Endoscopic retrograde pancreatography after pancreaticojejunostomy

Background: Retrograde surgical drainage is the treatment of choice for relieving incapacitating abdominal pain in patients (pts) with chronic pancreatitis (CP) and pancreatic duct (PD) dilatation. Lateral pancreaticojejunostomy (PJEJ) - the so-called modified Puestow procedure - has evolved as the most commonly used operation. If symptoms persist or recur after PJEJ, pts often present for endoscopic retrograde cholangiopancreatography (ERCP). To our knowledge, the ERCP appearances after PJEJ have not been reported. Methods: Patients with PJEJ who underwent ERCP at our institution were identified from endoscopic, radiologic, and surgical databases. Hospital charts, endoscopy reports and radiographs were reviewed. Results: Twenty-three pts (12 males/11 females; age 16-76; mean age 47) with previous PJEJ underwent a total of 42 ERCPs between 1989 and 1997. All pts had a history of CP, related to alcoholism (n=10), pancreas divisum (n=4), or hereditary pancreatitis (n=3). CP was considered "idiopathic" in 6 pts. The mean interval between PJEJ and ERCP was 17 months (range 3-96 months). The indication for ERCP was persistent or recurrent abdominal pain in all pts. The anastomosis of PD with jejunum was visualized in 20/22 pts and was located in neck (n = 12) or body (n = 8) of the gland. It appeared patent in 17/20 pts. Rapid drainage of contrast into the jejunum made the interpretation of delayed images difficult. In one pt, a large stone was lodged at the anastomosis which, after removal of the stone, appeared patent. 3/20 pts underwent balloon dilation for anastomotic strictures. The anastomosis could not be identified in 2/22 pts due to an abrupt PD cut-off in the body of the gland; these pts were referred for further surgery. PD strictures in the body of the gland were noted in 4 patients and were treated with step dilators. PD irregularity with structuring in the head of the gland was frequently seen (9/23 pts) and was generally not treated as enteric drainage of the rest of the gland was felt to be adequate. Conclusions: 1. Knowledge of the normal post-operative anatomy is essential for interpreting pancreatograms in patients with pancreaticojejunostomy. 2. Detailed examination of the remaining PD (and/or biliary tree, if indicated) is best performed early during the exam, as contrast accumulation in the jejunum may rapidly obscur details. 3. Anastomotic and ductal strictures can be treated with stricture dilation if clinically indicated.

Duke Scholars

Author Erik Karl Paulson Radiology, Abdominal Imaging

Author Paul Simon Jowell Medicine, Gastroenterology

Author Malcolm Stanley Branch Medicine, Gastroenterology

Author Theodore N. Pappas Surgery, Minimally Invasive Surgery