Helmick1 , Ranjodh Singh2, Jeffery Welshhans3, El l iotJ Fegelman3, Hassan Shahid4

Affi l iations: 1MD, Resident Physician 5th year, Departmentof Surgery, The Jewish Hospital, Cincinnati , OH, UnitedStates; 2MD, Resident Physician 4th year, Department ofSurgery, The Jewish Hospital, Cincinnati , OH, UnitedStates; 3MD, Attending Surgeon, Department of Surgery,The Jewish Hospital, Cincinnati , OH, United States;4Medical Student 3rd year, Department of Surgery, TheJewish Hospital, Cincinnati , OH, United States.Corresponding Author: Ranjodh Singh, MD, 4777 E.Galbraith Rd, Cincinnati , Ohio, United States, USA 45236;Ph: (51 3) 686-5466; Fax No: (51 3) 686-5469; Email :travis287@yahoo.com

Received: 1 8 June 201 2Accepted: 09 October 201 2Published: 02 July 201 3

Helmick et al. 1 7

IJHPD – International Journal of Hepatobil iary and Pancreatic Diseases, Vol. 3, 201 3. ISSN – [2230–901 2]

IJHPD 201 3;3:1 7–21 .www.ijhpd.com Helmick et al. 1 8

of the gastric remnant is the challenge when faced withpancreatic resection in this patient population.The most frequently reported technique ofpancreaticoduodenectomy reconstruction involves aremnant gastrectomy. However, some authors use asecond Roux limb for drainage of the gastric remnant,while others utilize no drainage procedure. Noimmediate complications after pancreaticoduodenectomyhave been reported to date by these methods. Wepresent our experience to illustrate the fundamentalaspects of performing a safe pancreaticoduodenectomyin a patient with prior RYGB.

CASE SERIESTwo patients with prior RYGB for weight losspresented for pancreaticoduodenectomy. Each wastreated by a single surgeon. The patients’ recordsbetween June 2010 and December 2010 wereretrospectively reviewed and analyzed for differences.Patients were assessed first on postoperative morbidityand length of stay, and also compared based on theirpathologic findings and surgical techniques.Comparisons were then made between the two patientstreated at our hospital as well as the available patientreports in the surgical literature.Case 1: The first patient was a 71­year­old male withupper abdominal pain for two weeks and history ofRYGB for weigh loss in 2006. The RYGB was performedat another institution and thus no follow­up history wasavailable. Initial laboratory examination at the time ofadmission demonstrated an elevated alkalinephosphatase 215 μkat/L, carcinoembryonic antigenCEA 1.7 μg/L, and Ca 19–9 54 kU/L. Magneticresonance cholangiopancreatography (MRCP)demonstrated normal biliopancreatic ductal anatomyand a 6 mm cystic lesion in the head of the pancreas.The lesion was not evident on contrast enhancedcomputed tomography (CT) scan. Endoscopic biopsywas not performed in order to avoid potential risk ofperforation and increased risk of pancreatitis.Based on the provisional diagnosis of a cysticpancreatic head mass, we proceeded with a standardpancreaticoduodenectomy involving a distalgastrectomy with removal of the pancreatic head,duodenum, first 15 cm of the jejunum, common bileduct, and gallbladder (Figure 1). The histopathologyshowed an intraductal papillary mucinous neoplasmwith pancreatic intraepithelial neoplasia grade 2. Thepatient was reconstructed in standard fashion withgastrojejunostomy to the remnant stomach. The gastricpouch and roux limb, as well as the jejunojejunostomy,were not altered.Postoperatively the patient was monitored in thesurgical intensive care unit until postoperative day­3.He was quickly advanced to a regular diet. Onpostoperative day­5, the patient experienced aprecipitous decline secondary to bile leak and wasreturned to intensive care. Computed tomography scandemonstrated a leak from the gastrojejunostomy

(Figure 2) and the patient required multiplepercutaneous drains, a percutaneous gastrostomy tube,total parenteral nutrition, dialysis and drotrecogin alfa(activated) at 24 μg/kg/hr for 96 hours. The patientultimately recovered and was shifted to a skillednursing facility on postoperative day 53. This patient isnow deceased.Case 2: The second patient was a 58­year­oldfemale Jehovah’s Witness who presented with a three­day history of epigastric pain with jaundice whichstarted seven days prior to the onset of pain. She alsoreported elevated liver enzymes assessed by her primarycare physician. The patient had undergone a RYGB in2005 for a BMI of 46 kg/m2 with a 19% reduction inBMI at one­year follow­up. A CT scan revealed a 6x14 mmlow attenuation lesion in the head of the pancreas with

Figure 1: Diagrammatic representation of final reconstructionin pancreaticoduodenectomy after Roux­en­Y gastric bypass.

IJHPD – International Journal of Hepatobil iary and Pancreatic Diseases, Vol. 3, 201 3. ISSN – [2230–901 2]

IJHPD 201 3;3:1 7–21 .www.ijhpd.com Helmick et al. 1 9

dilated pancreatic and common bile ducts. Magneticresonance cholangiopancreatography demonstrated adouble duct sign but did not show any lesions. She had apercutaneous transhepatic cholangiogram with externaldrain for biliary decompression. Fluoroscopy via thisdrain demonstrated a sudden termination of the bileduct. Carcinoembryonic antigent CEA level was 10.0μg/L and Ca 19­9 level was <1.0 kU/L. Biopsyperformed by interventional radiologist showed atypicalcells and inflammatory changes.There was no metastatic disease and we proceededwith the pancreaticoduodenectomy. Final pathologyreport showed chronic pancreatitis with fibrosis. Thereconstruction was identical to that in Case 1 with theaddition of a Stamm gastrostomy tube in the remnantstomach.Postoperatively the patient was monitored in theintensive care unit with her gastrostomy tube placed togravity drainage. She was transferred to the ward onpostoperative day­2 and was advanced to a regular diet.Her gastrostomy tube continued to gravity drainageuntil postoperative day­9 when it was clamped. She wasdischarged to a skilled nursing facility for physicalrehabilitation on postoperative day­10. Nocomplications were reported in the subsequent follow­ups. The most current follow­up, six months aftersurgery, shows that the patient remains asymptomatic.

Figure 2: Coronal computed tomography scan of patient onpostoperative day­5. The large arrow indicates the distendedgastric remnant, while the small arrow indicates the leak fromthe gastrojejunostomy.

DISCUSSIONThe population of morbidly obese patients choosingsurgical solutions for weight management is growing byapproximately 200,000 patients yearly [1]. This trendhas generated a large population with altered foregutanatomy creating diagnostic and therapeutic challenges.The RYGB patients who develop pancreatic head massespresent special diagnostic challenges, as the standardpre­operative evaluations with endoscopic ultrasoundand endoscopic retrograde cholangiopancreatographyare generally unavailable. The techniques to performendoscopic retrograde cholangiopancreatography orendoscopic ultrasound in the post­bypass patientrequires surgical access via the gastric remnant [2, 3].Surgically assisted endoscopy is difficult to coordinateand many centers are unfamiliar with the technique.The majority of patients who require decompression ofthe biliary tree will require percutaneous transhepaticcholangiography with external drainage. Definitivesurgical treatment is complicated by the post bypassanatomy and management of the gastric remnant is thekey to safe resection.Rutkoski et al. describe the case of onepancreaticoduodenectomy after bypass for pancreaticadenocarcinoma. The resection was standard and thegastric remnant was drained with a second Roux limb[4]. Although this increased the complexity of theprocedure, the remnant was able to drain and thepatient experienced no immediate postoperativecomplications.The most well reported technique involves resectionof the gastric remnant along with the head of thepancreas and duodenum. Nikfarjam et al. and Khithaniet al. each reported two patients who underwentpancreaticoduodenectomy with remnant gastrectomyprior to pancreaticobiliary reconstruction [5, 6]. Thelargest reported experience is from the Mayo Clinic,where five patients with pancreatic head malignancyunderwent pancreaticoduodenectomy. Four of thosepatients also had remnant gastrectomy, while this wasnot technically feasible in the fifth patient due toadhesions. None of these patients experiencedpostoperative complications [7].Our experience with pancreaticoduodenectomy afterRYGB was markedly different between the two patients.One was critically ill with a prolonged hospital stay andsignificant morbidity, while the other experienced noperi­operative morbidity. The key difference betweenour patients was placement of a gastrostomy tube at theinitial operation. The first patient disrupted hisgastrojejunal anastamosis due to stasis in thebiliopancreatic limb causing gastric distension. Thesecond patient had a gastrostomy tube present, whichfunctioned as an overpressure valve in the immediatepostoperative period. The optimum duration forgastrostomy drainage is approximately seven daysassuming drainage is minimal and patient is toleratingthe diet. If it is not needed for feeding access, thegastrostomy tube may be removed in two months as isstandard for removal of a Stamm gastrostomy.

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A key operative step in patients undergoingpancreaticoduodenectomy after RYGB is decompressionof the biliopancreatic limb and specifically the remnantstomach. Other authors have accomplished this viaremnant gastrectomy, however our cases would suggestthat decompression of the remnant stomach with agastrostomy will suffice as well. Other reported cases ofpancreaticoduodenectomy after RYGB primarilyemphasize removal of the gastric remnant, which ineffect eliminates the potential for a leak from thegastrojejunostomy. The single case reported by Rutkoskiet al. include a drainage procedure for the gastricremnant, the crucial component to this operation [4].Precautionary measures when operating on suchpatients are of utmost importance. The indications forsurgery should be clearly established. However, theseare often difficult in face of limited and altered pre­operative workup. Imaging and endoscopic orientationof altered foregut anatomy is important beforeproceeding with the procedure. A heightened vigilanceduring postoperative period is warranted to monitorpatient for anastomotic leaks.

CONCLUSIONIn patients undergoing pancreaticoduodenectomyafter Roux­en­Y­gastric bypass creation of a second rouxlimb to drain the gastric remnant is not ideal, as thecomplexity of the operation increases and twoanastomoses have the potential for complication.Performing remnant gastrectomy at the time ofpancreaticoduodenectomy simplifies the reconstruction,however increases the difficulty of dissection andoperative time. Placement of a gastrostomy tube withinthe gastric remnant achieves the key aspect of safety,namely drainage of the stomach, while limiting theamount of dissection during the resection. Thistechnique preserves the gastric remnant if enteralfeeding access is required, without manipulation of thegastric pouch or Roux limb, or placement of ajejunostomy tube.

*********Author ContributionsRyan Helmick – Substantial contributions to conceptionand design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedRanjodh Singh – Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedJeffery Welshhans – Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedElliot J Fegelman – Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be published

Hassan Shahid – Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be published

GuarantorThe corresponding author is the guarantor ofsubmission.Conflict of InterestAuthors declare no conflict of interest.Copyright© Ryan Helmick et al. 2013; This article is distributedunder the terms of Creative Commons Attribution 3.0License which permits unrestricted use, distributionand reproduction in any means provided the originalauthors and original publisher are properly credited.(Please see www.ijhpd.com/copyright­policy.php formore information.)

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