Endoscopic drainage of postoperative pancreatic leaks: A great idea!

Abstract

Every pancreatic surgeon should read this article by this group of talented interventional gastroenterologists from 3 university centers in Germany. Why? Because all of us pancreatic surgeons (at least those of us who are honest) have observed pancreatic leaks, and these leaks can be very difficult to manage. Having been on the surgical staff at Mayo Clinic Rochester for 30 years, I have had the privilege of working in a truly multidisciplinary environment with unbelievably gifted interventional gastroenterologists (like Todd Baron, who was one of the pioneers in the late 1990s in this aggressive endoscopic management of pancreatic collections), complemented by similarly gifted interventional radiologists, who would manipulate our operatively placed, peripancreatic drains into adjacent, inappropriately or undrained, peripancreatic collections after a pancreatectomy. So yes, this endoscopic technique is really important, helpful, and will often prevent reoperative intervention or a prolonged hospital course! Concerning this multicenter review by Jürgensen and colleagues,1Jürgensen C. Distler M. Arlt A. et al.EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video).Gastrointest Endosc. 2019; 89: 311-319Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar I am going to concentrate on why this article is important for surgeons and gastroenterologists alike. Yes, there are several points of contention about the authors’ claims in the manuscript that I believe are not supported by their data, such as the obvious bias in patient selection, the scientific inability to do any meaningful statistical comparisons because of the lack of comparability of the patient groups, and possibly the use of the term “resolution,” because they claim resolution within very short periods (days); yet, the endoscopically placed drains remained in place for a median of 100 days. Some of the authors’ conclusions are obviously unfounded, but aside from that, the message I want to emphasize are the strengths and true importance of this article. First, these authors separated the patients with postoperative pancreatic leaks into 2 groups: (1) patients with a peripancreatic fluid collection and (2) patients without such a collection who had persistently draining fistulas that were apparently “controlled.” This distinction is both important and crucial. Let’s start with the patients with a pancreatic leak associated with peripancreatic collection. Because these collections occur after pancreatic resection, most all are fluid filled and in direct apposition to the stomach (or rarely the neoduodenum after a proximal pancreatectomy); this advantageous anatomic positioning lends these collections to endoscopic, transgastric access aided by EUS, especially when there is no obvious bulging of the cavity into the stomach. Equally attractive is the possibility of internal drainage (vs the uncomfortable and often unwieldy external drainage) with the possibility of creating a potentially permanent or, at the least, a long-lasting “fistula” enterically back into the stomach; this allows not only decompression and drainage of the often infected (or colonized) cavity but also the possibility for the source of the leak to heal (ie, the pancreatoenteric anastomosis or the pancreatic transection margin), which with decompression and effective drainage thankfully allows most of these collections to heal! These collections usually have some element of an inflammatory fibrous wall adhering the cavity to the serosal side of the stomach; this apposition and semblance of a fibrous wall helps to assure that gastric secretions (from the transgastric access approach) will not diffuse throughout the peritoneal cavity—a concept now well appreciated with the endoscopic treatment of established pseudocysts or postnecrotic fluid/solid collections after necrotizing pancreatitis. The newer, recently introduced covered metal stents offer a much larger internal diameter than the plastic stents, which markedly facilitates drainage/decompression/debridement while allowing the stents to be removed in the future. The most impressive aspect of this article is the treatment of pancreatic fistulas that lack a collection. I will stress that this technique requires a dedicated, skilled, and experienced interventionalist who is equally skilled in manipulating guidewires under EUS guidance. (I remember well some of our concerns, unfounded in retrospect, with the initial experience when EUS physicians in our group were micropuncturing the pancreatic duct via a transgastric route!) For us as surgeons, although most pancreatocutaneous fistulas close “eventually,” it is always difficult and uncomfortable to try to convince the patient of this; sometimes, unfortunately, the fistula does not close, thereby requiring an often-difficult reoperative intervention. This complicated push/pull endoscopic technique of converting an externally drained fistula into an internally drained fistula is an incredibly attractive option and, although obviously difficult, offers a new, currently unappreciated technique that bails us out as surgeons—and we do appreciate all such techniques! As a surgeon, I may in several instances urge caution, such as for acute pancreatic leaks in the early postoperative setting where a formal cavity is not evident, similar to the situation of pancreatic ascites. Yes, most pancreatic leaks after pancreatic surgery are associated with the development of an informal cavity related to the inflammatory aspects not only from the operative trauma but also from the leaking enteropancreatic secretions themselves; on rare occasions, however, the leak can disseminate throughout the peritoneal cavity (and this possibility may be more often these days with a laparoscopic resection, which leads to many fewer adhesions). In such a situation, transgastric “drainage” using a drain with a large internal diameter (like some of the metal stents) could in theory lead to the equivalent of a perforated ulcer with “leak” of gastric secretions intraperitoneally. In summary, this article accomplishes and emphasizes several important points. First, this technique of endoscopic transgastric drainage/decompression of selected pancreatic leaks after pancreatic surgery will prevent the need for reoperation or the need for insertion of multiple percutaneous drains, thereby facilitating a faster, less-uncomfortable discharge. Second, the technique for pancreatic fistulas without a cavity is a new, innovative approach but requires a special skill level. Third, this article reinforces the importance of a multidisciplinary approach to patient care, from both a surgical and a medical standpoint. As surgeons we have always found this type of multidisciplinary interaction/cooperation with our gastroenterologic colleagues to be a hallmark of excellent care and an important, constant advantage and privilege of our work in the operating room. The author disclosed no financial relationships relevant to this publication. EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video)Gastrointestinal EndoscopyVol. 89Issue 2PreviewPostoperative pancreatic leakage and fistulae (POPF) are a leading adverse event after partial pancreatic resection. Treatment algorithms are currently not standardized. Evidence regarding the role of endoscopy is scarce. Full-Text PDF