Management of pancreatic fistulas

Use of Polyglycolic Acid Sheets for the Prevention of Pancreatic Fistula after Laparoscopic Gastrectomy: A Single-Center Retrospective Study

BACKGROUND

Laparoscopic gastrectomy (LG) indications have been extended to advanced gastric cancer requiring expansive lymph node dissection. Despite the huge benefits of this minimally invasive surgery, major complications such as postoperative pancreatic fistula (POPF) remain a concern. With technical advances in surgical procedures, the treatment outcomes of gastric cancer surgery have improved. However, effective methods for preventing POPF have not yet been established. Herein, we examined the usefulness of polyglycolic acid (PGA) sheets for preventing POPF after LG.

METHODS

We retrospectively assessed 142 patients who underwent curative LG at our institution between January 2017 and August 2022. The 142 patients were divided into 2 groups; PGA group (n = 61): the site of lymph node dissection at the superior margin of the pancreas and pancreatic head was covered with PGA sheets, and nPGA group (n = 81): the site was not covered. We retrospectively compared the short-term surgical outcomes including POPF incidence.

RESULTS

There was no significant difference in the background factors between the 2 groups and in the incidence of Grade II or higher postoperative complications according to the Clavien-Dindo (CD) classification. However, the incidence of CD Grade II or higher POPF was significantly lower in the PGA group than in the nPGA group (.0% vs 2.3%, respectively, P = .007).

CONCLUSIONS

There was no POPF in any of the 61 patients in the PGA group. This outcome suggests that POPF incidence may be reduced by covering the lymph node dissection site with PGA sheets after LG.

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

BACKGROUND

Pancreaticojejunal (PJ) anastomosis occasionally fails several months after pancreaticoduodenectomy (PD) with Child reconstruction and can ultimately result in a late-onset complete pancreaticocutaneous fistula (Lc-PF). Since the remnant pancreas is an isolated segment, surgical intervention is necessary to create internal drainage for the pancreatic juice; however, surgery at the previous PJ anastomosis site is technically challenging even for experienced surgeons. Here we describe a simple surgical procedure for Lc-PF, termed redo PJ anastomosis, which was developed at our facility.  METHODS: Between January 2008 and December 2020, six consecutive patients with Lc-PF after PD underwent a redo PJ anastomosis, and the short- and long-term clinical outcomes have been evaluated. The abdominal cavity is carefully dissected through a 10-cm midline skin incision, and the PJ anastomosis site is identified using a percutaneous drain through the fistula tract as a guide, along with the main pancreatic duct (MPD) stump on the pancreatic stump. Next, the pancreatic stump is deliberately immobilized from the dorsal plane to prevent injury to the underlying major vessels. After fixing a stent tube to both the MPD and the Roux-limb using two-sided purse-string sutures, the redo PJ anastomosis is completed using single-layer interrupted sutures. Full-thickness pancreatic sutures are deliberately avoided by passing the needle through only two-thirds of the anterior side of the pancreatic stump.

RESULTS

The redo PJ anastomosis was performed without any intraoperative complications in all cases. The median intraoperative bleeding and operative time were 71 (range 10-137) mL and 123 (range 56-175) min, respectively. Even though a new mild pancreatic fistula developed postoperatively in all cases, it could be conservatively treated within 3 weeks, and no other postoperative complications were recorded. During the median follow-up period of 92 (range 12-112) months, no complications at the redo PJ anastomosis site were observed.

CONCLUSIONS

This research shows that the redo PJ anastomosis for Lc-PF we developed is a safe, feasible, and technically no demanding procedure with acceptable short- and long-term clinical outcomes. This procedure has the potential to become the preferred treatment strategy for Lc-PF after PD.

Acute Pancreatitis with an Ongoing Pancreatic Duct Leak Complicated by Refractory Pleural Effusion: A Case Report

Patient: Female, 52-year-old

Final Diagnosis: Pancreatic duct leak

Symptoms: Epigastric pain

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

New polyglycolic acid fabric for the prevention of postoperative pancreatic fistulas

BACKGROUND

The incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy is approximately 30%. The most serious complications of pancreatic resection, such as mortality and prolonged hospitalization, are unresolved despite the proposal of various surgical procedures. We developed a new polyglycolic acid (PGA) fabric composed of fine diameter fibers to prevent POPF, and macroscopically and microscopically evaluated the effects of applying it to the pancreatic remnant.

METHODS

The ventral pancreatic surface was cauterized to create the experimental model of POPF in 33 female Wistar/ST rats. The injured sites were wrapped with nonwoven PGA fabrics of different fiber diameters and porosities in the treated rats; one group of rats remained untreated. Survival, incidence of generalized peritonitis, and microscopic findings around the pancreas were investigated.

RESULTS

The PGA fabrics acted as a scaffold for tissue repair and resulted in superior survival. Generalized peritonitis was milder in the PGA treated groups. With the new PGA fabric, abundant fibroblast infiltration and a uniformly-developed, self-organized barrier wall prevented both pancreatic leak and spread of inflammation.

CONCLUSION

Application of the newly developed PGA fabric to the pancreatic remnant prevented POPF, and the essential factor for preventing pancreatic leak was the early formation of a self-organized barrier.

Endoscopic Ultrasound-Guided Treatment of Pancreaticocutaneous Fistulas

Pancreaticocutaneous fistulas (PCFs) may be refractory to medical therapy or endoscopic retrograde cholangopancreaticography. Four patients underwent endoscopic ultrasound-guided management of refractory PCFs, which were internalized by endoscopic ultrasound-guided transmural puncture of the pancreatic duct (n = 2), fistula tract (n = 1), or both (n = 1), with placement of transmural stents providing internal drainage to the stomach (n = 3) or duodenum (n = 1). Drainage from PCFs ceased in all patients, and all percutaneous drains were removed; internal stents were left in place indefinitely. Endoscopic ultrasound-guided interventions may successfully treat PCFs, allowing removal of percutaneous drains, and are an attractive alternative for patients who might otherwise require pancreatic resection.

Pancreaticopericardial fistula: a rare complication of chronic pancreatitis

Pancreaticopericardial fistula (PPF) is an extremely rare clinical problem encountered in patients with chronic pancreatitis. The diagnosis should be suspected if a patient presents with pericardial effusion on a background of chronic pancreatitis. Significantly raised amylase in the pericardial fluid offers an important clue for the diagnosis. CT is the initial imaging modality to look for pancreatic and pericardial changes. The therapeutic options include medical, endoscopic or surgical interventions. Medical and endoscopic therapies are the preferred modes of treatment while surgery is reserved for those who fail these measures.

Pancreaticopericardial Fistula: A Case Report and Literature Review

Purpose. Pancreaticopericardial fistula (PPF) is an extremely rare complication of acute or chronic pancreatitis. This paper presents a rare case of PPF and provides systematic review of existing cases from 1970 to 2014. Methods. A PubMed search using key words was performed for all the cases of PPF from January 1970 to December 2014. Fourteen cases were included in the study. The cases were reviewed for demographic characteristics, diagnostic modalities, and treatment. Descriptive analysis of these variables was performed. Results. Median age was 43 years. 78% were known alcoholics and 73.3% had chronic pancreatitis. Dyspnea was present in 78%. Cardiac tamponade was present in 53%; 75% of patients had known chronic pancreatitis (RR = 0.74). Surgery was associated with best treatment outcomes and 50% of patients who underwent endoscopic treatment survived. Conclusion. PPF is a rare disease. This paper indicates that acute cardiac tamponade in patients with history of alcoholism and chronic pancreatitis could be a sign of an existing pancreaticopericardial fistula and early surgical intervention could be life-saving.

Pancreaticojejunostomy Versus Pancreaticogastrostomy After Pancreaticoduodenectomy: An Up-to-date Meta-Analysis

BACKGROUND

The reconstruction of the pancreas after pancreaticoduodenectomy (PD) is a crucial factor in preventing postoperative complications as pancreatic anastomosis failure is associated with a high morbidity rate and contributes to prolonged hospitalization and mortality. Several techniques have been described for the reconstruction of pancreatic digestive continuity in the attempt to minimize the risk of a pancreatic fistula. The aim of this study was to compare the results of pancreaticogastrostomy and pancreaticojejunostomy after PD.

METHODS

A systematic review and meta-analysis were conducted of randomized controlled trials (RCTs) published up to January 2015 comparing patients with pancreaticogastrostomy (PG group) versus pancreaticojejunostomy (PJ group). Two reviewers independently assessed the eligibility and quality of the studies. The meta-analysis was conducted using either the fixed-effect or the random-effect model.

RESULTS

Eight RCTs describing 1,211 patients were identified for inclusion in the study. The meta-analysis shows that the PG group had a significantly lower incidence rate of postoperative pancreatic fistulas [OR 0.64 (95% confidence interval 0.46-0.86), p = .003], intra-abdominal abscesses [OR 0.53 (95% CI, 0.33-0.85), p = .009] and length of hospital stay [MD -1.62; (95% CI 2.63-0.61), p = .002] than the PJ group, while biliary fistula, mortality, morbidity, rate of delayed gastric emptying, reoperation, and bleeding did not differ between the two groups.

CONCLUSION

This meta-analysis suggests that the most effective treatment for reconstruction of pancreatic continuity after pancreatoduodenectomy is pancreaticogastrostomy. However, the advantage of the latter could potentially be demonstrated through further RCTs, including only patients at high risk of developing pancreatic fistulas.

Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review

Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.

Pancreatico-pericardial fistula as a complication of chronic pancreatitis

Pancreatico-pericardial fistula is an extremely rare complication of chronic pancreatitis. We present a case of a 58-year-old man who presented with syncope. Transthoracic echocardiogram revealed a pericardial effusion with tamponade physiology. Pericardiocentesis and pericardial fluid analysis demonstrated a lipase level of 2321 U/L. Subsequently, an endoscopic retrograde cholangiopancreatography (ERCP) was performed, confirming the presence of a pancreatico-pericardial fistula (PPF) from the distal body of the pancreas. A pancreatic duct stent was placed across the duct disruption on two separate occasions; however, despite stent placement, the patient continued to re-accumulate pericardial fluid and deteriorated. While rare, PPFs may complicate chronic pancreatitis, may not respond to pancreatic duct stenting and may portend a poor prognosis.