Leakage of the gastroenteric anastomosis after pancreatoduodenectomy

Endoscopic clipping of gastrojejunostomy leakage following Whipple procedure: A case report

BACKGROUND

Currently, perioperative complications of classic Whipple surgery occur at a rate of approximately 40%. Common complications include delayed gastric emptying, pancreatic fistula, and bile leakage, whereas gastrojejunostomy (GJ) leakage is rare.

CASE SUMMARY

This case report will assess the management of a GJ leak in a 71-year-old male patient following the Whipple procedure. After surgery, the patient was transferred to the clinic after four days of intensive care, where vacuum therapy was used to handle a developing subcutaneous collection. The patient, who had bile in the drains and incision during follow-up, underwent endoscopic examination on the 21st day after the operation. An opening of approximately 4 mm was observed in the GJ anastomosis during endoscopy. Five titanium clips were used to close the openings. The drainage of bile decreased to less than 50 mL on the first day after the procedure, and the patient's oral intake was opened.

CONCLUSION

Current literature reports a GJ leakage rate of 0. 54% following Whipple surgery, with clinical findings lasting on average between 4-34 days. Surgery was the main form of therapy for this case, with a success rate of 84%, and percutaneous drainage was also utilized as a treatment option. This case report is the first to document endoscopic treatment of GJ leaks following the classic Whipple procedure.

Serum pancreatic enzymes in the early postoperative period predict complications associated with pancreatic fluid after pancreas transplantation: A retrospective, single-center, observational cohort study

BACKGROUND

Pancreas transplantation (PT) is a radical treatment for diabetes mellitus (DM). Although the results of PT have been improving, surgical complications remain. Few reports have focused on complications associated with pancreatic fluid (CAPF) after PT. We aimed to investigate the risk factors and predictors for CAPF after PT.

METHODS

Sixty-nine patients, who underwent deceased-donor PT for type 1 DM at our institution from August 2001 to May 2020, were retrospectively studied. We identified CAPF from those with Clavien-Dindo Classification ≥grade III and assessed risk factors by univariate and multivariate analyses using logistic regression.

RESULTS

Twenty-one (30.4%) patients had complications with Clavien-Dindo Classification ≥grade III. Eleven (16.0%) patients were diagnosed with CAPF. Median serum pancreatic amylase (P-AMY) levels with CAPF on postoperative day (POD)1 and POD2 were significantly higher than those without CAPF (P = .019 and P = .027, respectively). In multivariable analysis, serum P-AMY levels on POD1 were an independent predictive factor for CAPF (odds ratio 1.83, 95% confidence interval 1.07-3.14, P = .008).

CONCLUSIONS

Complications associated with pancreatic fluid after PT is associated with high serum P-AMY in the early postoperative period. Serum pancreatic enzymes in the first few postoperative days after PT may be a significant predictive factor for CAPF.

Gastro- or Duodenojejunostomy Leaks After Pancreatoduodenectomy: Single Center Experience and Narrative Literature Review

BACKGROUND AND METHODS

Gastro- or duodenojejunostomy leaks after pancreatoduodenectomy is rare. This study aims to analyze the incidence, management, and outcome of gastro- or duodenojejunostomy leaks after pancreatoduodenectomy based on a single center experience from 2004 to 2020 with a narrative literature review.

RESULTS

Of a total of 1494 pancreatoduodenectomies, eight patients with gastrojejunostomy (n=1) or duodenojejunostomy (n=7) leak were identified from the institutional pancreatic database. All leaks were treated operatively. In two patients dismantling of the duodenojejunostomy, distal gastrectomy, and closure of the pyloric and jejunal side, a percutaneous endoscopic gastrostomy and a feeding jejunostomy ultimately had to be performed after an unsuccessful attempt of gastrojejunostomy and suture of the duodenojejunostomy, respectively. The literature search revealed three more studies specifically addressing this complication after pancreatoduodenectomy (36 patients of a total of 4739 pancreatoduodenectomies). Based on an analysis of the current study and the literature review, the overall incidence of gastro- or duodenojejunostomy leaks after pancreatoduodenectomy was 0.71 % (44/6233 pancreatoduodenectomies). The occurrence of a gastro- or duodenojejunostomy leak was associated with a concomitant postoperative pancreatic fistula in 50 % of the cases, an increased length of hospital stay, and a mortality rate of 15.9 %. Surgical treatment was performed in 84 % of the cases.

CONCLUSION

Gastro- or duodenojejunostomy leak is a rare complication after pancreatoduodenectomy. Prompt diagnosis and early repair is important. In most cases, a surgical intervention is necessary for a good outcome. Under salvage conditions, a bailout strategy may be to temporarily dismantle the gastro- or duodenojejunal anastomosis.

Endoscopic Management of a Complex Gastrojejunal and Pancreatic Leak Following Pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy remains the mainstay of surgical treatment of malignant periampullary disorders. Postoperative morbidity rates are driven by postoperative pancreatic fistula. Although most can be managed conservatively or with percutaneous techniques, complex fistulas including gastroenteric leakage frequently require operative reexploration. Endoscopic therapies in this setting offer an opportunity to avoid invasive reoperation.

CASE REPORT

We present the case of a 67-year-old male individual who developed a complex intra-abdominal abscess after pancreaticoduodenectomy with confirmed pancreaticojejunal disruption, gastric staple line dehiscence, and enterocutaneous fistula. Five endoscopic sessions utilizing advanced techniques over a period of 60 days led to complete healing of the patient's external fistula, resolution of complex abdominal abscess, creation of functional communication between the gastric staple line disruption and the afferent jejunum, and return of normal gastrointestinal function. Baseline functional and dietary status was restored without gastrointestinal symptoms or necessity for supplemental tube feedings.

Management of Borderline Resectable Pancreatic Cancer

With the rapid development of imaging modalities and surgical techniques, the clinical entity representing tumors that are intermediate between resectable and unresectable pancreatic adenocarcinoma has been identified has been termed "borderline resectable" (BR). These tumors are generally amenable for resection but portend an increased risk for positive margins after surgery and commonly necessitate vascular resection and reconstruction. Although there is a lack of consensus regarding the appropriate definition of what constitutes a BR pancreatic tumor, it has been demonstrated that this intermediate category carries a particular prognosis that is in between resectable and unresectable disease. In order to downstage the tumor and increase the probability of clear surgical margins, neoadjuvant therapy is being increasingly utilized and studied. There is a lack of high-level evidence to establish the optimal treatment regimen for BR tumors. When resection with negative margins is achieved after neoadjuvant therapy, the prognosis for BR tumors approaches and even exceeds that for resectable disease. This review presents the current definitions, different treatment approaches, and the clinical outcomes of BR pancreatic cancer.

Duodenal invasion by pancreatic adenocarcinoma: MDCT diagnosis of an aggressive imaging phenotype and its clinical implications

Despite advances in oncologic and imaging technology, pancreatic ductal adenocarcinoma remains a highly deadly disease. The only curative option, pancreaticoduodenectomy or pancreatectomy, carries a significant morbidity. Current imaging plays a role in pre-operative staging to determine the probability of achieve disease-free margins. However, a small but not insignificant number of pancreatic cancers have a relatively higher aggressive biology, despite being resectable based on traditional criteria. Recently, imaging biomarkers that serve as a surrogate for tumors with such aggressive phenotype have been described. These include duodenal invasion and extrapancreatic perineural invasion. This review will focus on the former highlighting the summary of literature supporting duodenal invasion as a surrogate for aggressive disease as well as review its MDCT imaging features.

Buttressing hepaticojejunostomy's with hepatic round ligament flap may be beneficial

BACKGROUND

Bile leaks and anastomotic strictures are important complications of hepaticojejunostomy (HJ). Evidence suggests that the use of hepatic round ligament (HRL) to buttress HJ may be beneficial. This study evaluates the feasibility of this approach.

METHODS

HJs performed over 2 years (Jun 2014- May 2016), with HRL reinforcement, were analyzed. Operative outcomes measured included technical difficulty, blood loss, time necessary for flap harvest, and reinforcement of HJ. The postoperative outcomes measured were the presence of bile leak and anastomotic stricture.

RESULTS

Forty-one patients (27 M: 14 F), aged 2-79 years, median age of61 years, underwent HJ with HRL buttress; 27 for periampullary/ head of the pancreas carcinoma; 4 for choledochal cysts; 4 for chronic pancreatitis; 3 for gallbladder carcinoma; 3 for benign biliary stricture. The time for harvesting HRL flaps and buttressing HJ was <10 minutes. No blood was lost during harvesting the flaps. One patient (2.5 %) had grade A leak following radical cholecystectomy, and structures were not observed during a median follow-up of 18 months (6 months to 2years).

CONCLUSION

HRL-based buttressing of HJ can reduce the bile leak and/or stricture rate.

Post-pancreaticoduodenectomy hemorrhage: DSA diagnosis and endovascular treatment

Objective

To explore the diagnostic value of digital subtraction angiography (DSA) and the effectiveness of endovascular treatment for a post-pancreaticoduodenectomy hemorrhage (PPH).

Results

During the DSA examination, positive results were found in 29 patients, yielding a positive rate of 69.0%. The manifestations of the DSA examination included contrast medium extravasation, pseudoaneurysm, and artery walls coarse. All 29 patients with positive results underwent endovascular treatment, including transartery embolization (TAE) in 28 patients and covered stents placement in one patient. The technical success and clinical success rates were 100% and 72.4%, respectively. Re-bleeding occurred in 8 of the 29 patients after the first treatment (27.6%). The mortality of PPH was 17.2% (5 of 29). Two of the five PPH patients died following severe infections, and three died from multiple organ failure.

Materials and Methods

A DSA examination was conducted using clinical and imaging data of 42 patients, and endovascular treatment for delayed PPH was retrospectively analyzed.

Conclusions

DSA examination is a minimally invasive and rapid method for the diagnosis of delayed PPH. For patients with positive DSA results, endovascular treatment can be performed rapidly, safely, and effectively. Therefore, the DSA examination and endovascular treatment could be considered a preferred treatment approach for delayed PPH.

Postoperative Outcomes of Enucleation and Standard Resections in Patients with a Pancreatic Neuroendocrine Tumor

Background

Either enucleation or more extended resection is performed to treat patients with pancreatic neuroendocrine tumor (pNET). Aim was to analyze the postoperative complications for each operation separately. Furthermore, independent risk factors for complications and incidence of pancreatic insufficiency were analyzed.

Methods

Retrospective all resected patients from two academic hospitals in The Netherlands between 1992 and 2013 were included. Postoperative complications were scored by both ISGPS and Clavien–Dindo criteria. Based on tumor location, operations were compared. Independent risk factors for overall complications were identified. During long-term follow-up, pancreatic insufficiency and recurrent disease were analyzed.

Results

Tumor enucleation was performed in 60/205 patients (29 %), pancreatoduodenectomy in 65/205 (31 %), distal pancreatectomy in 72/205 (35 %) and central pancreatectomy in 8/205 (4 %) patients. Overall complications after tumor enucleation of the pancreatic head and pancreatoduodenectomy were comparable, 24/35 (69 %) versus 52/65 (80 %). The same was found after tumor enucleation and resection of the pancreatic tail (36 vs.58 %). Number of re-interventions and readmissions were comparable between all operations. After pancreatoduodenectomy, 33/65 patients had lymph node metastasis and in patients with tumor size ≤2 cm, 55 % had lymph node metastasis. Tumor in the head and BMI ≥25 kg/m² were independent risk factors for complications after enucleation. During follow-up, incidence of exocrine and endocrine insufficiency was significant higher after pancreatoduodenectomy (resp. 55 and 19 %) compared to the tumor enucleation and distal pancreatectomy(resp. 5 and 7 % vs.8 and 13 %). After tumor enucleation 19 % developed recurrent disease.

Conclusion

Since the complication rate, need for re-interventions and readmissions were comparable for all resections, tumor enucleation may be regarded as high risk. Appropriate operation should be based on tumor size, location, and functional status of the pNET.

Postoperative pancreatic fistula successfully treated with "PEG-Like" endoscopic vacuum therapy

INTRODUCTION

One of the latest methods for management of pancreaticogastrostomy (PG) leakage after pancreaticoduodenectomy (PD) is endoscopic vacuum therapy.

SUBJECTS AND METHODS

PD was performed on a 72-year-old man suffering from a nonfunctioning pancreatic neuroendocrine tumor of the head of the pancreas. On postoperative Day 6 after the primary surgery, postoperative pancreatic fistula (POPF) of the PG was revealed. Based on the International Study Group of Pancreatic Fistula recommendations, total parenteral nutrition, a regimen of somatostatin analogs, and intravenous antibiotics were implemented. The patient was qualified for a re-exploration because of the doubtful safety of percutaneous drainage of fluid collection detected in the ultrasonography scan. However, this management was not efficient. Endoscopic vacuum treatment (E-VAC) was initiated. The E-VAC was placed directly into the POPF site using a modified "percutaneous endoscopic gastrostomy (PEG)-like" technique.

RESULTS

Over the next few days, the E-VAC was started. The volume of fluid collection from percutaneous drainage rapidly decreased, whereas the volume of E-VAC the following day after vacuum therapy was approximately 1000 mL. There were no signs of leakage of PG confirmed with endoscopy, and there was no fluid collection from peripancreatic drainage. The E-VAC therapy was stopped after 6 days. The patient's general condition improved significantly. There were no abnormalities observable in both clinical and imaging examinations.

CONCLUSIONS

In selected patients, the "PEG-like" modification can be used successfully in the management of POPF. This technique allows the E-VAC to be placed directly in the POPF site under the endoscopic camera, which is what makes this method safe and efficient.