Rapid progressive long esophageal stricture caused by gastroesophageal reflux disease after pylorus-preserving pancreatoduodenectomy

Abstract

Background: Delayed gastric emptying (DGE) is a major postoperative complication after pylorus-preserving pancreatoduodenectomy (PpPD) and sometimes causes reflux esophagitis. In most cases, this morbidity is controllable by proton-pump inhibitor (PPI) and very rarely results in esophageal stricture. Balloon dilation is usually performed for benign esophageal stricture, and esophagectomy was rarely elected. In the present case, there were two important problems of surgical procedure; how to perform esophageal reconstruction after PpPD and whether to preserve the stomach or not.

Case presentation: A 63-year-old man underwent PpPD and Child reconstruction with Braun anastomosis for lower bile duct carcinoma. Two weeks after surgery DGE occurred, and a 10 cm long stricture from middle esophagus to cardia developed one and a half month after surgery in spite of the administration of antacids. Balloon dilation was performed, but perforation occurred. It was recovered with conservative treatment. Even the administration of a proton pump inhibitor (PPI) for approximately five mouths did not improve esophageal stricture. Simultaneous 24-h pH and bilirubin monitoring confirmed that this patient was resistant to PPI. We performed middle-lower esophagectomy with total gastrectomy to prevent gastric acid from injuring reconstructed organ and remnant esophagus through a right thoracoabdominal incision, and we also performed reconstruction with transverse colon, adding Roux-Y anastomosis, to prevent bile reflux to the remnant esophagus. Minor leakage developed during the postoperative course but was soon cured by conservative treatment. The patient started oral intake on the 25th postoperative day (POD) and was discharged on the 34th POD in good condition.

Conclusion: Long esophageal stricture after PpPD was successfully treated by middle-lower esophagectomy and total gastrectomy with transverse colon reconstruction through a right thoracoabdominal incision. Conventional PD or SSPPD with Roux-en Y reconstruction rather than PpPD should be selected to reduce the risk of DGE and prevent bile reflux, in performing PD for patients with hiatal hernia or rapid metabolizer CYP2C19 genotype; otherwise, fundoplication such as Nissen and Toupet should be added.

Keywords: Delayed gastric emptying; Esophageal stricture; Esophagectomy; Pancreatoduodenectomy.

Fig. 1

Upper gastrointestinal series. Severe long esophageal strictures and sliding esophageal hiatal hernia were confirmed. The narrow lesion is between white arrows; the length was 10 cm

Fig. 2

a. Endoscopic findings on the 150th POD after PpPD showed severe stricture of the middle thoracic esophagus and longitudinal esophageal ulcer scars on the oral side. b Endoscopic findings before PpPD showed sliding esophageal hiatal hernia and mild esophagitis, which was classified as Grade A according to the Los Angeles classification

Fig. 3

Simultaneous 24-h pH and bilirubin monitoring. In the narrow lesion, the proportion of time at pH < 4 was 3.0 %. With a drip of omeprazole of 20 mg, pH in the stomach rapidly increased to approximately 6 and but then rapidly decreased to less than 4. (Omeprazole treatment was started 3 days before the test.) The fraction of time with pH < 4 was 89.3 %. Just beyond the narrow lesion, the proportion of time at bilirubin absorbance >0.14 was 20.4 %

Fig. 4

Schema of the operation. The first surgical procedure involved PpPD and Child reconstruction with Braun anastomosis. We performed middle-lower esophagectomy and total gastectomy through a right thoracoabdominal incision. The transverse colon with the vascular pedicle of the left colic vessel was pulled up to the cut end of the esophagus through a hiatus. The anal cut end of the transverse colon was anastomosed to the jejunum in a Roux-Y fashion. Jejunojejunostomy was performed 40 cm from the anal side of the colonojejunostomy