Stenotic Complications of Chronic Pancreatitis

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Stenotic Complications of Chronic Pancreatitis

• V Baskaran
• Department of Surgery
• Armed Forces Medical College
• Pune

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Magnitude of the problem

• Initially thought to be uncommon
• Current figures 50 of patients of CP
  undergoing surgery

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Stenotic complicationsPathophysiology

• Extension of inflammation into peripancreatic
  tissues
• Involve CBD, duodenum, colon, Portal vein,
  Splenic vein
• Oedema
• Fibrosis
• Transient or Permanent
• To be distinguished from compression caused by
  pseudocysts

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Stenotic complications

• CBD
• Duodenum
• Colon

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Bile duct stricture
21

• Incidence 3.2 to 62 !!
• Clinical jaundice 7.8 to 9
• Anicteric cholestasis gt 8.5

Complications
Where to draw the line?
Cholestasis
No cholestasis
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Bile duct stricture
CP patients 78
Stricture 50
Prox dilatation 24
No dilatation 26
Altered LFT 3
Altered LFT 16
Clinical Jaundice 5
Angelina et al Ital J Gastroenterol 1994
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Bile duct stricture

• Equal incidence in alcoholic non-alcoholic CP
• Higher incidence in CP with inflammatory head
  mass

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Bile duct strictureNatural history

• Difficult to predict!
• Many resolve
• Some persist
• Some progress
• Complications

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Bile duct strictureComplications

• Cholangitis 6-15 of stricture patients
• Biliary cirrhosis- 3 to 10
• Liver fibrosis
• Common -up to 73
• Not evaluated often
• Reduction after decompression

Huizinga et al Int Surg 1993
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Bile duct stricture Morphological types

• Long regular stenosis
• Short stenosis at upper margin of head of
  pancreas
• ?Stenosis at distal CBD

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Bile duct stricture

• CBD obstruction does not cause pain in patients
  with CP
• Prior PJ does not prevent development of CBD
  stricture later

Kahl S et al Pancreas 2004
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Bile duct stricture When to intervene?

• Absolute indications
• Complications
• Persistent jaundice
• Relative indications
• Being considered for intervention for some other
  reason
• Previous history of cholangitis
• Dilated system with cholestasis
• Observation

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Bile duct stricture Management options

• Observation
• Endoscopic biliary stenting
• Surgery

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Bile duct stricture Endoscopic stenting

• Technically possible nearly in all
• Risk of stent block cholangitis
• Regular change mandatory with plastic stents
• Better results with metallic stents

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Bile duct stricture Results - plastic stents-Best

• Protocol- dilatation stenting
• Change 3-4 months
• 80 of strictures respond and dilate after a
  course of stenting for 12-18 months
• Stricture free mean follow-up 32 m

Vitale G et al Surg Endosc 2000
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Bile duct stricture Results - plastic stents

• Respond better to the increasing numbers of
  endoscopic stents, and remain stent free for
  medium term periods

Pozsar A et al Eur J Clin Gastroenterol. 2004
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Bile duct stricture Results - plastic
stents-Usual

• Improved 18
• Improved but stricture persists 41
• Failure 31
• Death 10

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Bile duct stricture Results - plastic stents

• Excellent short term results
• Moderate medium term results median 40 months
• 17-fold risk of failure of a 12 month course of
  endoscopic stenting more with calcifications of
  the pancreatic head

Kahl S et al Am J Gastroenterol. 2003
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Bile duct stricture Results - plastic stents

• The high incidence of late complications due to
  non-compliance is a limitation of stenting in
  alcoholic CP
• Potentially harmful.

Kiehne K et al Endoscopy 2000
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Bile duct stricture Results with metallic stents

• Excellent short-term results
• Moderate to excellent medium term results
• In long-term treatment for purely palliative
  purposes, metal stents remain patent far longer
  than plastic stents

Born P et al Hepatogastroenterology. 1998
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Bile duct stricture Results with metallic stents

• Most patients with metallic stents will develop
  recurrent cholangitis or stent obstruction
• Chronic inflammation and obstruction may
  predispose the patient to cholangiocarcinoma

Lopez RR Jr et al Arch Surg. 2001
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Bile duct stricture Surgical options

• Choledochoduodenostomy
• Choledochojejunostomy
• Cholecystoduodenostomy
• Cholecystojejunostomy
• T-tube drainage
• Resectional procedures

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Bile duct stricture Surgical procedures

• Higher initial post procedure risk
• Acceptable morbidity in the majority
• Near zero mortality
• Excellent long term results

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Bile duct stricture Surgical drainage

• CDD and CDJ are safe and reliable
• CCE is associated with failure in 50 31
  require conversion to CDD or CDJ
• Cholecystojejunostomy only for the terminal
  patients requiring a short-term biliary bypass

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Bile duct stricture Stenting vs surgery

• gt30 do not benefit of biliary stenting, who are
  candidates for surgery
• Surgical treatment provides better long-term
  results than endoscopic therapy
• Along with another surgical procedure

Pozsar A et al Eur J Clin Gastroenterol. 2004
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Bile duct stricture Stenting vs surgery

• Initial therapy before surgery
• Can be the definitive approach for older and
  morbid patients
• Should not be considered as a routine procedure
  for symptomatic cases

Eickhoff A et al Eur J Gastroenterol Hepatol.
2001
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Bile duct strictureWhat to offer?

• Absolute indications
• Good risk pt- surgery
• Plan to delay surgery- Stenting
• Poor risk pt- Stenting
• Failure of endoscopic drainage Surgery
• Relative indications
• Being considered for intervention for some other
  reason -Surgery
• Previous history of cholangitis Surgery
• Dilated system with cholestasis

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Duodenal stricture
17

• Incidence 1 to 36 !!
• Wide spectrum
• Majority transient
• Diagnose on history
• Confirm with Ba meal UGIE
• Exclude common causes of GOO

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Duodenal stricture Pathophysiology

• Second part, at times 3rd part
• Duodenal wall oedema
• Intramural haematoma
• Fibrous stricture
• Cause- ?Ischaemic

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Duodenal stricture Natural history

• Majority transient
• Most partial obstruction
• Few- complete obstruction

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Duodenal stricture When to intervene

• Most need no intervention
• TPN
• Intervention when obstruction persists for gt 2
  weeks

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Duodenal stricture Surgical options

• GJVagotomy
• Pyloroplasty
• Stricturoplasty
• Duodenal widening with pedicled jejunal transplant

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Duodenal stricture Pancreaticoduodenectomy

• Coexisting strictures of PD and CBD
• Severe pain associated with GOO

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Colonic stricture

• Very rare
• Involvement of tr colon splenic flexure
• Usually short segment stricture
• Adynamic ileus of tr colon
• Resection

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Stenotic complications of CPSummary

• Frequent
• Higher detection with higher index of suspicion
  higher level of investigations
• Majority need no therapy
• Intervention to be tailor made
• Stents- Low initial risk with high cumulative
  risk
• Surgery- High initial risk with low cumulative
  risk