SIGNIFICANT PROLONGED DELAYED GASTRIC EMPTYING AFTER WHIPPLE PROCEDURE: A MULTI-SPECIALTY APPROACH TO DELAYED GASTRIC EMPTYING PROCESS

Objectives: The Whipple procedure is the gold standard for patients with resectable pancreatic adenocarcinoma. However, it is not, without its fair share of complications, wound infections, anastomotic leak, pancreatic fistula, gastric outlet obstructions, and delayed gastric emptying (DGE) [1,2]. Although DGE has become the most common cause of morbidity; gastric outlet obstruction (GOO) although rarer, should also be considered on the differential [5]. There are two causes of GOO after Whipple procedure using a gastrojejunostomy (GJ). These are the Afferent (ALS) and Efferent Limb syndrome (ELS), which is a mechanical obstruction of either limb. These are difficult to differentiate due to similar presentation, but ALS is described in literature more frequently. Early ELS is typically due to poor surgical technique and presentation can be delayed in the setting of intestinal hernias, adhesions, and usually occurs late due to recurrence of malignancy [1].

We present a 69-year-old patient with pancreatic head adenocarcinoma who underwent Whipple procedure with Portal vein, SMV resection, and reconstruction with polyester vascular graft with extensive dissection of variant replaced common hepatic artery from the SMA. He had high nasogastric tube (NGT) output and was unable to tolerate oral intake. CT and UGI imaging showed no oral contrast through the GJ anastomosis at the efferent loop. He then had Esophagogastroduodenoscopy (EGD) with questionable mechanical obstruction via the efferent limb of his GJ secondary to edema. He underwent Fully Covered Self Expanding Stent (FCSES) placement via EGD and steroid therapy was added for edema. He still had nausea when eating and an UGI still did not show passage beyond GJ efferent loop. The case was complicated by migration of the stent into the stomach and was removed. The efferent loop was patent at the time of stent removal but he still had significant DGE. Although prolonged, he did recover his ability to have oral intake after 9.5 weeks on total parental nutrition (TPN).

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Conclusion: Conservative and interventional approaches have been discussed to manage mechanical and functional obstructions [4,5]. Here we utilized multiple adjuncts with nasogastric decompression, pro-motility agents, TPN, and FCSES and ultimately the DGE resolved. Due to the significant length of inability to take in oral nutrition, both functional and mechanical obstruction, use of interventions, as well as conservative therapy make this case both an educational and a clinical challenge to learn from. Further alternative surgical technique to reduce the DGE may be warranted to explore.