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Yamamoto M, Zaima M, Yazawa T, Yamamoto H, Harada H, Yamada M, Tani M. Redo pancreaticojejunal anastomosis for late-onset complete pancreaticocutaneous fistula after pancreaticojejunostomy. World J Surg Oncol 2022; 20:223. [PMID: 35786384 PMCID: PMC9252026 DOI: 10.1186/s12957-022-02687-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Michihiro Yamamoto
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan.
| | - Masazumi Zaima
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Tekefumi Yazawa
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Hidekazu Yamamoto
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Hideki Harada
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Masahiro Yamada
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
| | - Masaki Tani
- Department of Surgery, Shiga General Hospital, 4-30 Moriyama 5-chomeShiga Prefecture, Moriyama City, 524-8524, Japan
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Dokmak S, Tetart A, Aussilhou B, Choquet A, Rebours V, Vullierme MP, Soubrane O, Ruszniewski P, Lévy P, Sauvanet A. French reconnection: A conservative pancreato-enteric reconnection for disconnected pancreatic duct syndrome. Pancreatology 2021; 21:282-290. [PMID: 33168404 DOI: 10.1016/j.pan.2020.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/03/2020] [Accepted: 10/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Disconnectedpancreatic duct syndrome (DPDS), a severe complication of acute necrotizing pancreatitis (ANP), may require surgery, usually by distal splenopancreatectomy, thus increasing the risk of diabetes. We describe a new technique reconnecting the distal pancreas to the digestive tract. METHODS This technique was proposed after failure of non-surgical treatment and at least 3 months after the onset of ANP in non-diabetic or non-insulin dependent diabetic patients with a distal pancreas of at least 5 cm. The ruptured zone was identified and the distal side was anastomosed to the stomach or the jejunum. RESULTS From 2013 to June 2019, 36 patients (median age = 49 years) with DPDS underwent a "French reconnection" procedure, indicated for chronic pain/recurrent pancreatitis (n = 35; 97%), persistent pancreatic fistula (n = 33; 91%), or digestive compression/fistulisation (n = 9; 25%). Median preoperative weight loss was 10 kg (4-27), the median number of hospitalisations per patient was 5(1-8) and 24(67%) patients had received endoscopic/percutaneous treatment. Surgery was performed in median 279(90-2000) days after ANP, laparoscopically in 9(25%) patients. The remnant pancreas (median length = 70 mm; range = 50-130) was anastomosed to the stomach (n = 30) or the jejunum (n = 6). There were 13(36%) postoperative grade B/C pancreatic fistulas and 3(10%) bleedings including one death (mortality = 3%). The median hospital stay was 18 (7-121) days. After a median follow-up of 24 (4-53) months, all pancreatic fistulas had healed and the clinical success rate was 91%. Median BMI increased from 22 to 25 kg/m2. In patients with normal pancreatic function, postoperative de novo endocrine and severe exocrine insufficiencies were observed in 4/27 (15%) and 7/22 (32%), respectively. CONCLUSIONS The "French reconnection" procedure, as an alternative to distal splenopancreatectomy for the treatment of DPDS, provides good control of symptoms and decreases the risk of pancreatic insufficiency.
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Affiliation(s)
- Safi Dokmak
- Department of HPB Surgery, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France.
| | - Auriana Tetart
- Department of HPB Surgery, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Béatrice Aussilhou
- Department of HPB Surgery, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Anaïs Choquet
- Department of HPB Surgery, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Vinciane Rebours
- Department of Gastroenterology and Pancreatic Diseases, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Marie Pierre Vullierme
- Department of Radiology, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Olivier Soubrane
- Department of HPB Surgery, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Philippe Ruszniewski
- Department of Gastroenterology and Pancreatic Diseases, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Philippe Lévy
- Department of Gastroenterology and Pancreatic Diseases, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
| | - Alain Sauvanet
- Department of HPB Surgery, Assistance Publique Hôpitaux de Paris - University of Paris, Beaujon Hospital, 100 Bd du Général Leclerc, 92110, Clichy, France
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Alexandrescu ST, Zlate AC, Grigorie RT, Ionescu M, Popescu I. Deliberate external pancreatic fistula after pancreaticoduodenectomy performed in the setting of acute pancreatitis, and its internalization through fistula-jejunostomy. Hepatobiliary Pancreat Dis Int 2020; 19:94-96. [PMID: 31706857 DOI: 10.1016/j.hbpd.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/21/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Sorin T Alexandrescu
- Fundeni Clinical Institute, Dan Setlacec Centre of General Surgery and Liver Transplantation, Sos. Fundeni nr. 258, sector 2, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Andrei C Zlate
- Fundeni Clinical Institute, Dan Setlacec Centre of General Surgery and Liver Transplantation, Sos. Fundeni nr. 258, sector 2, Bucharest, Romania
| | - Razvan T Grigorie
- Fundeni Clinical Institute, Dan Setlacec Centre of General Surgery and Liver Transplantation, Sos. Fundeni nr. 258, sector 2, Bucharest, Romania
| | - Mihnea Ionescu
- Fundeni Clinical Institute, Dan Setlacec Centre of General Surgery and Liver Transplantation, Sos. Fundeni nr. 258, sector 2, Bucharest, Romania
| | - Irinel Popescu
- Fundeni Clinical Institute, Dan Setlacec Centre of General Surgery and Liver Transplantation, Sos. Fundeni nr. 258, sector 2, Bucharest, Romania; Titu Maiorescu University, Faculty of Medicine, Bucharest, Romania
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Desai G, Narkhede R, Pande P, Varty P, Mehta H, Kulkarni D. Roux-en-Y fistulojejunostomy in the management of persistent external pancreatic fistula: is it olde worlde? Turk J Surg 2018; 35:62-69. [PMID: 32550305 DOI: 10.5578/turkjsurg.4110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/03/2018] [Indexed: 11/15/2022]
Abstract
Objectives This article aimed to identify patient selection criteria and approach in treating persistent external pancreatic fistulas surgically with Roux-en-Y fistulojejunostomy, and the study evaluated the outcomes of Roux-en-Y fistulojejunostomy with a review of the relevant literature. Material and Methods A retrospective data analysis from January 2010 to May 2017 revealed 6 patients managed with Roux-en-Y fistulojejunostomy for persistent external pancreatic fistulas, and their details were entered in a proforma. Standard surgical steps were performed in all patients, and the patients were followed up postoperatively for 1 year. Data were analyzed for outcomes, and the literature was reviewed. Results Four of 6 patients had persistent external pancreatic fistulas following pancreatic necrosectomy, 1 had surgery for pancreatic pseudocyst, and 1 after pancreaticoduodenectomy for pancreatic head mass. An average duration of conservative management was 14 weeks, and Roux-en-Y fistulojejunostomy was performed at a median distance of 6 cm from pancreas via a midline laparotomy. All patients recovered without major complications. Only 1 patient developed diabetes at a 1-year follow-up. Conclusion Fistulojejunostomy is a safe and effective treatment for persistent pancreatic fistula having the benefit of avoiding a difficult major pancreatic resectional surgery in an already debilitated patient with frozen tissue planes, along with low postoperative morbidity and mortality. The short- and mid-term outcomes in the literature for this procedure are good, as it has also been seen in our study on diverse indications.
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Affiliation(s)
- Gunjan Desai
- Litavati Hastanesi Araştırma Merkezi, Gastroenteroloji Cerrahi Bölümü, Mumbai, Hindistan
| | - Rajvilas Narkhede
- Litavati Hastanesi Araştırma Merkezi, Gastroenteroloji Cerrahi Bölümü, Mumbai, Hindistan
| | - Prasad Pande
- Litavati Hastanesi Araştırma Merkezi, Gastroenteroloji Cerrahi Bölümü, Mumbai, Hindistan
| | - Paresh Varty
- Litavati Hastanesi Araştırma Merkezi, Gastroenteroloji Cerrahi Bölümü, Mumbai, Hindistan
| | - Hitesh Mehta
- Litavati Hastanesi Araştırma Merkezi, Gastroenteroloji Cerrahi Bölümü, Mumbai, Hindistan
| | - Dattaprasanna Kulkarni
- Litavati Hastanesi Araştırma Merkezi, Gastroenteroloji Cerrahi Bölümü, Mumbai, Hindistan
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Dhar VK, Sutton JM, Xia BT, Levinsky NC, Wilson GC, Smith M, Choe KA, Moulton J, Vu D, Ristagno R, Sussman JJ, Edwards MJ, Abbott DE, Ahmad SA. Fistulojejunostomy Versus Distal Pancreatectomy for the Management of the Disconnected Pancreas Remnant Following Necrotizing Pancreatitis. J Gastrointest Surg 2017; 21:1121-1127. [PMID: 28397026 DOI: 10.1007/s11605-017-3419-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/30/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes. METHODS Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated. RESULTS Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15). CONCLUSIONS Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ.
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Affiliation(s)
- Vikrom K Dhar
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Jeffrey M Sutton
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Brent T Xia
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Nick C Levinsky
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Milton Smith
- Department of Medicine, Division of Gastroenterology, University of Cincinnati, Cincinnati, OH, USA
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Jonathan Moulton
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Doan Vu
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Ross Ristagno
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Michael J Edwards
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA.
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Luo SC, Cheng SB, Wu CC, Huang CC, Lin YL, P'eng FK. Embedding fistulojejunostomy: An easy and secure technique for refractory external pancreatic fistula. Asian J Surg 2016; 41:143-147. [PMID: 27816407 DOI: 10.1016/j.asjsur.2016.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/20/2016] [Accepted: 09/23/2016] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Refractory external pancreatic fistula (REPF) is a rare but troublesome event. Fistulojejunostomy with direct suture of the fistula wall to jejunal wall has been demonstrated as a solution. However, it is sometimes technically difficult and some cases of failure were reported. METHODS An embedding fistulojejunostomy (EFJ) was designed. The fistula tract was detached from the abdominal wall and impactedly inserted into a Roux-en-Y jejunal lumen without direct suture of the fistula wall to the jejunal wall. Five patients with REPF for > 3 months underwent this procedure in the past 10 years. The preoperatively-placed drainage tubes temporarily exteriorized the pancreatic fluid for 30 days. RESULTS All fistulojejunostomy procedures were accomplished within 15 minutes. Four patients had uneventful recovery with a postoperative hospital stay ≤ 10 days. One patient had wound infection and needed hospitalization for 23 days. Except for one patient who required pancreatic enzyme supplements for 8 months, no other patient had pancreatic exocrine insufficiency. After follow up for 12-124 months, no patient required pancreatic enzyme supplements, and no patient had recurrent fistula or diabetes mellitus. CONCLUSION EFJ makes fistulojejunostomy easier and more secure with a satisfactory early and long-term outcome. It may be a desirable technique for REPF.
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Affiliation(s)
- Shao-Ciao Luo
- Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Shao-Bin Cheng
- Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan; Department of Surgery, Chung-Shan Medical University, Taichung 402, Taiwan
| | - Cheng-Chung Wu
- Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan; Department of Surgery, Chung-Shan Medical University, Taichung 402, Taiwan; Department of Surgery, Faculty of Medicine, National Yang-Ming University, Taipei 112, Taiwan; Department of Surgery, Taipei Medical University, Taipei 110, Taiwan.
| | - Chu-Chun Huang
- Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Yi-Ling Lin
- Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Fang-Ku P'eng
- Department of Surgery, Taichung Veterans General Hospital, Taichung 407, Taiwan; Department of Surgery, Faculty of Medicine, National Yang-Ming University, Taipei 112, Taiwan
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Kawakatsu S, Kaneoka Y, Maeda A, Fukami Y. Salvage anastomosis for postoperative chronic pancreatic fistula. Updates Surg 2016; 68:413-417. [PMID: 27522612 DOI: 10.1007/s13304-016-0383-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 07/15/2016] [Indexed: 11/30/2022]
Abstract
Salvage anastomosis for postoperative chronic pancreatic fistula is challenging, and its safety and surgical outcomes remain unclear. Four patients with postoperative chronic pancreatic fistulas who underwent surgical interventions in our institute were retrospectively reviewed. A re-pancreatojejunostomy was performed in two patients with a disruption of the pancreatojejunostomy and a dilated main pancreatic duct of the remnant pancreas. A fistulojejunostomy was performed in the remaining two patients with a duct disruption after necrosectomy for necrotic severe acute pancreatitis and non-dilated main pancreatic duct. The median duration from the onset of the pancreatic fistula to the surgical intervention was 4.5 months (range 4-6 months). The median operation time was 151 min (range 38-257 min) and the median blood loss was 200 mL (range 5-350 mL). According to the Clavien-Dindo classification, one patient had grade 0, two patients had grade I, and one patient had grade II (wound infections). The median length of hospital stay was 22 days (range 21-28 days). There were no recurrences of pancreatic fistulas. Salvage anastomosis according to the simple radiologic classification for postoperative chronic pancreatic fistulas is a safe and effective procedure.
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Affiliation(s)
- Shoji Kawakatsu
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Yuji Kaneoka
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Yasuyuki Fukami
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan.
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Giovinazzo F, Butturini G, Salvia R, Mascetta G, Monsellato D, Marchegiani G, Pederzoli P, Bassi C. Drain management after pancreatic resection: state of the art. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 18:779-84. [PMID: 21861143 DOI: 10.1007/s00534-011-0431-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Placement of intraperitoneal drain (ID) after abdominal surgery is a common practice. Postoperative pancreatic fistula (POPF), incidence of which ranges from 2% to more than 30%, represents the most common major complication after pancreatic resection. The goal of this paper is to review the state of the art in ID management after pancreatic resection. METHODS Data from randomized controlled trials (RCT) are reported together with data from our institution in the period before and after the start of the two reported RCTs. RESULTS One thousand five hundred eighty patients underwent surgical resection for pancreatic lesions at our institution from 1990 to 2010. The overall rate of POPF was 23% before and 19.5% after (p = 0.24) the performance of the RCTs. Both postoperative morbidity and average in-hospital stay were higher in the period before the RCTs (13.6 ± 11.4 versus 13.4 ± 10.3 days, respectively). CONCLUSIONS POPF is a complex and multifactorial complication after pancreatic surgery. On the basis of the present results and review of the RCTs, the value of ID and its management after pancreatic surgery remain unclear.
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Affiliation(s)
- Francesco Giovinazzo
- Surgical Department, Pancreas Centre, Hospital of 'G.B.Rossi', University of Verona, Piazzale 'L.A. Scuro', 37134, Verona, Italy
| | - Giovanni Butturini
- Surgical Department, Pancreas Centre, Hospital of 'G.B.Rossi', University of Verona, Piazzale 'L.A. Scuro', 37134, Verona, Italy
| | - Roberto Salvia
- Surgical Department, Pancreas Centre, Hospital of 'G.B.Rossi', University of Verona, Piazzale 'L.A. Scuro', 37134, Verona, Italy
| | - Giuseppe Mascetta
- Surgical Department, Pancreas Centre, Hospital of 'G.B.Rossi', University of Verona, Piazzale 'L.A. Scuro', 37134, Verona, Italy
| | - Daniela Monsellato
- Surgical Department, Pancreas Centre, Hospital of 'G.B.Rossi', University of Verona, Piazzale 'L.A. Scuro', 37134, Verona, Italy
| | - Giovanni Marchegiani
- Surgical Department, Pancreas Centre, Hospital of 'G.B.Rossi', University of Verona, Piazzale 'L.A. Scuro', 37134, Verona, Italy
| | - Paolo Pederzoli
- Surgical Department, Pancreas Centre, Hospital of 'G.B.Rossi', University of Verona, Piazzale 'L.A. Scuro', 37134, Verona, Italy
| | - Claudio Bassi
- Surgical Department, Pancreas Centre, Hospital of 'G.B.Rossi', University of Verona, Piazzale 'L.A. Scuro', 37134, Verona, Italy.
- Department of Surgery, General Surgery B, P.Le L.A. Scuro 10, 37134, Verona, Italy.
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Toihata T, Hashimoto D, Hayashi H, Chikamoto A, Beppu T, Baba H. Intraoperative gastrojejunoscopy-assisted fistulojejunostomy for postoperative pancreatic fistula. Asian J Endosc Surg 2014; 7:311-3. [PMID: 25354375 DOI: 10.1111/ases.12130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 07/06/2014] [Accepted: 07/07/2014] [Indexed: 01/17/2023]
Abstract
Postoperative pancreatic fistula is a known complication after pancreaticojejunostomy. When an anastomosis collapses completely, two-stage reconstruction is necessary. Herein, we describe the case of a 70-year-old woman who underwent subtotal stomach-preserving pancreaticoduodenectomy with pancreaticojejunostomy after she had developed a severe postoperative pancreatic fistula. The pancreaticojejunostomy was divided, and an external pancreatic drainage tube was placed. Four months later, fistulojejunostomy between the pancreas and the stump of the jejunum was performed successfully using intraoperative gastrojejunoscopy.
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Affiliation(s)
- Tasuku Toihata
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Malleo G, Pulvirenti A, Marchegiani G, Butturini G, Salvia R, Bassi C. Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg 2014; 399:801-10. [PMID: 25173359 DOI: 10.1007/s00423-014-1242-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 08/11/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the leading complication after partial pancreatic resection and is associated with increased length of hospital stay and resource utilization. The introduction of a common definition in 2005 by the International Study Group of Pancreatic Surgery (ISGPS), which has been since employed in the vast majority of reports, has allowed a reliable comparison of surgical results. Despite the systematic investigation of risk factors and of surgical techniques, the incidence of POPF did not change in recent years, whereas the associated mortality has decreased. PURPOSE The purposes of this review article were to summarize the current evidence on the diagnosis and management strategies of POPF and to provide a concise reference for the practicing surgeons and physicians. CONCLUSION The high incidence of POPF was accompanied by a shift from operative to non-operative management. However, the current management strategy is driven by the patient's condition and local expertise and is generally based on poor evidence. A randomized trial showed that enteral nutrition is superior to total parenteral nutrition, and pooled data of randomized trials failed to show any advantage of somatostatin analogs for accelerating fistula closure. The choice of percutaneous versus endoscopic drainage of peripancreatic collections remains arbitrary, and-when re-operation is needed-there are very few comparative data regarding local drainage with or without main pancreatic stenting as opposed to anastomotic revision or salvage re-anastomosis. The continuous development of specialist, high-volume units with appropriate resources and multidisciplinary experience in complication management might further improve the evidence and the outcomes.
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Affiliation(s)
- Giuseppe Malleo
- Unit of Surgery B, The Pancreas Institute, Department of Surgery, G.B. Rossi Hospital, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy,
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12
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Ramia JM, Fabregat J, Pérez-Miranda M, Figueras J. [Disconnected panreatic duct syndrome]. Cir Esp 2014; 92:4-10. [PMID: 23845879 DOI: 10.1016/j.ciresp.2013.02.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 02/15/2013] [Accepted: 02/19/2013] [Indexed: 02/07/2023]
Abstract
Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotizing pancreatitis treated medically, by percutaneous drainage, or necrosectomy. There are no clear epidemiological data on the real incidence of DPDS; approximately 10 to 30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic and surgical management have been described. We have performed a sytematic review of the literature on DPDS.
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Affiliation(s)
- Jose Manuel Ramia
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - Joan Fabregat
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Bellvitge, Barcelona, España
| | | | - Joan Figueras
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Josep Trueta, Gerona, España
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Nair RR, Lowy AM, McIntyre B, Sussman JJ, Matthews JB, Ahmad SA. Fistulojejunostomy for the management of refractory pancreatic fistula. Surgery 2007; 142:636-42; discussion 642.e1. [PMID: 17950358 DOI: 10.1016/j.surg.2007.07.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 07/26/2007] [Accepted: 08/18/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic fistula (PF) formation is a known complication of pancreatic surgery, pancreatitis, and pancreatic injury. When medical or endoscopic interventions fail to resolve PF, operation remains the only viable treatment option. Unfortunately, operation for the correction of PF is often difficult and associated with significant morbidity. METHODS Herein, we report on our experience with a previously described technique for the management of PF that is performed easily and is associated with reduced morbidity. During the period of 2003-2006, 8 patients (males = 6, female = 2) with PF were treated with prolonged percutaneous drainage. Once a mature scar tract formed around the percutaneous drain, patients underwent a fistulojejunostomy. RESULTS The age of these patients ranged from 43 to 61 years. Of the 8 patients, 5 had fistulas secondary to necrotizing pancreatitis. The remaining 3 patients had fistulas resulting from previous pancreatic surgery. The average interval between drain placement and fistulojejunostomy was 6 months (range, 4-7 months). The average duration of operation was 2.5 h (range, 1-4.5 h). The average blood loss was 280 mL (range, 50-600 mL). Average duration of stay was 9 days (average, 4-14 days). At a mean follow-up of 17 months (range, 2-58 months), 6 of 8 patients had resolution of their pancreatic fistulas, could resume regular diet, and were free of narcotic use. One patient developed a recurrent pseudocyst and required a distal pancreatectomy, and the final patient was lost to follow-up. CONCLUSIONS Fistulojejunostomy is an effective therapy for the definitive treatment of pancreatic fistulas.
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Affiliation(s)
- Rajalakshmi R Nair
- Department of Surgery, The University of Cincinnati Medical Center, Cincinnati, Ohio 45247, USA
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Crippa S, Bassi C, Salvia R, Falconi M, Butturini G, Pederzoli P. Enucleation of pancreatic neoplasms. Br J Surg 2007; 94:1254-9. [PMID: 17583892 DOI: 10.1002/bjs.5833] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Standard resections for benign and borderline neoplasms of the pancreas are associated with a significant risk of long-term functional impairment, whereas enucleation preserves healthy parenchyma and pancreatic function. The aim of this study was to evaluate postoperative and long-term oncological and functional results after pancreatic enucleation. METHODS Data collected prospectively from 61 consecutive patients who underwent pancreatic enucleation were analysed. RESULTS There were no deaths. A clinically significant pancreatic fistula was reported in 14 patients (23 per cent), and five patients (8 per cent) had a further operation for fistula-related complications. The most common indication for surgery was endocrine neoplasm (38 patients; 62 per cent) and two patients (3 per cent) had a final histopathological diagnosis of malignant neoplasm. At a median follow-up of 61 months no patient had developed tumour recurrence or exocrine insufficiency. Two elderly patients developed non-insulin-dependent diabetes. CONCLUSION Enucleation is an effective procedure for the radical treatment of benign and borderline neoplasms of the pancreas, with good long-term outcomes.
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Affiliation(s)
- S Crippa
- Department of Surgery, Policlinico 'GB Rossi', University of Verona, Piazzale L. A. Scuro 10, 37134 Verona, Italy
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Imaging and Intervention in Acute Pancreatic Conditions. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Beecherl EE, Shires GT, Shires GT. Treatment of Post-pancreaticoduodenectomy Complications. ACTA ACUST UNITED AC 2004; 7:365-370. [PMID: 15345207 DOI: 10.1007/s11938-004-0049-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pancreaticoduodenectomy is a complex operation that is becoming more common as treatment for both malignant and benign diseases. While postoperative mortality has improved over the last two decades, morbidity continues to remain high. The improvement in mortality is attributed to better perioperative care, including aggressive early diagnosis of complications and a multidisciplinary approach to their treatment. In addition to a high clinical suspicion for postoperative complications, ready access to state of the art diagnostic radiology and endoscopy are essential for the early and accurate diagnosis of complications. After the diagnosis of a complication is made, the patient should have expertise available in interventional radiology, gastroenterology, and hepatobiliary and pancreatic surgery. Optimal treatment may involve any one of these specialties or an orchestrated effort from them all. The need for a critical mass of expertise in many specialties and subspecialties has prompted the development of new tertiary centers devoted to hepaticopancreaticobiliary (HPB) diseases. These HPB centers are becoming more prevalent in the United States as the value of this subspecialty is becoming more recognized. These HPB centers should continue to show improvements in quality and cost of care in treating complex liver, pancreatic, and biliary diseases that have rapidly evolving treatment options.
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Affiliation(s)
- Ernest E. Beecherl
- Department of Surgery, Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, Texas 75231 USA.
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Le Moine O, Matos C, Closset J, Devière J. Endoscopic management of pancreatic fistula after pancreatic and other abdominal surgery. Best Pract Res Clin Gastroenterol 2004; 18:957-75. [PMID: 15494289 DOI: 10.1016/j.bpg.2004.06.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Post-operative pancreatic fistulae represent a challenge for all the actors in gastroenterology: for surgeons, because they want to prevent and treat conservatively this complication since re-operation is associated with high morbidity and mortality rates; for radiologists, because they have to provide the best staging and informations without any additional risk; and for endoscopists, because endoluminal treatment is emerging as a safe and effective procedure provided it is performed in highly experienced tertiary centres in the setting of a multidisciplinary approach. Herein, we review the definitions, the causes, the staging and the possible options to prevent or treat post-operative pancreatic fistulae. Special attention is paid to the endoscopic management of this complication: including the relief of ductal obstructions, the stenting of leakages and the drainage of bulging or non-bulging fluid collections. Practical problems and issues are clearly outlined as well as the need for future improvements in staging and management of the patients having such complications.
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Affiliation(s)
- Olivier Le Moine
- Department of Gastroenterology, ULB-Hôpital Erasme, 808 route de lennik, B-1070 Brussels, Belgium.
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Tann M, Maglinte D, Howard TJ, Sherman S, Fogel E, Madura JA, Lehman GA. Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients. J Comput Assist Tomogr 2003; 27:577-82. [PMID: 12886147 DOI: 10.1097/00004728-200307000-00023] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The lack of ductal continuity between a viable pancreatic tissue and the gastrointestinal tract results in the disconnected pancreatic duct syndrome (DPDS). The purpose of our study is to describe accurately the imaging features of CT scanning and endoscopic retrograde pancreatography (ERCP) that define the DPDS. METHODS We conducted a retrospective analysis of the computed tomography (CT) and ERCP examinations in 26 consecutive patients with surgically proven disconnected pancreatic ducts treated over a 5-year period at our institution. Two abdominal radiologists concurrently defined the imaging features (presence and size of fluid collection along the course of the pancreatic duct, upstream enhancing pancreatic parenchyma, and ERCP abnormalities) via consensus for both exams. Patient demographics, etiology of pancreatitis, surgical treatment, initial CT interpretation, and the delay between symptom onset to correct diagnosis were recorded. RESULTS A discrete, intrapancreatic fluid collection (average size = 27 cm2 (range, 4-74 cm2) along the course of the main pancreatic duct with upstream viable pancreatic parenchyma was identified by CT in 26 cases. ERCP showed ductal obstruction at the level of the intrapancreatic fluid collection in all patients with extravasation of contrast in 14 (54%). All patients were treated by operation: 15 (58%) by internal drainage into a Roux-en-Y limb of jejunum and 11 (42%) by distal pancreatic resection. No prior CT interpretation correctly identified DPDS. The average delay between symptom onset and definitive diagnosis was 9.3 months (range, 3-36 months). CONCLUSIONS A discrete intrapancreatic fluid collection along the expected course of the main pancreatic duct with viable upstream pancreatic parenchyma suggests the diagnosis of DPDS. ERCP findings of ductal obstruction at the level of this fluid collection with or without contrast extravasation confirm this diagnosis. Treatment is surgical and requires either internal drainage or distal pancreatic resection for complete resolution.
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Affiliation(s)
- Mark Tann
- Department of Radiology, Indiana University School of Medicine, 550 N. University Boulevard, RM0279, Indianapolis, IN 46202-5253, USA.
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Abstract
Although enteric drainage of the fistula tract is a widely accepted treatment for pancreaticocutaneous fistula, few data have been published on the outcome of this procedure. We conducted a retrospective chart review of 30 patients with pancreaticocutaneous fistula who underwent surgical management at a single institution over a 13-year period. The operative morbidity rate was 30%. Overall the incidence of recurrent ductal leaks requiring further intervention was 23%. Six of seven patients who had a recurrence had an ongoing inflammatory pathology, and three of seven had pancreas divisum. Recurrence was most likely when cystenterostomy was used. Enteric drainage of pancreaticocutaneous fistulas is not always curative. Fistulojejunostomy gives a better outcome than cystenterostomy. Recurrence may be expected in patients with continuing inflammatory ductal pathology.
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Affiliation(s)
- Miranda Voss
- Division of Surgery, Duke University Medical Center, Box 3110, 27710, Durham, NC
| | - Amjad Ali
- Division of Surgery, Duke University Medical Center, Box 3110, 27710, Durham, NC
| | - W Steve Eubanks
- Division of Surgery, Duke University Medical Center, Box 3110, 27710, Durham, NC
| | - Theodore N Pappas
- Division of Surgery, Duke University Medical Center, Box 3110, 27710, Durham, NC
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Abstract
External and internal pancreatic fistulas have a different etiology and natural history. Approximately 50% of internal and 70% to 90% of external pancreatic fistulas can be expected to heal with nonoperative management. Nonclosure is predicted by anatomic factors, which may be defined at endoscopic retrograde cholangiopancreatography or by CT if disconnected pancreatic segments are seen. Enteral nutrition beyond the ligament of Treitz is probably as effective as total parenteral nutrition in reducing fistula output. Octreotide reduces output and, possibly, time to closure. It does not increase the incidence of closure, and there is no convincing evidence that it prevents significant postoperative leaks. Endoscopic stenting has been reported to be effective treatment for side leaks, particularly when associated with stenoses or calculi. However, it is not widely available and has a significant complication rate related to pancreatic sphincterotomy and stent blockage. Surgical treatment is indicated for end leaks with a disconnected pancreatic segment. The choice of appropriate procedure is important. Percutaneous interventional therapies are emerging as options for treatment of end leaks but are still investigational.
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Affiliation(s)
- Miranda Voss
- Duke University Medical Center, PO Box 3479, Duke University, Durham, NC 27710, USA. E-mail:
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Gumbs AA, Bassi C. II. The Endocrine and Pancreatic Unit at the University of Verona, Italy. HPB (Oxford) 2002; 4:171-3. [PMID: 18332949 PMCID: PMC2020553 DOI: 10.1080/13651820260503828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Howard TJ, Rhodes GJ, Selzer DJ, Sherman S, Fogel E, Lehman GA. Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis. Surgery 2001; 130:714-9; discussion 719-21. [PMID: 11602903 DOI: 10.1067/msy.2001.116675] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Roux-en-Y (RNY) internal drainage has been our primary surgical strategy to definitively treat disconnected duct syndrome in patients after severe acute pancreatitis (SAP). This study compares the results of internal drainage with the results of distal pancreatectomy-splenectomy (DPS) performed in a contemporaneous group of patients. METHODS For 5 years (June 1995 to June 2000), 27 consecutive patients with disconnected duct syndrome after SAP were identified: 13 treated with internal drainage and 14 with DPS. Fistula characteristics, operative management, and clinical outcome were analyzed. Comparisons between groups were made with the Student t test and Fisher exact test, with statistical significance defined as P <.05. RESULTS Age, sex, etiology of pancreatitis, comorbid diseases, and prior operations were similar between groups. Internal drainage required less operative time (211 +/- 37 vs 269 +/- 88 minutes, P =.04), blood loss (735 +/- 706 vs 2757 +/- 3062 mL, P =.03), and transfusion requirements (0.69 +/- 1.7 vs 4.21 +/- 8.0 units, P =.05). Clinical outcomes--as measured by postoperative complication rate, reoperation rate, fistula recurrence rate, and death rate--were similar between groups. CONCLUSIONS RNY internal drainage, when technically feasible, is the best surgical option to treat disconnected duct syndrome after SAP.
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Affiliation(s)
- T J Howard
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Ind, USA
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