Rapid progressive long esophageal stricture caused by gastroesophageal reflux disease after pylorus-preserving pancreatoduodenectomy

Delayed gastric emptying (DGE) is a major postoperative complication after pylorus-preserving pancreatoduodenectomy (PpPD) and sometimes causes reflux esophagitis. In most cases, this morbidity is controllable by proton-pump inhibitor (PPI) and very rarely results in esophageal stricture. Balloon dilation is usually performed for benign esophageal stricture, and esophagectomy was rarely elected. In the present case, there were two important problems of surgical procedure; how to perform esophageal reconstruction after PpPD and whether to preserve the stomach or not.

A 63-year-old man underwent PpPD and Child reconstruction with Braun anastomosis for lower bile duct carcinoma. Two weeks after surgery DGE occurred, and a 10 cm long stricture from middle esophagus to cardia developed one and a half month after surgery in spite of the administration of antacids. Balloon dilation was performed, but perforation occurred. It was recovered with conservative treatment. Even the administration of a proton pump inhibitor (PPI) for approximately five mouths did not improve esophageal stricture. Simultaneous 24-h pH and bilirubin monitoring confirmed that this patient was resistant to PPI. We performed middle-lower esophagectomy with total gastrectomy to prevent gastric acid from injuring reconstructed organ and remnant esophagus through a right thoracoabdominal incision, and we also performed reconstruction with transverse colon, adding Roux-Y anastomosis, to prevent bile reflux to the remnant esophagus. Minor leakage developed during the postoperative course but was soon cured by conservative treatment. The patient started oral intake on the 25th postoperative day (POD) and was discharged on the 34th POD in good condition.

Long esophageal stricture after PpPD was successfully treated by middle-lower esophagectomy and total gastrectomy with transverse colon reconstruction through a right thoracoabdominal incision. Conventional PD or SSPPD with Roux-en Y reconstruction rather than PpPD should be selected to reduce the risk of DGE and prevent bile reflux, in performing PD for patients with hiatal hernia or rapid metabolizer CYP2C19 genotype; otherwise, fundoplication such as Nissen and Toupet should be added.