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\title{Perforated marginal ulcer following Whipple procedure: A case report}



\author[1]{Sabina Rijal}%
\author[2]{Shila Awal}%
\author[3]{Sunil Basukala}%
\author[4]{Kunda Shah}%
\affil[1]{Western Command Hospital}%
\affil[2]{Suryabinayak Municipal Hospital}%
\affil[3]{Nepalese Army Institute of Health Sciences College of Medicine}%
\affil[4]{Nepalese Army Institute of Health Sciences}%


\vspace{-1em}



  
  \date{June 06, 2024}


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Perforated marginal ulcer following Whipple procedure: A case report

Abstract

Marginal ulcers are rare complications of pancreatoduodenectomy. Patient
can present with varying symptoms such as epigastric discomfort, pain,
dysphagia, or can land in emergency with complications like bleeding and
perforation.

Introduction

Whipple procedures are performed for variety of benign and malignant
lesions affecting the pancreatic head, duodenum, and distal bile
duct.\textsuperscript{1} Marginal ulcer, one of the rare long term
complications of pancreatoduodenectomy, are ulcerations that occur at or
around the gastrointestinal anastomosis.\textsuperscript{2} Their
associated morbidity and mortality have been infrequently described in
literature.\textsuperscript{3} Here we present a case of a gentleman
with a 6 year old history of Whipple procedure who presented in
emergency department with acute onset abdominal pain and was later
diagnosed with perforated marginal ulcer.

Case presentation

A 64-year-old retired soldier who underwent the Whipple procedure six
years ago for carcinoma head of pancreas, adenocarcinoma
(well-differentiated adenocarcinoma) presented to emergency department
with complaints of severe abdominal pain for a one day on the day of
presentation. The pain was acute in onset, continuous, non-radiating,
and increasing in severity, which used to be aggravated after ingestion
of food and movement. He had three episodes of vomiting since morning on
the day of presentation. On his past history, he underwent the Whipple
procedure six years ago and has received complete six cycles of
chemotherapy after surgery. He was under irregular follow-ups for past
two years. The patient had no other comorbid illnesses.

On his arrival to the emergency department, his pulse rate was 130beats
per minute, regular; oxygen saturation 85 \% on room air; blood pressure
110/70 mm Hg, body temperature 38.7 *C, and respiratory rate(RR) 22
breaths/min. On his physical examination, his abdomen was distended with
diffuse tenderness. There was diffuse guarding and rigidity all over the
abdomen. Bowel sounds were absent. Digital rectal examination revealed a
normal sphincter tone with a collapsed rectum and absent fecal stain on
the gloved finger. He was immediately administered crystalloids and
supplemental oxygen at 4 L/min. Nasogastric tube decompression and Foley
catheterization were done. His laboratory parameters showed leukocytosis
with raised amylase. Liver function test revealed total bilirubin 1.80
mg/dL, conjugated bilirubin 0.8 mg/dL and alkaline phosphatase 712U/L.
On radiological examination, supine abdominal X-ray showed prominent
dilated small bowel loops and free gas under right hemi diaphragm
pointing towards hollow viscous perforation (Fig. 1). Ultrasonography of
the abdomen and pelvis was unremarkable with minimal free fluid in the
pelvis.

After an initial fluid resuscitation, an emergency laparotomy was done.
Intraoperatively, The findings were 300 ml of bilious fluid in the
peritoneal cavity and dense adhesion between the small bowel loops and
previous surgical scar. Adhesions were meticulously released and
gastrojejunostomy site perforation was there, which was around 1 cm
Fig.1. A thorough peritoneal lavage was done and the gastrojejunostomy
site perforation was closed with a well-vascularized omental patch after
a biopsy from the ulcer edge. He received Meropenem IV 1 g and
Vancomycin IV 500 mg twice daily along with low molecular weight Heparin
60 mg twice daily the following day. His condition gradually improved
and was discharged on 10\textsuperscript{th} post operative day.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1. Intra operative picture showing marginal perforation in
gastrojejunostomy site along with previous rooftop incision done for
Whipple's procedure.

Discussion

Whipple procedures (Pancreatoduodenectomy) are complex surgical
procedures performed for variety of benign and malignant lesions
affecting the pancreatic head and periampullary
region.\textsuperscript{1,4,5} Despite advances in surgical techniques,
postoperative complications still show up and this has been documented
to be around 40 percent of all cases.\textsuperscript{5}

Various complications of Whipple procedure have been described in
literature. Although short term complications such as pancreatic
fistula, hemorrhage, and abdominal sepsis are among the most dangerous
complications after pancreatectomy, long term complications also need to
be monitored; some of them include marginal ulcer, reflux esophagitis,
diabetes mellitus, and biliary stricture.\textsuperscript{1,4}

Marginal ulcers that occur at or within 3cm of the gastrojejunal or
duodenojejunal anastomosis are well known long term complication of the
surgery\textsuperscript{3} and they tend to occur at a time varying from
1 month to 6 years after surgery.\textsuperscript{6} The incidence of
marginal ulcer ranges from 0\% to 18\% , and the median time to
diagnosis is 15.5 months.\textsuperscript{3} In our case , patient
presented with the condition after 6 years of surgery.

Patients may present with varied symptoms. They can present with
epigastric pain, gastrointestinal upset and dysphagia owing to
stricture. They can also land up in emergency department with
complications such as severe bleeding, perforation and
peritonitis.\textsuperscript{1,6,7} Our patient also presented with
perforation with peritonitis which is considered to be fatal unless
promptly treated.\textsuperscript{6}

While several mechanisms have been proposed for the etiology of these
ulcers, the commonly believed mechanisms include gastric acid
,inflammation, angulation, foreign bodies and ischemia on the
gastrojejunal anastomosis.\textsuperscript{1,2,6} Risk factors include
smoking, use of alcohol, Non-steroidal anti-inflammatory drugs (NSAIDS),
immunosuppressive medications and discontinuation of Proton pump
inhibitors (PPI) among others. \textsuperscript{3,8}

Treatment of marginal ulcer consists of elimination of risk factors, PPI
, and regular endoscopic monitoring.\textsuperscript{9} They are rarely
refractory to medical management which brings up the necessity of
revision surgery that includes resection and reconstruction of
anastomosis.\textsuperscript{9,10} Emergency laparotomy is necessary
when patient presents with perforation of marginal ulcer; perforated
ulcer can be managed with simple closure and omental patch
closure.\textsuperscript{1,9} In our case, the patient also presented
with perforated ulcer and it was closed with omental patch.

\subsection*{Acknowledgement}

{\label{acknowledgement}}

No acknowledgements.

\subsection*{Conflict of interest}

{\label{conflict-of-interest}}

None declared.

\textbf{Author contributions}

SB involved in conceptualization. All authors, SR, SA, SB and KBS have
contributed to writing, editing, and preparation of manuscript and have
reviewed it before submission.

\subsection*{Ethical approval}

{\label{ethical-approval}}

Written informed consent was obtained from the patient for publication
of case report and associated images. Since this report involves no
experiments, the ethical approval is waived.

\subsection*{Consent}

{\label{consent}}

A copy of written consent is available for review by editors of this
journal on request.

References

1. Sulieman I, Strobel O, Scharenberg C, Mihaljevic AM, M\selectlanguage{ngerman}üller BM,
Diener MK, Mehrabi A, Schneider M, Berchtold C, Tjaden C, Hinz U, Feisst
M, Büchler MW, Hackert T, Loos M. Symptomatic marginal ulcer after
pancreatoduodenectomy. Surgery. 2020 Jul;168(1):67-71. doi:
10.1016/j.surg.2020.02.012. Epub 2020 Apr 7. PMID

2. Park Y, Hwang DW, Lee JH, Song KB, Jun E, Lee W, Kwon J, Kim SC.
Analysis of Symptomatic Marginal Ulcers in Patients Who Underwent
Pancreaticoduodenectomy for Periampullary Tumors. Pancreas. 2020
Feb;49(2):208-215. doi: 10.1097/MPA.0000000000001470. PMID

3. P A, C K, R P, Chidambaranathan S, O L NB. Marginal Ulcer Perforation
in a Whipple Survivor: A Rare Long-Term Complication. Cureus. 2022 Aug
16;14(8):e28050. doi: 10.7759/cureus.28050. PMID

4. Wu JM, Tsai MK, Hu RH, Chang KJ, Lee PH, Tien YW. Reflux esophagitis
and marginal ulcer after pancreaticoduodenectomy. J Gastrointest Surg.
2011 May;15(5):824-8. doi: 10.1007/s11605-011-1463-4. Epub 2011 Feb 24.
PMID

5. Wang L, Su Ap, Zhang Y, Yang M, Yue Pj, Tian Bl. Reduction of
alkaline reflux gastritis and marginal ulcer by modified Braun
enteroenterostomy in gastroenterologic reconstruction after
pancreaticoduodenectomy. J Surg Res. 2014 Jun 1;189(1):41-7. doi:
10.1016/j.jss.2014.01.025. Epub 2014 Jan 23. PMID

6. Marcotte, E. Treatment of Marginal Ulcers After Gastric Bypass. In:
Chand, B. (eds) Endoscopy in Obesity Management. Springer, Cham. DOI

7. Su AP, Ke NW, Zhang Y, Wang WG, Zhang ZD, Liu XB, Hu WM, Tian BL.
Does modified Braun enteroenterostomy improve alkaline reflux gastritis
and marginal ulcer after pancreaticoduodenectomy? Dig Dis Sci. 2013
Nov;58(11):3224-31. doi: 10.1007/s10620-013-2803-x. Epub 2013 Aug 6.
PMID

8. Di Palma A, Liu B, Maeda A, Anvari M, Jackson T, Okrainec A. Marginal
ulceration following Roux-en-Y gastric bypass: risk factors for ulcer
development, recurrence and need for revisional surgery. Surg Endosc.
2021 May;35(5):2347-2353. doi: 10.1007/s00464-020-07650-0. Epub 2020 May
18. PMID

9. Fringeli Y, Worreth M, Langer I. Gastrojejunal Anastomosis
Complications and Their Management after Laparoscopic Roux-en-Y Gastric
Bypass. J Obes. 2015;2015:698425. doi: 10.1155/2015/698425. Epub 2015
Oct 18. PMID

10. Bonanno A, Tieu B, Dewey E, Husain F. Thoracoscopic truncal vagotomy
versus surgical revision of the gastrojejunal anastomosis for
recalcitrant marginal ulcers. Surg Endosc. 2019 Feb;33(2):607-611. doi:
10.1007/s00464-018-6386-7. Epub 2018 Aug 21. PMID

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