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

Abstract

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.

Treatment of pancreatic fistula after pancreatoduodenectomy using a hand-made T-tube

“…Another advantage of the T-tube treatment is that our hand-made T-tube can be exchanged easily; furthermore, patency of the anastomosis of the pancreaticojejunostomy is consistently preserved. More recently, Komatsu et al [36] reported an interventional treatment technique for grade C POPF in a case report. Their technique and ours are very similar in that bilateral guidewires are used to connect the dehiscent jejunal limb and pancreatic duct.…”

Redo pancreaticojejunal anastomosis for late-onset complete pancreaticocutaneous fistula after pancreaticojejunostomy

“…Recently, a few small numbers of case studies have reported successful radiologic or endoscopic interventions for establishing internal drainage [10][11][12][13][14]; however, these nonsurgical strategies may not become the standard treatment because of the enormous variation in peri-pancreatic anatomy of each patient [15]. Conversely, direct surgical management of the previous PJ site after PD in such patients is not routinely performed because it is considered technically challenging even for experienced pancreatic surgeons [7,12]. To the best of our knowledge, no reports have yet described redo PJ anastomosis for Lc-PF.…”

“…Direct surgical management of such failure of the PJ anastomosis is considered technically demanding because intraabdominal dissection in the chronic phase after PD is unsafe due to the presence of tight adhesions, scar tissue, obscure anatomy, and risk of critical injury to adjacent major vessels or organs, even if performed by experienced pancreatic surgeons [1,[7][8][9]. Although alternative radiologic and endoscopic management strategies have been reported as small case series [10][11][12][13][14], these nonsurgical treatments are not yet the standard procedure [15] due to large and patient-dependent variations in peri-pancreatic anatomy after PD.…”