Cure of intractable pancreatic fistula by subcutaneous fistulojejunostomy

Abstract

Fistulojejunostomy was performed at the subcutaneous level in two patients with intractable pancreatic fistula that occurred after surgery for cancer of the ampulla of Vater and carcinoma of the lower bile duct. The treatment yielded mostly satisfactory results, though one patient incurred postoperative wound dehiscence, which was healed with conservative measures. Compared with conventional procedures, this method is technically easy to perform, as it does not involve surgical separation of the fistula up to a site deep within the abdominal cavity, rarely results in side injury, and poses few potential risks of cicatricial stenosis of the fistular lumen, because blood supply to the fistula is preserved. Subcutaneous fistulojejunostomy is considered to be recommendable for pancreatic fistulas that occur long after surgery and which are stenosed at the site of the pancreatojejunal stenosis and thus require surgical treatment.

Intraoperative gastrojejunoscopy‐assisted fistulojejunostomy for postoperative pancreatic fistula

“…Adhesiolysis has a large impact on the risk of bowel injury . As previous cases did not employ endoscopy during the procedure , we would like to emphasize the benefit of intraoperative gastrojejunoscopy in guiding the external pancreatic duct tube to the afferent loop and in avoiding extensive adhesiolysis around the pancreatic stump and the jejunal stump in the present case.…”

“…Fistulojejunostomy has been previously performed for pancreatic fistula with pancreatitis rather than for POPF . To perform fistulojejunostomy, a substantial period is needed so that a fibrous fistula tract can develop surrounding an external drainage tube .…”

Roux-en-Y fistulojejunostomy in the management of persistent external pancreatic fistula: Is it olde worlde?

“…When these factors are present, endoscopic or endoscopic-ultrasound-(EUS) guided transmural drainage with/without stenting or percutaneous transfistulous distal pancreatic duct drainage or embolization with prolamine, ethylene-vinyl alcohol, fibrin sealant, or cyanoacrylate glue can be attempted with variable results. When the duct is not demonstrable, an outside-in (percutaneous) approach followed by an endoscopy-or EUS-guided transmural drainage is required (1,4,7).…”

Roux-en-Y fistulojejunostomy in the management of persistent external pancreatic fistula: is it olde worlde?

“…High mortality rates ranging between 13% and 36% have been reported. Initial conservative management is often successful in 90% of the patients without development of fever, tachycardia, leucocytosis, severe wound infection, or peritonitis (1,3,4). Clinical deterioration warrants a step-up approach, with total parenteral nutrition, optimal wound care, drainage of intra-abdominal collections via percutaneous drains, repositioning of previously placed drains, and occasionally, re-exploration with abdominal lavage.…”