Benign Anastomotic Stricture after Hepaticojejunostomy

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Benign Anastomotic Stricture after
Hepaticojejunostomy Incidence? Natural
History? Risk Factors? Management?
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(No Transcript)
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Benign HJ Stricture- The Sinai Hospital Experience
250 hepatico-jejunostomies (200
pancreaticduodenectomy) 5 benign HJ strictures
(2)
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Management Options- Benign HJ Strictures Percuta
neous biliary drainage/balloon cholagnioplasty Pe
rcutaneous wall stent placement Revision
hepaticojejunostomy
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PTC/PBD Algorithm
Initial PTC/PBD Monthly upsizing/balloon
cholangioplasty 6 months PBD Clinical trial
/Biliary Manometery Discontinuation of PBD
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Assessment of PTC/stricturoplasy result
Clinical Trial- stent positioned proximal to
stricuroplasty site (2-3 weeks) Biliary
Manometric Perfusion Test (BMPT) Biliary stent
positioned proximal to site of stricturoplasty,
½ strength contrast material injected at rates
of 2, 4, 8, 15, and 20 ml/minute for 5, 5, 5,
3, 2 min respectively. After each injection
period, intrahepatic pressure monitorednormal
remains less than 20 cm H2O 1 year patency
rates exceed 90 if either study
performed/passed
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Patient/Tumor Characteristics
CBD diam Preop Stent Operation Path 10 mm
None PPW Serous cystadenoma 8 mm
(path) Endostent PPW (fm 1cm) Ampullary
Adenoma 8 mm None PPW (fm 1cm)
IPMN 12 mm B PTC HJ (Roux-en-y)
Benign Stricture CBD (hx
gallstones/ERCP/ stent x 2) 6 mm
None PPW (fm 1cm) Metastatic
Colorectal UGI bleed 3rd portion
duodenum
GD JC PG CG TW
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Time to Stricture Management
Long-term
88 mos PTC/PBD (benign) ? 1 mos 8
mos PTC/PBD (benign) Revision
HJ 6 mos 12 mos 24 mos PTC/PBD
(benign stone) None 6 mos 24 mos 11
mos PTC/PBD (benign stone)
? lt1mos 12 mos PTC/PBD (benign)
Revision HJ 6 mos 2 mos
GD JC PG CG TW
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STUDY DESIGN
Retrospective review of a prospectively collected
patient database derived from the Johns Hopkins
experience with pancreaticoduodenectomy for
periampullary disease.
Period of study Jan 1995 - Apr 2003 (100
months) Total patients 1,595 1203
malignant 392 benign Total surgeons 11
From House, et. al Presented at Pancreas Club
Meeting 2005
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Incidence of biliary strictures
Number of HJ strictures (Incidence) Patients
overall 42 (2.6) Patients w/ benign
disease 10 (2.6) Patients w/ malignant
disease 32 (2.6) Median time to stricture
formation (Range) Patients overall 13 mo (1
- 106) Patients w/ benign disease 13.5 mo
(1-50) Patients w/ malignant disease 13 mo
(2 106)
From House, et. al Presented at Pancreas Club
Meeting 2005
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Tumor-related risk factors for biliary strictures
With post-op Without post-op Stricture Stricture
N ( of pts) N ( of pts)
P-value
Total patients 42 1,553 Pre-op
jaundice Present 27 (64) 1040 (67)
0.72 Tumor Factors Benign pathology 10
(24) 382 (25) 0.54 Malignant
pathology Pancreatic cancer 18 (43) 654
(42) 0.92 Cholangiocarcinoma 8
(20) 153 (10) 0.09
Ampullary cancer 2 (5) 180 (12)
0.26 Nodal disease 22 (52) 644
(41) 0.21
From House, et. al Presented at Pancreas Club
Meeting 2005
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Surgeon-related risk factors for biliary
strictures
With post-op Without post-op Stricture Stricture
N ( of pts) N ( of pts)
P-value
Total patients 42
1,553 Preoperative Factors Biliary stenting 27
(64) 992 (64) 0.92 Endostent 8
(19) 555 (36) 0.04 PBD 19 (45)
437 (28) 0.025 Operative
Factors Procedure PPPD 29 (69) 1,096 (71)
0.87 Classic 10 (24) 383 (25)
0.89 Total 3 (7) 74 (5)
0.95 EBL (ml) 972 102 918
24 0.13 Operative time (min)
376 12.5 380 2.5 0.67
From House, et. al Presented at Pancreas Club
Meeting 2005
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Surgeon-related risk factors for biliary
strictures
With post-op Without post-op Stricture Stricture
N ( of pts) N ( of pts)
P-value
Total patients 42
1,553 Postoperative Factors Biliary stenting 27
(64) 698 (45) 0.013 PBD 19
(45) 398 (26) 0.007
T-tube 8 (19) 300 (19)
0.89 Pancreatic fistula 3 (7) 186 (12)
0.85 Chemoradiotherapy 19 (60) 489
(42) 0.085
From House, et. al Presented at Pancreas Club
Meeting 2005
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Multivariate risk factors for biliary strictures
Odds ratio P-value 95 CI
Pre-op PBD 2.38 0.15 0.75 - 4.75 Post-op
PBD 2.11 0.18 0.82 - 4.85 Cholangiocarcinoma
1.56 0.20 0.62 2.20
From House, et. al Presented at Pancreas Club
Meeting 2005
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MANAGEMENT OF HJ STRICTURES
PBD/serial balloon cholangioplasty 37/42
(88) PBD/wallstents 3/42 (7) PBD/redo
HJ 2/42 (5)
From House, et. al Presented at Pancreas Club
Meeting 2005
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OUTCOMES
Overall Benign Malignant
Mean PBD exchanges/manipulations 7.5 (1
38) 11.7 (1 38) 6.25 (1 25) Median duration
of PBD (mos) 5.5 (0.5 82) 6.75 (1 82) 5.5
(0.5 47.5) Mean admissions for stricture
management 1.6 (0 6) 1.1 (0 6) 1.75 (0 5)
From House, et. al Presented at Pancreas Club
Meeting 2005
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Outcomes of patients with malignant disease and
HJ strictures
Number of patients 32 Stricture
management Balloon cholangioplasty 28
Wallstent 3 Redo HJ 1 Tumor
recurrence at time of stricture
Biliary/anastomotic 3/32 (9)
From House, et. al Presented at Pancreas Club
Meeting 2005
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CONCLUSIONS

• Stricture at the site of the hepaticojejunostomy
  following Whipple occurs in 2.5 of patients,
  regardless of benign v. malignant disease
• Univariate risk factors for stricture use of
  preop PBD, presence of nodal disease, and
  cholangiocarcinoma
• Postoperative biliary strictures in Whipple
  patients with a history of malignant disease
  should not be attributed to recurrent disease at
  the HJ anastomosis
• Biliary strictures can be managed successfully
  with percutaneous biliary drainage and dilatation
  in most cases

From House, et. al Presented at Pancreas Club
Meeting 2005