Endoscopic approach for biliopancreatic disease after pancreaticoduodenectomy: a 10-year single center experience

Aims In surgically altered anatomy (SAA), endoscopic retrograde cholangiopancreatography (ERCP) can be challenging. Limits from the most recent and up-to-date reviews in this field were the comparison of heterogeneous studies in terms of sample and endoscopic technique. Consequently, it remains debatable the choice of the optimal endoscopic approach within this context.

We aim to show our experience and evaluate technical and clinical success of ERCP performed in the setting of pancreaticoduodenectomy (PD).

Methods This study was conducted on a retrospective cohort of patients presenting biliopancreatic complications after PD from 01/01/2012 to 31/12/2022. All patients underwent ERCP at our Digestive and Interventional Endoscopy Unit. Clinical and instrumental data were collected, included anatomical reconstruction, characteristics of biliopancreatic disease and characteristics of endoscopic treatment. Data from follow-up were reported in terms of recurrence of the index disease.

Results 133 patients were included in the study (80 M, mean age 65 years) with 296 total endoscopic procedures (median=2 procedures/treatment). The indications for ERCP were biliary in 76 cases (57.1%) and pancreatic in 38 cases (28.5%), while in 6 cases (4.5%) were biliopancreatic combined leak, and 13 (9.7%) were neoplastic recurrence.

Deep cannulation was registered in 113 out of 133 cases (85%). In 20 out of 133 patients (15%), retrograde cannulation was not achieved. Among these, 8 patients underwent EUS-guided treatment, achieving technical success. Thus, technical success was obtained in 121 patients of 133 (90.9%). 112 out of 121 (92.5%) obtained clinical success: 104 with retrograde approach (92% of whom achieved cannulation) and 8 without it. Nine patients of 112 (8%) experienced adverse event, which were all solved (1 respiratory failure, 2 perforations, 2 cutaneous fistulas due to decubitus of the stents and 4 major bleedings).

Clinical success rates were statistically different between patients with biliary, pancreatic and neoplastic recurrence (93.4% vs 73.6% vs 53.8%, p<0.0001) [1].

Septic patients were 38 (22 M, mean age 68 years, range 50-87) and showed a worse prognosis than non-septic once (clinical success: 25/38, 65.7% vs 87/95, 91.5%, p=0.0001) and a more frequent procedural-related adverse event (8/38, 21%, 6 of them determining clinical failure vs 10/95, 10.5%, p=0.05).

During follow-up of patients who obtained clinical success, 9 patients (8%), patients experienced recurrence of the index biliopancreatic disease with a mean onset of 15 months (IQR 6-38 months).

Conclusions Our case series demonstrated that the use of a pediatric colonoscope in ERCP procedures for patients who have undergone PD is both safe and effective in treating the condition, even in a long-term follow-up.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Mutignani M.. Triple stenting to treat a complete Wirsung-to-jejunum anastomotic leak after pancreaticoduodenectomy. Endoscopy 2018

Publication History

Article published online:
15 April 2024