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Background:
Patients with altered anatomy due to Roux-en-Y gastric bypass (RYGB) present unique diagnostic and therapeutic challenges when they present with periampullary pathology. We describe a series of patients who underwent pancreatoduodenectomy (PD) after gastric surgery with Roux-en-Y reconstruction and review the literature to highlight te...
Context in source publication
Context 1
... some of our patients underwent RYGB at the same institution as the PD, it is worthwhile to note that a variety of options for performing the operation exist and pancreatic sur- geons will need to be vigilant to determine the exact anatomy of these patients and obtain prior operative records. A common configuration after RYGB is shown in Fig. 1, which represents the preferred reconstruction by our bariatric surgeons. Major variations include either a divided or non-divided stomach, and a retrocolic or antecolic Roux limb of varying ...
Citations
... The review found 11 authors that reported pancreatic and cholangiocarcinoma with total 27 reported cases 3,19,[22][23][24][25][26][27][28][29][30][31] . ...
... With regards to surgical management of the pancreatic cancer, majority of authors reported the option of gastrectomy of the remnant stomach and when not feasible gastrostomy was the option of choice. The remnant stomach was spared in six cases where pancreaticoduodenectomy with other with reconstruction was performed3,24,[26][27][28]31 . ...
Background: Pancreatic cancer (PC) is among foremost causes of cancer related deaths worldwide due to generic symptoms and lack of screening. The risk of developing pancreatic cancer in obese or overweight individuals is 1.5 times higher than individuals with a normal BMI. Bariatric Surgery has been associated with a reduction of obesity- related cancer, however, the number of cases that developed pancreatic cancer post Bariatric surgery is not known. Aim: Examine the relationship between Bariatric Surgery and Pancreatic cancer and identify reported cases of pancreatic cancer after bariatric surgery. Materials and Methods: A narrative review of the literature was conducted. A MEDLINE database search was performed using the following Medical Subject Headings (MeSH) terms: pancreatic cancer, bariatric surgery, weight reduction surgery, pancreatic adenocarcinoma. These were combined with the following: postoperative, after surgery, and during surgery. A WebScience search was then performed using similar terms. Additional references were then identified by manual search of the articles obtained from the MEDLINE and Web of Science. Cancer cases that were identified at the pre-operative period or intra-operatively were excluded. The searches covered the period from January 2000 to November 2020. Results/Review: Epidemiological evidence has shown that obesity as a risk factor for the development of PC is a dose dependent risk. The review found that the risk of developing pancreatic cancer in obese or overweight individuals is 1.5 times higher than individuals with a normal BMI. At the same time, evidence from literature demonstrated that weight reduction by dietary restriction, physical activities, pharmacotherapy or weight reduction surgery reduces risk of PDAC. A total of 24 cases of pancreatic cancer were identified and reported post Bariatric Surgery in the literature. The average age at diagnosis was 57.2 years and onset from surgery to diagnosis ranged from 2 months to 25 years. Of the identified cases, 23 cases were post Roux-en-Y Gastric Bypass and one case post Duodenal Switch. The review found that PDAC was the commonest reported pancreatic cancer post bariatric surgery accounting for 58.3%, followed by Neuroendocrine Tumours (NET) 16.7%. Conclusions: Along with weight reduction and improving comorbidities, Bariatric surgery reduces risk of obesity-related carcinogenesis. Given the variation in onset of diagnosis, bariatric surgery did not increase cancer risk but rather accelerated the diagnosis of pancreatic cancer.
... Several studies describe the operative experience for pancreatic adenocarcinoma or biliary strictures in these patients, with fate of the remnant gastrectomy and management of the biliopancreatic limb being key considerations. [30][31][32][33] Given the long duration between RYGB and symptom development, more RYGB patients will likely be referred to hepatobiliary centers for management of benign and malignant biliary disease in the coming years, despite the decreasing frequency of RYGB being performed for morbid obesity. ...
Background
Ampullary stenosis following Roux-en-Y gastric bypass (RYGB) is increasingly encountered. We describe cases of biliary obstruction from ampullary stenosis and choledocholithiasis to illustrate the associated diagnostic and interventional challenges with this condition.
Methods
We reviewed medical records of patients with prior RYGB who underwent a biliary access procedure or surgery for non-malignant disease from January 2012–December 2018.
Results
We identified 15 patients (4 male, 11 female; mean age 53.7 years) who had RYGB on average 11.7 years (range 1–32) years before diagnosis of biliary obstruction. Fourteen patients reported abdominal pain, 5 had nausea/emesis, 12 had elevated liver function tests, and 6 had ascending cholangitis. Mean common bile duct (CBD) diameter at presentation was 16.9 mm (range 4.0–25.0 mm). Operations included 3 transduodenal ampullectomies (2 with biliary bypass), 2 CBD explorations with stone extraction, 1 laparoscopic cholecystectomy alone, 1 Whipple procedure, 1 balloon enteroscopy with sphincterotomy, and 7 transgastric endoscopic retrograde cholangiopancreatography. All ampulla pathology was benign in patients who underwent resection. At follow-up (mean 15.4 months; range 0.23–44.5 months), 12/15 (80%) reported symptom resolution or improvement.
Discussion
Ampullary stenosis after RYGB presents challenges for diagnostic evaluation and intervention, often requiring multi-disciplinary expertise. The underlying pathology remains to be elucidated.
... Reports on PD after a previous RYGB are limited to single patient case reports and case series of handful patients. A review of the international literature revealed a total of 121 patients (7)(8)(9)(10)(11)(12)(13)(14)(15) (16). In this cohort, 20 different reconstruction methods were described out of 37 possible choices, with no significant difference in outcome between the different reconstructive options. ...
The obesity epidemic continues to increase around the world with its attendant complications of metabolic syndrome and increased risk of malignancies, including pancreatic malignancy. The Roux-en-Y gastric bypass (RYGB) is an effective bariatric procedure for obesity and its comorbidities. We describe a report wherein a patient with previous RYGB was treated with a novel reconstruction technique following a pancreaticoduodenectomy (PD). A 59-year-old male patient with previous history of RYGB was admitted with painless progressive jaundice. Imaging revealed a distal common bile duct stricture and he underwent PD. There are multiple options for reconstruction after PD in patients with previous RYGB. The two major decisions for pancreatic surgeon are: (I) resection/preservation of remnant stomach and (II) resection/preservation of original biliopancreatic limb. This has to be tailored to the patient based on the intraoperative findings and anatomical suitability. In our patient, the gastric remnant was preserved, and distal part of original biliopancreatic limb was anastomosed to the stomach as a venting anterior gastrojejunostomy. A distal loop of small bowel was used to reconstruct the pancreaticojejunostomy and hepaticojejunostomy and further distally a new jejunojejunostomy performed. The post-operative course was uneventful, and the patient was discharged on 7th day. With the increase in number of bariatric procedures performed worldwide, pancreatic surgeons should be aware of the varied surgical reconstruction options for PD following RYGB. This should be tailored to the patient and there is no "one-size-fits-all".
... 7 Consequentially, literature on this topic has been primarily restricted to case studies. 15,17 The infrequency of this situation makes it unlikely that this topic could be successfully analyzed through a randomized trial. Thus, it is important to examine operative reconstructions that have been used and their associated outcomes in a collective manner. ...
... Previous studies have argued that decreased operative time, elimination of an added anastomosis, and avoiding injury to the alimentary limb advocate for using the original BP limb if possible. 15 However, there were no significant differences in operative time (360 vs. 302.5 min; P = 0.387), blood loss (400 vs. 375 mL; P = 0.495), or other important outcome metrics or markers of resource utilization in cases that employed the original BP limb or those that used a new secondary Roux. ...
Purpose
This study aimed to identify optimal management decisions for surgeons preforming pancreatic head resection on patients with altered anatomy due to a previous Roux-en-Y gastric bypass (RYGB).
Methods
A multi-national (4), multi-center (28) collaborative of 55 pancreatic surgeons who have performed pancreatoduodenectomy or total pancreatectomy following RYGB for obesity (2005–2018) was created. Demographics, operative details, and perioperative outcomes from this cohort were analyzed and compared in a propensity-score matched analysis with a multi-center cohort of 5533 pancreatoduodenectomies without prior RYGB.
Results
Ninety-six patients with a previous RYGB undergoing pancreatic head resection were assembled. Pathologic indications between the RYGB and normal anatomy cohorts did not differ. Propensity score matching of RYGB vs. patients with unaltered anatomy demonstrated no differences in major postoperative outcomes. In total 20 distinct reconstructions were employed (of 37 potential options); the three most frequent reconstructions accounted for 52.1%, and none demonstrated superior outcomes. There were no differences in outcomes observed between original biliopancreatic limb use (66.7%) and those where a secondary Roux limb was created for biliopancreatic reconstruction. Remnant stomachs were removed in 54.7% of cases, with no outcome differences between resected and retained stomachs. Venting gastrostomy tubes were used in 36.2% of retained stomachs without obvious outcome benefits. Jejunostomy tubes were used infrequently (11.7%).
Conclusions
Pancreatic head resection after RYGB is an infrequently encountered, unique and challenging scenario for any given surgeon. These patients do not appear to suffer higher morbidity than those with unaltered anatomy. Various technical reconstructive options do not appear to confer distinct benefits.
... It has since become and remains the gold standard operation in the battle against the obesity epidemic [2]. Although the risk of developing pancreas cancer after a gastric bypass is low [3], with the increased number of gastric bypass procedures being performed, it is anticipated that the number of patients with gastric bypass requiring a pancreaticoduodenectomy will certainly increase [4,5]. In the event of a periampullary tumor or pancreatic head lesion requiring resection of the head of the pancreas, the operation poses an additional challenge that is the reconstruction of the alimentary tract due to the altered anatomy. ...
... Most cases (25/26) were performed by open approach and remnant gastrectomy was done in 69% of cases (18/26). Although resection of remnant stomach may increase morbidity of the procedure, it is recommended because reduces the number of anastomosis, delayed gastric emptying and other complications related to drainage of the stomach [5]. Robotic pancreaticoduodenectomy is feasible and safe in experienced hands even in patients with prior Roux-en-Y gastric bypass. ...
... Eight of these articles were found to specifically address PD after RYGB. In the included articles, 25 patient cases were reported; our institution included an additional case, for a total of 26 cases (Fig. 1) [13][14][15][16][17][18][19][20]. Table 1 contains a synopsis of all reported cases with regard to clinicopathological characteristics. ...
Background:
Obesity is a risk factor for pancreatic cancer which may be treated with Roux-en-Y gastric bypass and represents an increasing morbidity. Post-RYGB anatomy poses considerable challenges for reconstruction after pancreaticoduodenectomy (PD), a growing problem encountered by surgeons. We characterize specific strategies used for post-PD reconstruction in the RYGB patient.
Methods:
PubMed search was performed using MeSH terms "Gastric Bypass" and "Pancreaticoduodenectomy" between 2000 and 2018. Articles reporting cases of pancreaticoduodenectomy in post-RYGB patients were included and systematically reviewed for this study.
Results:
Three case reports and five case series (25 patients) addressed PD after RYGB; we report one additional case. The typical post-gastric bypass PD patient is a woman in the sixth decade of life, presenting most commonly with pain (69.2%) and/or jaundice (53.8%), median 5 years after RYGB. Five post-PD reconstructive options are reported. Among these, the gastric remnant was resected in 18 cases (69.2%), with reconstruction of biliopancreatic drainage most commonly achieved using the distal jejunal segment of the pre-existing biliopancreatic limb (73.1%). Similarly, in the eight cases where the gastric remnant was spared (30.8%), drainage was most commonly performed using the distal jejunal segment of the biliopancreatic limb (50%). Among the 17 cases reporting follow-up data, median was 27 months.
Conclusion:
Reconstruction options after PD in the post-RYGB patient focus on resection or preservation gastric remnant, as well as creation of new biliopancreatic limb. Insufficient data exists to make recommendations regarding the optimal reconstruction option, yet surgeons must prepare for the possible clinical challenge. PD reconstruction post-RYGB requires evaluation through prospective studies.
A female patient in her 50s presented with abdominal pain, nausea and jaundice. She had a history of prior Roux-en-Y gastric bypass and her body mass index was 52.5 kg/m². Biochemical testing revealed a total bilirubin level of 14.3 mg/dL (normal<1.2 mg/dL) and carbohydrate antigen 19–9 of 38.3 units/mL (normal<36.0 units/mL). CT demonstrated a 3.2 cm pancreatic head mass, biliary and pancreatic duct dilation and cystic replacement of the pancreas. The findings were consistent with a diagnosis of mixed-type intraductal papillary mucinous neoplasm (IPMN) with invasive malignancy. The patient’s Roux-en-Y anatomy precluded endoscopic biopsy, and she underwent upfront resection with diagnostic laparoscopy, open total pancreatectomy, splenectomy and remnant gastrectomy with reconstruction. Pathology confirmed T2N1 pancreatic adenocarcinoma, 1/29 lymph nodes positive and diffuse IPMN. She completed adjuvant chemotherapy. IPMNs have malignant potential and upfront surgical resection should be considered without biopsy in the appropriate clinical setting.
Background and objective:
Bariatric surgery with Roux-en-Y gastric bypass (RYGB) is widely used to treat morbid obesity and present diagnostic and therapeutic challenges in patients with pancreatic and periampullary tumors. The aim of this study was to describe diagnostic tools and challenges in performing pancreatoduodenectomy (PD) on patients with altered anatomy after RYGB.
Methods:
Patients undergoing PD after RYGB from April 2015 to June 2022 at a tertiary referral center were identified. Preoperative workup, operative techniques, and outcomes were reviewed. A literature search was performed to identify articles reporting PD in post-RYGB patients.
Results:
Of a total of 788 PDs, six patients had previous RYGB. The majority were women (n = 5), and median age was 59 years. The patients most commonly presented with pain (50%) and jaundice (50%) with a median of 5.5 years after RYGB. The gastric remnant was resected in all cases, and reconstruction of the pancreatobiliary drainage was achieved using the distal part of the pre-existing pancreatobiliary limb in all patients. Median follow-up was 60 months. The Clavien-Dindo grade ⩾3 complications occurred in two patients (33.3%), and 90 days mortality occurred in one patient (16.6%). The literature search revealed 9 articles reporting a total of 122 cases, specifically addressing PD after RYGB.
Conclusions:
Reconstruction after PD in post-RYGB patients may be challenging. Resection of the gastric remnant and use of the pre-existing biliopancreatic limb may be a safe strategy, but surgeons should be prepared for other reconstruction options for creation of a new pancreatobiliary limb.
Background:
The need for pancreaticoduodenectomy (PD) after Roux-en-Y (RY) reconstruction after tumor removal is expected to increase in future, but current studies on outcome are sparse. This surgery is challenging, due to intraabdominal adhesions and/or anatomical changes introduced by the previous abdominal surgery. Here, we investigated the surgical outcomes of PD after RY reconstruction following tumor removal.
Methods:
We enrolled 283 patients that underwent PD. Surgical outcomes for PD were compared between patients with or without a history of RY reconstruction after tumor removal. Outcomes were also compared between two different surgical procedures for the post-PD reconstruction.
Results:
Among 283 patients, 11 had a history of RY reconstruction after tumor removal (3.9%). Among these, RY reconstructions had been performed where the small intestine was anastomosed to a remnant stomach after distal gastrectomy (n = 2), to remnant stomach after proximal gastrectomy (n = 1), to the esophagus after total gastrectomy (n = 6), or to the hepatic duct after extrahepatic bile duct resection (n = 2). Surgical outcomes were not significantly different between cases with and without RY reconstructions. We identified two different reconstruction procedures after removing the periampullary tumor during PD. The surgical outcomes were not significantly different between these two reconstruction groups.
Conclusions:
The surgical outcome of PD was not significantly affected by a history of RY reconstruction. Similarly, the type of reconstruction performed during PD did not significantly affect the outcome. These results could be useful when planning PD in patients with a history of RY reconstruction after tumor removal.
Little has been reported regarding outcomes of pancreaticoduodenectomy (PD) in patients with previous Roux-en-Y gastric bypass (RYGB). We performed a retrospective case-control study of patients undergoing PD after RYGB from January 2012 through July 2017 at 2 institutions. Of the 380 patients who underwent PD, 12 (3.2%) had previous RYGB. They were matched (by age, sex, diagnosis, operative approach, and year of surgery) to 36 non-RYGB patients undergoing PD (1:3 ratio). No difference was found between groups in mean operative time, length of hospitalization, or postoperative morbidity. A history of RYGB in patients with pancreatic head pathology did not delay surgical intervention. Outcomes of PD were similar for patients who did or did not have prior RYGB.
