A technique for witzel tunnel catheter drainage of the biliary and pancreatic anastomosis of a Whipple procedure

Abstract

Presenter: Mridul Pansari MD | Florida Atlantic University Background: Stenting of the pancreatic and biliary anastomoses of a Whipple procedure has been shown to lower the rate of anastomotic leak in several retrospective and prospective studies. We describe here a combined biliary and pancreatic ductal external drainage catheter we have used successfully in our pancreatico-duodenectomy operations. Methods: We have identified a combined biliary and pancreatic ductal external drainage catheter / stent which we construct on the operating table to decompress the small bowel limb and both anastomoses. The single catheter is a combination of a red Robinson catheter and a silastic pediatric feeding tube each of appropriate size for the duct they are draining. The silastic feeding tube is inserted into the lumen of the red rubber catheter though a small tight fenestration in the elastic external segment of the red catheter and exits the red rubber catheter through a similar fenestration at the level of the choledocho or hepatico- jejunostomy. The silastic feeding tube is then advanced well into the lumen of the pancreatic duct where it is secured to the small bowel mucosa with a fine absorbable suture to prevent dislodgement. Multiple small extra openings are cut into both tubes at their distal segments to facilitate ductal drainage. The combined tubes then exeunt the small bowel “Whipple limb” though a Witzel tunnel. The small bowel is secured to the right upper quadrant abdominal wall with several interrupted 3-0 Vicryl sutures. The tube is secured to the skin externally with a heavy nylon suture. The pediatric feeding tube is then secured to the outer part of the red rubber catheter with benzoin and three ¼ inch steri-strips. Both catheters are connected to separate external drainage bags. We perform our pancraetico- jejunostomy with a single layer of interrupted 3-0 silk suture and our bile duct anastomosis with a single layer of 4-0 or 5-0 PDS or Maxon suture. Two 10 mm Jackson Pratt drains are then placed in the right upper quadrant. Results: There are several theoretical advantages that our procedure offers. First, it diverts the pancreatic fluid and bile, decreasing it's flow through the respective anastomosis which helps in the healing of the anastomosis. Secondly, our technique is a more durable way of stenting the two anastomoses and prevent the migration of the stents. The pediatric feeding tube has three areas of resistance that prevents its migration. The fenestration in the external portion, the fenestration in the internal portion and the mucosal stitch that is placed to hold it in place. The red rubber catheter is kept in place by the Witzel tunnel itself. Third advantage is that it provides an opportunity to study the two anastomosis via contrast administration. Fourth, the witzel tunnel and the anchoring of the jejunal limb to the lateral abdominal wall opens the door for several wire based treatments in a Seldinger fashion, should a leak be identified in the post operative period. Conclusion: The use of a combined biliary and pancreatic ductal external drainage catheter / stent system has many theoretical advantages.