The Obstructed Pancreatico-biliary Drainage Limb: Presentation, Management, and Outcomes

Introduction: Obstruction of the pancreatico-biliary (PB) drainage limb following major PB operations creates unique diagnostic and management dilemmas. We describe the etiology and prevalence, as well as diagnostic and therapeutic approaches for this challenging problem. Methods: Individuals with PB limb obstruction were identified from a cohort of 477 patients undergoing major PB resections or bypasses for benign and malignant (N=265) diseases from September 2000 to January 2010. Their presentation, management, short-term outcomes, and survival were analyzed. Results: Thirteen patients developed eventual PB limb obstruction with a mean time to presentation of 18.4 months (range 0.5-41.9), representing an overall adjusted incidence of 4%. Presenting symptoms were reflective of limb obstruction (elevated LFTs, jaundice, cholangitis, and pancreatitis). CT scans demonstrated dilation of the PB drainage limb in all 13 patients and evidence of intrahepatic biliary dilation in eight. Endoscopy was not valuable for either diagnostic or therapeutic purposes in the five patients evaluated in this manner. Percutaneous transhepatic biliary drainage (PTC) was pursued in six patients and provided definitive palliation in two, while three were temporized by this modality prior to a definitive operation, and it was employed postoperatively in another. Operative management occurred in 11 of 13 patients. Causative lesions were not accurately predicted by preoperative imaging and included adhesions, limb volvulus, abscess, malignant local recurrence, solitary metastatic disease, and carcinomatosis. Surgical interventions varied (five enteric bypasses, three adhesiolyses, two explorations, and one external limb venting). There were two perioperative mortalities, but limited morbidity otherwise (one myocardial infarction, one wound dehiscence, and one empyema from PTC placement). The median duration of postoperative hospital stay was 9 days, and no patient required readmission for further surgical management. No patients suffered subsequent recurrence of PB obstruction. In follow-up, nine of the remaining 11 patients are deceased with a median survival of 2.3 months (0.6-9.4 months). The other two are alive at a mean follow-up of 48 months. Conclusion: Although infrequent, PB limb obstruction occurs for a variety of reasons and most commonly in the setting of an original malignancy. Since numerous therapeutic modalities are available, an improved understanding of the condition is important in managing these complex patients. Decisive operative intervention accurately assesses the cause and extent of the problem and, for most presentations, provides definitive palliation with limited morbidity for this near-terminal event.