Abstract
Objective: Pancreatic fistula (PF) is an early complication after pancreatoduodenectomy. PF occurs because of disruption to the pancreatodigestive tract anastomosis with stricture or occlusion. A strategy to treat PF using interventional methods is proposed. Methods: We treated a total of 6 patients with PF by endoscopic ultrasound (EUS)-guided or percutaneous pancreatic duct drainage. In this paper, these patients are reviewed based on the applied treatment for PF. Results: At the time of introduction to our department, all the patients, except for one, had a percutaneous drainage tube implanted prior to surgery. In 2 patients undergoing pancreatojejunostomy within 3 months of the previous surgery, percutaneous introduction of a guidewire into the anastomosed jejunum, via the disrupted anastomosis, through the percutaneous fistula and the implantation of a percutaneous jejunal tube for 6 weeks was an effective PF treatment. There were 4 patients (3 pancreatojejunostomy, 1 pancreatogastrostomy) with more than 3 months of PF, with an occluded anastomosis and the pancreatic juice flow had to be rerouted by making another pancreatodigestive tract anastomosis using percutaneous or EUS-guided puncture of the pancreatic duct. Conclusions: The optimal treatment for PF is considered to be the recanalization of the stricture or occluded anastomosis, or rerouting of the pancreatic juice flow by making another anastomosis. Considering our experiences in the treatment of PF, EUS-guided puncture of the pancreatic duct near the occluded anastomosis using a convex-type EUS endoscopy is the most preferable method to treat PF. In patients for whom it is difficult to introduce the endoscope into the afferent loop in the pancreatojejunostomy, various methods, including percutaneous approaches, are feasible to treat PF.
Highlights
Pancreatic fistula (PF) and acute recurrent pancreatitis (ARP) are the respective early and late stage complications after pancreatoduodenectomy (PD)
In the 2 patients suffering from PF for 45 days (Case 1) and 33 days, or 85 days after the previous surgery (Case 2), a 0.025-inch guidewire (GW) (Radifocus, Terumo, Japan) was introduced through the percutaneous tube and advanced into the anastomosed jejunum via the disrupted pancreatojejunostomy (Figure 2)
In 4 patients suffering from PF for over 3 months, a GW introduced through the percutaneous drainage tube could not pass through the disrupted anastomosis into the anastomosed digestive tract
Summary
Pancreatic fistula (PF) and acute recurrent pancreatitis (ARP) are the respective early and late stage complications after pancreatoduodenectomy (PD). The frequency of PF is low in patients with pancreatogastrostomy, with a rate of 0-12% [1], while it is more frequent among pancreatojejunostomy patients, with a rate of 10 to 20% [1]. The disruption of the anastomotic site is the cause of PF and is associated with stricture or occlusion of the anastomosis at early stages after PD. The frequency of ARP is low with the ratio of 2% in pancreatogastrostomy [1], and 1.6% [1] to 2.2% [2] in pancreatojejunostomy. The strictured or occluded anastomosis at the late stage post-PD causes ARP [3]
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