Figure 1. Intra operative picture showing marginal perforation in
gastrojejunostomy site along with previous rooftop incision done for
Whipple’s procedure.
Discussion
Whipple procedures (Pancreatoduodenectomy) are complex surgical
procedures performed for variety of benign and malignant lesions
affecting the pancreatic head and periampullary
region.1,4,5 Despite advances in surgical techniques,
postoperative complications still show up and this has been documented
to be around 40 percent of all cases.5
Various complications of Whipple procedure have been described in
literature. Although short term complications such as pancreatic
fistula, hemorrhage, and abdominal sepsis are among the most dangerous
complications after pancreatectomy, long term complications also need to
be monitored; some of them include marginal ulcer, reflux esophagitis,
diabetes mellitus, and biliary stricture.1,4
Marginal ulcers that occur at or within 3cm of the gastrojejunal or
duodenojejunal anastomosis are well known long term complication of the
surgery3 and they tend to occur at a time varying from
1 month to 6 years after surgery.6 The incidence of
marginal ulcer ranges from 0% to 18% , and the median time to
diagnosis is 15.5 months.3 In our case , patient
presented with the condition after 6 years of surgery.
Patients may present with varied symptoms. They can present with
epigastric pain, gastrointestinal upset and dysphagia owing to
stricture. They can also land up in emergency department with
complications such as severe bleeding, perforation and
peritonitis.1,6,7 Our patient also presented with
perforation with peritonitis which is considered to be fatal unless
promptly treated.6
While several mechanisms have been proposed for the etiology of these
ulcers, the commonly believed mechanisms include gastric acid
,inflammation, angulation, foreign bodies and ischemia on the
gastrojejunal anastomosis.1,2,6 Risk factors include
smoking, use of alcohol, Non-steroidal anti-inflammatory drugs (NSAIDS),
immunosuppressive medications and discontinuation of Proton pump
inhibitors (PPI) among others. 3,8
Treatment of marginal ulcer consists of elimination of risk factors, PPI
, and regular endoscopic monitoring.9 They are rarely
refractory to medical management which brings up the necessity of
revision surgery that includes resection and reconstruction of
anastomosis.9,10 Emergency laparotomy is necessary
when patient presents with perforation of marginal ulcer; perforated
ulcer can be managed with simple closure and omental patch
closure.1,9 In our case, the patient also presented
with perforated ulcer and it was closed with omental patch.
Acknowledgement
No acknowledgements.
Conflict of interest
None declared.