[Causes and treatment of jaundice associated with inflammatory pancreatic disease (author's transl)]

Late morbidity after duodenum-preserving pancreatic head resection with bile duct reinsertion into the resection cavity

BACKGROUND

Reinsertion of the distal common bile duct (CBD) into the pancreatic resection cavity during duodenum-preserving pancreatic head excision (DPPHE) may be an alternative option to Whipple resection or bilioenteric anastomosis when chronic pancreatitis is associated with CBD stenosis.

METHODS

Outcome in 82 patients with chronic pancreatitis who underwent DPPHE with CBD reinsertion was compared with that in 432 who had DPPHE without reinsertion and 50 who had a Whipple procedure or pylorus-preserving pancreatoduodenectomy (PPPD).

RESULTS

There were no deaths after DPPHE with CBD reinsertion, compared with four (0.9 per cent) after DPPHE without reinsertion and three (6 per cent) after classical resection. Overall morbidity rates were 30, 28.9 and 36 per cent respectively. Fifteen patients (18 per cent) who had DPPHE with CBD reinsertion developed a stricture at the reinsertion site, compared with a long-term stricture rate of 2.3 per cent (ten patients) after DPPHE without CBD reinsertion and 4 per cent (two patients) after PPPD/Whipple resection.

CONCLUSION

Although associated with a high incidence of anastomotic stricture, reinsertion of the CBD into the resection cavity as part of DPPHE can be used to preserve duodenal passage and offers an alternative to extended resection for chronic pancreatitis.

Cholestasis due to compression of the common bile duct by pancreatic pseudocysts

We studied 10 patients with pancreatitis who had persistent cholestasis secondary to compression of the common bile duct by a pancreatic pseudocyst. Elevation of the serum bilirubin or alkaline phosphatase levels, or both, (sensitive indicators of cholestasis) was present in each of our patients. The diagnosis of a pancreatic pseudocyst is best made by CAT scan and ultrasonography. These techniques will delineate the small intrapancreatic pseudocyst that otherwise may be difficult to recognize on inspection at operation. Endoscopic retrograde cholangiography and pancreatography are desirable because they delineate the anatomic alterations of the pancreatic and common bile ducts and may contribute information pertaining to the possibility of common duct obstruction by pancreatic fibrosis. In our opinion, cholestasis secondary to bile duct compression by a pseudocyst is an indication for operation. Each of our 10 patients had drainage of their pseudocysts. Cystoduodenostomy, performed in seven patients, was the method most commonly used. If there is concern regarding the patency of the common duct after drainage of the cyst, intraoperative cholangiography should be performed. This was carried out in three patients. In each patient, the preoperative elevations of serum alkaline phosphatase and serum bilirubin levels returned to normal limits after operative decompression of a pancreatic pseudocyst alone without an accompanying or subsequent bilioenteric bypass being required.

Stenosis of the common bile duct in chronic pancreatitis

The incidence of common bile duct stenosis in patients with chronic pancreatitis was studied in a consecutive series of patients admitted for endoscopic retrograde cholangiopancreatography (ERCP). Thirty-six out of 79 patients (46 per cent) with moderate or advanced chronic pancreatitis as defined by radiological criteria were found to have a stenosis of the intrapancreatic portion of the common bile duct. There were no age or sex differences between the patients with and without biliary stenosis, but significantly more patients with stenosis had advanced chronic pancreatitis. In about two-thirds of the patients the stenosis was smooth, symmetrical and tapering. In the remaining cases, a shorter stricture of the hour-glass type was found. A complete obstruction was never seen. About one-half of the patients with bile duct stenosis were icteric at the time of the investigation. The jaundice resolved spontaneously in all but 1 patient in 3-42 (median 14) days. Stenosis of the common bile duct is a frequent complication of chronic pancreatitis, but biliary-enteric bypass operation seems to be unnecessary in the great majority of the patients.