Surgical Procedures for Biliary Stricture in Chronic Pancreatitis

Abstract

Background: Biliary stricture (BS) in chronic pancreatitis (CP) is observed in up to 21% of patients
with CP. However, there are no clearly established criteria when the one should operate in case of the
CBD dilatation without increased liver enzymes. Attention is now paid to endoscopic interventions, the
disadvantage of which is the need for repeated procedures, as well as less effectiveness in the treatment
of pain in CP, while the operation can be aimed at various manifestations of CP. Early surgery - up to 3
years from onset of symptoms of CP showed improved results in terms of pain and exocrine function,
but it is unknown whether it is of value in prevention of BS.
Goal. To determine the optimal timing of surgery to prevent biliary stricture in CP, the optimal type of
intervention in the bile ducts, the optimal combination of surgery on the bile ducts and pancreas and to
establish indications for the latter.

Materials and methods: Retrospective analysis of case histories of patients who were operated
due to chronic pancreatitis from 2001 to 2020. Diagnostic criteria of BS were mechanical jaundice
and/or dilatation of CBD ≥10 mm. BS was confirmed by intraoperative cholangiography (IOCG).
Choledochoduodenostomy (CDS), hepatic and choledochoenterostomy (GEA / HEA), transduodenal
papillosphincterotomy (TDPST), duodenum-preserving resections of the pancreatic head (DPRPH)
were performed. The effectiveness of operations assessed by the absence of cholangitis / mechanical
jaundice during observation. Statistical analysis was performed using IBM SPSS Version27. Pearson's
χ², Fisher's exact criterion, was used to analyze categorical data. The level of statistical significance is
set at p <0,05 .

Results: No recurrence of BS achieved in 85.7% of patients. Recurrence of BS (cholangitis / jaundice)
was observed in 8 patients (14.3%). Signs of recurrence were found: in the group of TDPST in 33.3%,
in 16.7% of patients with CDS, in 9.7% of patients with DPRPH. For the latter, resection decompression
was supplemented in these patients by fenestration of the choledochus into the resection cavity. BS was
observed in 18.8% of patients with symptoms lasting up to 3 years and in 33.8% - more than 3 years.

Conclusions: Surgery up to 3 years from the onset of symptoms of CP prevents the occurrence of BS.
Dilatation of the choledochus ≥10 mm in a patient with CP indicates the presence of BS. In the case of
an inflammatory mass or pseudocyst in the head of the pancreas as a cause of BS, it may be sufficient
to eliminate it via DPRPH, in particular Frey's procedures. If external decompression of the CBD was
not sufficient, the best operation is choledochoenteroanastomosis (GEA / HEA). In the absence of
inflammatory mass in the head, it is also advisable to combine pancreatojejunostomy with GEA / HEA.