Novel interventional treatment technique for intractable pancreatic fistula due to dehiscence of pancreatico-jejunal anastomosis following pancreaticoduodenectomy

Despite recent technological advances in the treatment of hepatobiliary pancreatic disease, intractable external pancreatic fistula is still a major critical complication after pancreaticoduodenectomy, and the treatment strategy is not well defined. We report here a case that was successfully treated by our novel interventional internal drainage technique. A 62-year-old woman underwent pylorus-preserving pancreaticoduodenectomy for carcinoma of the papilla of Vater, with reconstruction by a modified Child's procedure. One year later, she was readmitted to our hospital because of external pancreatic fistula. Both computed tomography and fistulography demonstrated a pancreatic fistula derived from dehiscence of the pancreatico-jejunal anastomosis. The pancreatic fistula persisted for 1 week with conservative management. Therefore, we performed repeated fistulography and cannulation, using two comparatively stiff guidewires introduced into the main pancreatic duct and stenotic anastomosed jejunal lumen, respectively, and we placed an endoprosthesis, using bilateral guidewires to connect the two lumens. Consequently, the pancreatic fistula was successfully closed within a few days. Our novel technique is simple, rapid, and not costly. Therefore, it should be considered an effective treatment strategy for persistent pancreatic fistula following pancreaticoduodenectomy that fails to respond to initial conservative management and an endoscopic approach. Also, this technique is applicable to other intractable fistulous situations.     

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??Prevention and treatment for pancreatic fistula after distal pancreatectomy YANG Ming??WANG Chun-you. Department of Pancreatic Surgery, Union Hospital??Tongji Medical College??Huazhong University of Science and Technology??Wuhan 430022??China
Corresponding author: WANG Chun-you, E-mail: chunyouwang52@126.com
Abstract The incidence of pancreatic fistula after distal pancreatectomy is higher. Some of the main risk factors associated with pancreatic fistula after distal pancreatectomy include soft pancreatic texture, smaller pancreatic duct diameter and the handling of the pancreatic stump. Surgical techniques should been selected reasonably according to the pancreas texture and pathology, which is the key to decrease the incidence of pancreatic fistula. The optimal surgical method for a thick or edema pancreas is still a standardized hand-sewn closure technique of the pancreatic remnant. An anastomosis of the remnant to the intestine should be considered to prevent pancreatic fistula in the case of proximal duct obstruction associated with dilatation of the main pancreatic duct. The stapler technique should be recommended as the preferred method of pancreatic stump closure for a soft and flat pancreas. Most cases of pancreatic fistula could be cured by conservative treatment. Effective drainage plays an important role in the management of pancreatic fistula and in prevention of abdominal infection and bleeding. Pancreatic stent placement should be considered on the principle of failure of conservative treatment. Some of cases need fistulojejunostomy for refractory pancreatic fistulas.     

胰体尾切除术后胰瘘预防及处理

胰体尾切除术术后胰瘘发生率较高,主要与胰腺质地、胰管直径及胰腺残端的处理方式等有关。依据胰腺质地及病理检查结果合理选择胰腺残端处理方式是减少胰瘘发生的关键。胰腺肥厚或水肿质脆者胰瘘发生率较高,推荐残端手工缝合;如近端胰管存在梗阻并伴胰管扩张,建议行胰管-空肠吻合;对于胰腺扁平且质地柔软者,推荐使用直线切割闭合器。胰体尾切除术术后胰瘘经非手术治疗多可治愈。通畅引流可有效预防腹腔感染和出血的发生,是促进胰瘘愈合的关键。非手术治疗无效时可考虑胰管支架置入,部分难治性胰瘘病人须行窦道-空肠吻合。     

Colocación intraoperatoria anterógrada de stent pancreático y plastia de ligamento redondo para prevenir la fístula pancreática tras la pancreatectomía distal

Postoperative pancreatic fistula in distal pancreatectomy is one of the most important complications in this surgery and it is associated with high morbidity and mortality. Pancreatic fistula after distal pancreatectomy remains an unsolved problem and none preventive procedure has been shown effectively.We present a new technique that combine pancreatic stent placement with round ligament autologous patch over pancreatic edge.A guide is introduced through Wirsung duct prior to stent placement. After stent assessment, Wirsung duct is closed. Finally, falciform ligament autologous patch is placed over pancreatic edge. After 6-8 weeks, the stent is removed by oral endoscopy.This technique introduces a new issue on the pancreatic fistula prevention.     

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??Risk factors of pancreatic fistula after pancreaticoduodenectomy YANG Yin-mo. Department of Surgery??Beijing University First Hospital??Beijing 100034??China
Abstract Pancreaticoduodenectomy offers the only chance of curative resection for periampullary tumors??which is technically challenging and is accompanied by a substantial risk for postoperative complications. The most significant complication is pancreatic fistula which often causes infectious complications??hemorrhage??which makes it the leading risk factor for postoperative death. Risk factors for development of pancreatic fistula are now well known??and several technical modifications??which focus on the type of pancreatic anastomosis??duct stenting??somatostatin and analogues??have been suggested in prevention of pancreatic fistula. Although no one technique of pancreatic anastomosis has been shown to be superior in decreasing the rate of pancreatic fistula??meticulous attention to intraoperative details by surgeons is necessary to prevent pancreatic fistula.     

A new nonoperative method of percutaneous transgastric fistulo-drainage for an intractable external pancreatic fistula —A case report—

The external pancreatic fistula is a well-known complication of pancreatectomy and is conventionally classified as either a partial fistula or a total fistula. A partial fistula usually closes spontaneously and operative intervention is rarely needed, whereas, a total fistula on the other hand, very often, does not close and may therefore require surgical intervention. We report herein, a case of an intractable total pancreatic fistula following pancreatoduodenectomy which was successfully repaired by a new nonoperative method of percutaneous transgastric fistulo-drainage (PTFD). This technique, performed under the control of a two-way X-ray television system, is safe and considered useful for the treatment of an intractable total pancreatic fistula. In the future, this may be the method of choice for the management of such refractory total pancreatic fistulae.     

A new nonoperative method of percutaneous transgastric fistulo-drainage for an intractable external pancreatic fistula--a case report

The external pancreatic fistula is a well-known complication of pancreatectomy and is conventionally classified as either a partial fistula or a total fistula. A partial fistula usually closes spontaneously and operative intervention is rarely needed, whereas, a total fistula on the other hand, very often does not close and may therefore require surgical intervention. We report herein, a case of an intractable total pancreatic fistula following pancreatoduodenectomy which was successfully repaired by a new non-operative method of percutaneous transgastric fistulo-drainage (PTFD). This technique, performed under the control of a two-way X-ray television system, is safe and considered useful for the treatment of an intractable total pancreatic fistula. In the future, this may be the method of choice for the management of such refractory total pancreatic fistulae.     

胰十二指肠切除术后胰瘘发生危险因素认识及评价

胰十二指肠切除术是治疗壶腹部肿瘤的经典术式,术后并发症发生率较高,其中以胰瘘最常见,可致感染、出血甚至死亡。近年来,围绕术后胰瘘问题不断有各种改良术式出现,研究方法也逐步从回顾性研究过渡至前瞻性研究。影响胰瘘发生及严重程度的危险因素包括病人自身情况、重建方式及术者操作水平等。目前尚无具有显著优越性的吻合方式,术者可根据经验及熟悉程度选择,应强调及注重术者技术性因素对胰瘘发生的影响,提高胰腺消化道重建的质量。     

带蒂大网膜包裹胰肠吻合在胰十二指肠切除术中的应用

目的 探讨降低胰十二指肠切除术后胰肠吻合口漏的预防措施。方法 回顾性分析1999～2004年间施行的46例胰十二指肠切除术中采用大网膜包裹胰肠吻合口的手术方法。结论 46例患者术后出现胰漏1例,占2．17％,无围手术期死亡。结论 带蒂大网膜包裹胰肠吻合口,覆盖操作简单,对预防胰十二指肠切除术后胰肠吻合口漏有良好效果。