Pancreas-preserving surgical management of grade-C pancreatic fistulas after pancreatic head resection by external wirsungostomy

• Published in: Langenbeck's archives of surgery Vol. 401; no. 4; pp. 457 - 462
• Main Authors: Horvath, P., Beckert, S., Nadalin, S., Königsrainer, A., Königsrainer, I.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-06-2016
• Subjects: Abdominal Surgery; Aged; Carcinoma - pathology; Carcinoma - surgery; Cardiac Surgery; Female; General Surgery; Humans; Length of Stay; Male; Medicine; Medicine & Public Health; Middle Aged; Organ Sparing Treatments; Original Article; Pancreatectomy; Pancreatic Fistula - etiology; Pancreatic Fistula - surgery; Pancreatic Neoplasms - pathology; Pancreatic Neoplasms - surgery; Pancreaticoduodenectomy - adverse effects; Pancreaticojejunostomy - adverse effects; Retrospective Studies; Salvage Therapy - methods; Thoracic Surgery; Traumatic Surgery; Vascular Surgery; Pancreatic fistula; Pancreas preservation; Postoperative management
• ISSN: 1435-2443; 1435-2451
• DOI: 10.1007/s00423-016-1423-2

Purpose
Completion pancreatectomy for grade-C pancreatic fistula is associated with unacceptably high mortality and therefore this strategy should be reassessed. This study presents an update of our experience with a pancreas-preserving technique in the course of salvage re-laparotomy in terms of closure of the open jejunum via segmental resection and external drainage of the pancreas.
Methods
Between April 2004 and January 2015, 292 pancreaticoduodenectomies (PD) with pancreaticojejunostomy (PJ) were performed. Thirteen patients (5 %) underwent salvage re-laparotomy for symptomatic grade-C fistulas, and clinical data were retrospectively analyzed.
Results
In all patients, the preservation of the pancreas remnant and external drainage of the pancreatic juice was feasible. Median hospital stay was 58 days (range, 21–142 days). In 4/13 patients (31 %), further reoperations were necessary. In-hospital mortality was 15 % (2/13). 3/13 patients (23 %) were readmitted and two received inpatient non-surgical treatment. To date re-pancreaticojejunostomy was performed in seven of the remaining 11 patients (63 %) after 168 days in median. In 1/7 patients (14 %), a re-operation after re-PJ was necessary. In one patient, externalization of the pancreas juice was chosen as a definite option. In another patient, secretion ceased spontaneously without stasis and normal endocrine function. Neither before nor after re-anastomosis impairment of endocrine function was observed.
Conclusions
Closure of the intestinum and preservation of the pancreas remnant in grade-C pancreatic fistula is easy to perform and can be categorized as a life-saving procedure. Prevention of total pancreatectomy associated with high morbidity and mortality was achieved in all cases.