THE PATH TO WHIPPLE RECONSTRUCTION: TRANS-MESOCOLON OR THROUGH LIGAMENT OF TREITZ?
Adriana C. Gamboa*, Mohammad Y. Zaidi, Rachel M. Lee, Juan M. Sarmiento, David Kooby, Maria C. Russell, Kenneth Cardona, Shishir K. Maithel
Emory University, Atlanta, Georgia
The path of the jejunal limb for reconstruction of the pancreatic anastomosis during pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) can be trans-mesocolon (TM) or through the ligament of Treitz (LOT). Even after curative intent PD, incidence of recurrence in the surgical bed remains high and may lead to obstruction of the afferent limb. However, the association between path of jejunal limb and incidence of afferent limb obstruction (ALO) has not been studied. Primary aim was to determine whether path of reconstruction predisposes to ALO in the setting of local recurrence.
Pts who underwent PD for PDAC(2008-18) from a single institution were identified. As disease recurrence is the predominant cause of ALO, analysis was limited to pts with known recurrence at date of last f/u. Given a known median time to recurrence of 8-10mos after resection for PDAC, analysis was further limited to pts with at least 8mos of f/u. Primary outcome was incidence of ALO.
Of 517pts identified, 179 were included. Median age was 65yrs; 51% were male. Median f/u was 22mos. Path of reconstruction was TM in 36%(n=64) and through LOT in 64%(n=115). There was no difference between the two groups in clinicopathologic factors including age, tumor differentiation, grade, T-stage, N-stage, LVI or PNI (all p>0.05). Importantly, there was no difference in retroperitoneal margin positivity between groups (TM:8% vs LOT:10%, p=0.79). Both groups had similar post-operative outcomes including incidence of pancreatic fistula (TM:5% vs LOT:6%, p=0.74), median LOS (TM:6d vs LOT:6d, p=0.89) and median f/u (TM:21mos vs LOT:23mos, p=0.68).
ALO was detected in 8%(n=14) of which 14%(n=2) were in the TM group and 86%(n=12) were in the LOT group. Therefore, incidence of ALO was 3.1% in the TM group and 10.4% in the LOT group resulting in an absolute risk increase of 7.3%, risk ratio of 3.4 and relative risk increase of 2.3. There was no difference in median time to ALO between the groups (17.6mos vs 18.5mos, p=1.0). ALO was caused by locally recurrent PDAC in 93%(n=13) and kinking of the duodenojejunal anastomosis in 7%(n=1). Intervention was performed in 71%(n=10) and included surgical bypass in 29%(n=4), percutaneous drain in 21%(n=3) and endoscopic/surgical decompression in 21%(n=3).
Afferent limb obstruction is a known complication after PD for PDAC due to local recurrence in the surgical bed. This study shows that path of jejunal limb through the LOT may be associated with a higher incidence of afferent limb obstruction compared to TM as the position of the afferent limb in the surgical bed may be more predisposed to obstruction after local recurrence. Larger studies are needed; however, given this potential risk of subsequent obstruction, these data suggest that the reconstruction paths may not be equivalent when performing PD for PDAC.
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