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.

No acknowledgements.

None declared.