Therapeutic pancreatic endoscopy after Whipple resection requires rendezvous access

Introduction

Whipple pancreaticoduodenectomy is an intricate surgical procedure that has traditionally carried a high morbidity and mortality. Despite advances in surgical techniques, the pancreaticojejunal anastomosis remains the ”Achilles heel” of the surgery, and complications including acute duct leaks, stricturing of the pancreaticojejunostomy, and chronic pancreatic fistulae are not uncommon [1] [2] [3] [4] [5]. Acute duct leaks can often be managed conservatively with percutaneous drainage, whereas chronic strictures and fistulae may require more aggressive intervention. When re-operation and surgical revision of the pancreaticojejunal anastomosis is not possible, the only surgical option may be completion total pancreatectomy with or without islet cell autotransplantation [2] [3].

Less invasive measures such as endoscopic treatment of the pancreas in patients who have undergone pancreaticoduodenectomy seems preferable, although this approach poses multiple challenges. The technical success and outcomes of pancreatic therapeutic endoscopic retrograde cholangiopancreatography (ERCP) after Whipple resection remain largely unreported. To date there have been only two small published case series of ERCP after Whipple pancreaticoduodenectomy [4] [5]. In both series, success rates for diagnostic cannulation of the pancreatic duct were low, and neither series specifically addressed pancreatic endotherapy.

References

• 1 Reid-Lombardo K M, Ramos-De l a, Thomsen K. et al . Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases.  J Gastrointest Surg. 2007;  11 1704-1711
• 2 van Berge Henegouwen M I, De Wit L T, Van Gulik T M. et al . Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant.  J Am Coll Surg. 1997;  185 18-24
• 3 Blondet J J, Carlson A A, Kobayashi T. et al . The role of total pancreatectomy and islet auto-transplantation for chronic pancreatitis.  Surg Clin N Am. 2007;  87 1477-1501
• 4 Farrell J, Carr-Locke D, Garrido T. et al . Endoscopic retrograde cholangiopancreatography after pancreaticoduodenectomy for benign and malignant disease: indications and technical outcomes.  Endoscopy. 2006;  38 1246-1249
• 5 Chahal P, Baron T H, Topazian M D. et al . Endoscopic retrograde cholangiopancreatography in post-Whipple patients.  Endoscopy. 2006;  38 1241-1245
• 6 Mallery S, Matlock J, Freeman M L. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: report of 6 cases.  Gastrointest Endosc. 2004;  59 100-107
• 7 Sutherland D E. Current status of beta-cell replacement therapy (pancreas and islet transplantation) for treatment of diabetes mellitus.  Transplant Proc. 2003;  35 1625-1627
• 8 Feitoza A B, Baron T H. Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part I: reconstruction without alteration of pancreaticobiliary anatomy.  Gastrointest Endosc. 2001;  54 743-749
• 9 Feitoza A B, Baron T H. Endoscopy and ERCP in the setting of previous upper GI tract surgery. Part II: Postsurgical anatomy with alteration of the pancreaticobiliary tree.  Gastrointest Endosc. 2002;  55 75-79
• 10 Costamagna G. ERCP and endoscopic sphincterotomy in Billroth II patients: a demanding technique for experts only?.  Ital J Gastroenterol Hepatol. 1998;  30 306-309
• 11 Devereaux B M, Lehman G A, Fein S. et al . Facilitation of pancreatic duct cannulation using a new synthetic porcine secretin.  Am J Gastroenterol. 2002;  97 2279-2281
• 12 Gupta K, Mallery S, Hunter D, Freeman M L. Endoscopic ultrasound and percutaneous access for endoscopic biliary and pancreatic drainage after initially failed ERCP.  Rev Gastroenterol Disord. 2007;  7 22-37
• 13 Kahaleh M, Hernandez A J, Tokar J. et al . EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts.  Gastrointest Endosc. 2007;  65 224-230
• 14 Francois E, Kahaleh M, Giovannini M. et al . EUS-guided pancreaticogastrostomy.  Gastrointest Endosc. 2002;  56 128-133