Triple Bypass for Chronic Pancreatitis With Biliary and Duodenal Stenosis: A Report of Two Cases.

Pancreaticoduodenectomy is typically performed for patients with biliary and duodenal stenosis due to chronic pancreatitis. However, the procedure can be quite challenging in cases with severe inflammation and adhesions and may be too invasive for patients in poor general condition. We report two cases of triple bypass, a procedure that combines pancreatic duct drainage with biliary and gastric bypass, as an alternative to pancreaticoduodenectomy. Case 1 involves a 51-year-old man who underwent endoscopic pancreatic and biliary stenting for pancreatic and biliary stenosis caused by alcoholic chronic pancreatitis. Although coexistent duodenal stenosis was observed during upper gastrointestinal endoscopy, he was able to eat sufficiently at that time. Two years later, after self-interrupting treatment, he presented to our hospital with vomiting and jaundice. Due to the duodenal stenosis, endoscopic treatment was challenging, necessitating surgical intervention for the obstructed pancreatic and biliary stents. Triple bypass, including pancreaticojejunostomy, was performed instead of pancreaticoduodenectomy due to the patient's poor general condition and the development of collateral veins with superior mesenteric vein stenosis. Postoperatively, the patient experienced pancreatic fistula and fungal sepsis but was discharged from the hospital three months after surgery. Currently, his condition and nutritional status are good. Case 2 involves a 58-year-old man who was referred to our hospital due to pancreatic pseudocysts and pancreatic and biliary stenosis caused by alcoholic chronic pancreatitis. Endoscopic drainage for pancreatic pseudocysts and stenting for pancreatic and biliary stenosis were performed. After two years of follow-up, surgical treatment was performed due to the challenges posed by stenosis and multiple duodenal ulcers, which rendered endoscopic treatment difficult. Triple bypass, including longitudinal pancreaticojejunostomy with coring-out of the pancreatic head (Frey's procedure), was performed because pancreaticoduodenectomy was difficult due to severe inflammation and adhesions in the pancreatic head. His postoperative course was uneventful, and he was discharged 13 days after surgery. Triple bypass could serve as a viable alternative to pancreaticoduodenectomy in cases with poor general condition or a high risk of perioperative complications due to severe inflammation and adhesions.