Late Failure of Frey ProcedureDue toGastro

Atoosa Rabiee
1,2
, Kevin Moreman
2
, Parviz Nikoomanesh
2
, Dana K Andersen
1
Departments of
1
Surgery and
2
Medicine, Johns Hopkins Bayview Medical Center.
Baltimore, MD, USA
ABSTRACT
Context Local resection of the pancreatic head with longitudinal pancreaticojejunostomy (or Frey procedure) generally results in
excellent pain relief in chronic pancreatitis. We report a patient with chronic pancreatitis who experienced pain recurrence after an
uneventful longitudinal pancreaticojejunostomy. Case report This is a single case study of a 58-year-old female with chronic
pancreatitis undergoing longitudinal pancreaticojejunostomy for pain relief. Fifteen months after the surgery, the patient experienced
pain recurrence. Radiologic evaluation followed by surgical exploration revealed a gastroenteric fistula to the Roux-limb, with
obliteration of the anastomosis. After repair of the fistula and re-excavation of the pancreatic head, a two-layer longitudinal
pancreaticojejunostomy was reconstructed from the same Roux-limb. An omental flap was interposed between the Roux limb and
the repaired stomach. At 6-month follow-up, the patient was pain free and asymptomatic. Conclusion Late failure of the Frey
procedure due to a gastroenteric fistula to the Roux-limb of jejunum has not been previously reported. This finding may explain one
of the causes of longitudinal pancreaticojejunostomy late failure.
INTRODUCTION
The local resection of the pancreatic head with
longitudinal pancreaticojejunostomy (or Frey
procedure) has proven to be a durable method for the
relief of pain due to chronic pancreatitis [1]. With
excavation or “coring” out of the pancreatic head
added to a Roux-en-Y longitudinal pancreatico-jejunal
anastomosis, this procedure exceeds the long term
success rate of the Puestow procedure, and has been
shown to provide pain relief to 80% of chronic
pancreatitis patients for up to 5 years [2, 3, 4, 5, 6, 7,
8]. Late failures with recurrence of pain after either the
Frey or Puestow procedure are uniformly ascribed to
progression of the underlying chronic pancreatitis. We
recently cared for a patient with chronic pancreatitis
who experienced complete pain relief after an
uncomplicated longitudinal pancreaticojejunostomy
followed by the abrupt recurrence of pain 15 months
later. Evaluation revealed the spontaneous
development of a gastroenteric fistula from the gastric
antrum to the Roux-limb, presumably due to peptic
ulcer formation. The pancreaticojejunostomy
anastomosis was completely obliterated, suggesting
that the occurrence of the fistula may have caused the
failure of the decompression procedure, and that this
may represent a previously unrecognized cause for the
late
failure
of
Roux-en-Y
longitudinal
pancreaticojejunostomy.
CASE REPORT
A 58-year-old white female with chronic pancreatitis
associated with alcohol abuse underwent a longitudinal
pancreaticojejunostomy procedure in November 2005
after imaging studies confirmed the presence of duct
dilation. The excavation of the pancreatic head was
performed with the Cavitron®
device (Dentsply
International, York, PA, USA), and an uncomplicated
Roux-en-Y longitudinal pancreaticojejunostomy was
performed. No pathology was seen in the remainder of
the gastrointestinal tract. The patient experienced
complete pain relief, and gained 14 kg in the year
following the procedure. In July 2007, the patient
developed mid-epigastric pain associated with nausea
and vomiting, poor appetite, and an 8 kg weight loss.
She denied alcohol use, but was admitted twice with
chemical and CT evidence of acute pancreatitis.
Following initiation of total parenteral nutrition, proton
pump inhibitor and octreotide therapy, CT scan
revealed moderate duct dilatation and the Roux-limb
filled with contrast (Figure 1). EUS revealed a
gastroenteric communication just proximal to the
pylorus (Figure 2) and sonographic changes compatible
Received May 20th, 2009 - Accepted June 5th, 2009
Key words Fistula; Pancreaticojejunostomy; Pancreatitis, Chronic
Correspondence Atoosa Rabiee
Department of Surgery, JHBMC, 4940 Eastern Ave, A5,
Baltimore, MD 21224, USA
Phone: +1-410.550.8959; Fax: +1-410.550.1895
E-mail: arabiee1@jhmi.edu
Document URL http://www.joplink.net/prev/200907/18.html

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JOP. J Pancreas (Online) 2009 Jul 6; 10(4):445-447.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 4 - July 2009. [ISSN 1590-8577]
446
with chronic pancreatitis, with moderate duct dilatation
and a small cystic lesion, aspiration of which revealed
non-mucinous fluid consistent with pancreatic fluid.
An ERCP revealed mild to moderate duct dilatation
with no evidence of communication between the
pancreatic duct and the Roux limb of jejunum (Figure
3). After stabilization of pancreatitis and restoration of
nutritional abnormalities, the patient underwent
abdominal exploration. This confirmed the presence of
the gastroenteric fistula to the Roux-limb (Figure 4).
The fistula was taken down and repaired (Figure 5), the
Roux-limb was elevated from the pancreas, and a
complete occlusion of the prior pancreaticojejunostomy
anastomosis was seen. The pancreas head contained
scar tissue which was excavated (Figure 6) and a two-
layer longitudinal pancreaticojejunostomy was
reconstructed from the same Roux-limb. An omental
flap was interposed between the Roux-limb and the
stomach. The patient made an uneventful recovery, and
6 months later is pain free and has gained 9 kg. Repeat
upper endoscopy confirmed the absence of any lesions
or abnormalities in the stomach and duodenum.
DISCUSSION
Late failure of operative procedures performed for the
relief of pain due to chronic pancreatitis occur in 20-
30% of patients followed for over 5 years after the
performance of either the longitudinal pancreatico-
jejunostomy, the duodenum-preserving pancreatic head
resection or Beger procedure, or the Whipple
procedure [2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. Late failure
rates have been shown to be higher with the Puestow
procedure and higher still after caudal pancreatico-
jejunostomy or Duval procedure. Some symptomatic
failures after an end-to-end pancreaticojejunostomy
anastomosis, such as used in the Whipple, duodenum-
preserving pancreatic head resection, or caudal
pancreaticojejunostomy procedures, may be due to
recurrent stenosis of the pancreatic duct at the site of
the anastomosis [10]. However, with the longitudinal
(side to side) pancreaticojejunostomy late recurrence is
either ascribed to progression of disease in the head of
the gland (after the Puestow or Duval procedure) or
Figure 2. Upper endoscopic view showing the gastroenteric fistula
to the Roux-limb.
Figure 4. A gastroenteric fistula to the Roux-limb was observed at
abdominal exploration.
Figure 1. CT scan showing ductal dilatation and evidence of edema
surrounding the pancreas. The Roux-limb is filled with air and
contrast. The gastroenteric fistula to the Roux-limb is apparent but
was unappreciated at the time of study.
Figure 3. ERCP showing duct dilatation and dilated side branches.

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JOP. J Pancreas (Online) 2009 Jul 6; 10(4):445-447.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 4 - July 2009. [ISSN 1590-8577]
447
progression of the disease throughout the gland.
Mechanical causes for late failure of the decompressive
procedures have rarely been reported.
We discovered the occurrence of a gastroenteric fistula
to the Roux-limb of jejunum used to perform an
uncomplicated longitudinal pancreaticojejunostomy.
This was associated with recurrent pain after an initial
pain-free interval of over one year, and was found to be
accompanied by a complete occlusion of the
longitudinal pancreaticojejunostomy. The cause of the
fistula remains uncertain, but may have been related to
peptic ulcer disease. Takedown and repair of the fistula
was performed and a longitudinal pancreatico-
jejunostomy procedure was again performed, with
interposition of an omental flap between the gastro-
pyloric region and the Roux-limb of jejunum. The
patient was continued on proton pump inhibitors as
well as pancreatic enzyme supplements and her
subsequent recovery has been uneventful. Six months
after the procedure, she is pain free and has gained 9
kg, and upper endoscopy is unremarkable.
The development of gastroenteric fistula formation to
the Roux-limb of the longitudinal pancreatico-
jejunostomy has not been previously reported after
either the Puestow procedure or the longitudinal
pancreaticojejunostomy. Our case therefore raises the
possibility that this unusual development may represent
a cause for late failure after a longitudinal
pancreaticojejunostomy. The mechanism whereby the
development of the fistula causes obstruction of the
pancreaticojejunostomy anastomosis is unclear, but
may be due to the presence of gastric acid within the
defunctionalized Roux-limb. Awareness of this
complication may lead to greater surveillance for this
occurrence. Our experience indicates that upper
endoscopy should be included in the initial evaluation
of patients who experience a recurrence of pain after a
prior operation for chronic pancreatitis.
Conflict of interest disclosure The authors have
nothing to disclose
References
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3. Falconi M, Bassi C, Casetti L, Mantovani W, Mascetta G,
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