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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Intraoperative gastrojejunoscopy-assisted fistulojejunostomy for postoperative pancreatic fistula Tasuku Toihata, Daisuke Hashimoto, Hiromitsu Hayashi, Akira Chikamoto, Toru Beppu & Hideo Baba Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
Keywords Endoscopy-assisted surgery; fistulojejunostomy; pancreatic fistula Correspondence Hideo Baba, Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Kumamoto-city, 860-8556 Japan. Tel: 81 96 373 5213 Fax: 81 96 371 4378 Email: [email protected]
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.
Received 16 June 2014; revised 6 July 2014; accepted 7 July 2014 DOI:10.1111/ases.12130
Introduction A postoperative pancreatic fistula (POPF) is the most common complication after pancreaticoduodenectomy (PD) (1). Traditionally, surgical management of POPF has included reconstruction of a previous anastomosis or partial/complete pancreatectomy (2). However, reoperative pancreatic surgery can be associated with significant morbidity (3). Fistulojejunostomy, a technically demanding procedure, has rarely been reported as a means of treating POPF (2,4). Here, we describe our successful experience of fistulojejunostomy using intraoperative gastrojejunoscopy for POPF.
Case Presentation A 69-year-old woman underwent subtotal stomachpreserving PD for pancreatic metastasis from renal cell carcinoma. A modified Child’s reconstruction was performed with an end-to-side binding pancreaticojejunostomy as previously described (Figure 1) (5). One week after the subtotal stomach-preserving PD, reoperation for
grade C POPF was performed (1). The pancreaticojejunostomy was resected by a linear stapler, and an external pancreatic duct drainage tube was then placed without reconstruction of the pancreatico-digestive anastomosis. In case of future reoperation to make a new anastomosis, the pancreatic duct drainage tube was passed near the stump of the jejunum. During the postoperative period, about 150-mL pancreatic juice was drained from the tube each day, and no obstructions occurred. Four months after subtotal stomach-preserving PD, the patient underwent reoperation to create a new pancreaticojejunostomy. During laparotomy, the fistula tract was identified surrounding the pancreatic duct drainage tube and transected circumferentially (Figure 2). Guided by the surgeon’s intraperitoneal manipulation, the endoscopist inserted a gastroscope (GIF-Q260, working length 1030 mm; Olympus, Tokyo, Japan) through the gastrojejunostomy to the stump of the jejunum. The pancreatic duct drainage tube, which was inserted into the jejunum, was held by a snare from the endoscope (Figure 3a,b). Whereas there was severe adhesion around the jejunum, the pancreatic duct drain-
Asian J Endosc Surg 7 (2014) 311–313 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
311
Endoscopy-assisted fistulojejunostomy
T Toihata et al.
Figure 1 The modified Child’s reconstruction after subtotal stomach-preserving pancreaticoduodenectomy.
Figure 3 (a) Gastrojejunoscopy was used to guide the pancreatic duct drainage tube. A gastroscope reached at the stump of the jejunum and held the pancreatic duct drainage tube inserted into the jejunum (arrow), (b) with a snare. Arrowheads, fistula tract; #, jejunal stump; ※, pancreatic stump.
Figure 4 Insertion and fixation of the fistula tract. The fistula tract was inserted into the jejunum and fixed by Witzel’s method.
Figure 2 The stumps of the pancreas and the fistula tract. During the fistulojejunostomy, the fistula tract (arrowheads) was identified surrounding the pancreatic duct drainage tube and transected circumferentially. ※, the pancreatic stump.
age tube was easily pulled to the afferent loop, with guidance from the gastroscope. The fistula tract was inserted into the jejunum and fixed by Witzel’s method (Figure 4). The pancreatic duct drainage tube was passed from the afferent loop and fixed as an external drainage tube. Thus, the fistulojejunostomy was completed. The external pancreatic drainage tube was removed 4 weeks after the fistulojejunostomy without any postoperative complication.
312
Discussion POPF from a pancreatico-digestive anastomosis is the most common cause of morbidity, and it contributes significantly to the prolonged hospitalization and mortality of patients undergoing PD (1). POPF is usually treated conservatively with external drainage of intra-abdominal fluid collection (6). However, once a pancreaticodigestive anastomosis is divided completely as in the present case, reoperation is needed to create a new anastomosis. Fistulojejunostomy has been previously performed for pancreatic fistula with pancreatitis rather than for POPF (2,4,6–9). To perform fistulojejunostomy, a substantial
Asian J Endosc Surg 7 (2014) 311–313 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Endoscopy-assisted fistulojejunostomy
T Toihata et al.
period is needed so that a fibrous fistula tract can develop surrounding an external drainage tube (2). Bassi et al. recommended constructing a fistulojejunostomy at least 1.5–3 months after fistula onset (4). A fistula formation also depends on a patient’s condition. Severe adhesion exists in reoperative pancreatic surgery or around a fistula (3). Adhesiolysis has a large impact on the risk of bowel injury (10). As previous cases did not employ endoscopy during the procedure (2,4,6,7,9), we would like to emphasize the benefit of intraoperative gastrojejunoscopy in guiding the external pancreatic duct tube to the afferent loop and in avoiding extensive adhesiolysis around the pancreatic stump and the jejunal stump in the present case. In addition to sufficient preoperative simulation, careful surgical technique, and perioperative management to reduce and avoid mortality and high morbidity rates (2,4,6,7), we believe that fistulojejunostomy offers an effective treatment. It is applicable even in patients whose pancreatic duct and jejunal stump are relatively far apart.
Acknowledgments The authors received no financial support for this report.
2. Nair RR, Lowy AM, McIntyre B et al. Fistulojejunostomy for the management of refractory pancreatic fistula. Surgery 2007; 142: 636–642 discussion#. 3. Ahmed SA, Wray C, Rilo HL et al. Chronic pancreatitis: Recent advances and ongoing challenges. Curr Probl Surg 2006; 43: 127–238. 4. Bassi C, Butturini G, Salvia R et al. A single-institution experience with fistulojejunostomy for external pancreatic fistulas. Am J Surg 2000; 179: 203–206. 5. Hashimoto D, Hirota M, Yagi Y et al. End-to-side pancreaticojejunostomy without stitches in the pancreatic stump. Surg Today 2013; 43: 821–824. 6. Voss M, Ali A, Eubanks WS et al. Surgical management of pancreaticocutaneous fistula. J Gastrointest Surg 2003; 7: 542–546. 7. Howard TJ, Rhodes GJ, Selzer DJ et al. Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis. Surgery 2001; 130: 714–719 discussion 7. 8. Calu V, Dutu M, Pârvuletu R et al. Persistent pancreatic fistula after surgical necrosectomy for severe pancreatitis. Chirurgia (Bucur) 2012; 107: 796–801. 9. Shibuya T, Shioya T, Kokuma M et al. Cure of intractable pancreatic fistula by subcutaneous fistulojejunostomy. J Gastroenterol 2004; 39: 162–167. 10. ten Broek RP, Strik C, Issa Y et al. Adhesiolysis-related morbidity in abdominal surgery. Ann Surg 2013; 258: 98–106.
References 1. Bassi C, Dervenis C, Butturini G et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005; 138: 8–13.
Asian J Endosc Surg 7 (2014) 311–313 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
313
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Intraoperative gastrojejunoscopy-assisted fistulojejunostomy for postoperative pancreatic fistula Tasuku Toihata, Daisuke Hashimoto, Hiromitsu Hayashi, Akira Chikamoto, Toru Beppu & Hideo Baba Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
Keywords Endoscopy-assisted surgery; fistulojejunostomy; pancreatic fistula Correspondence Hideo Baba, Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Kumamoto-city, 860-8556 Japan. Tel: 81 96 373 5213 Fax: 81 96 371 4378 Email: [email protected]
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.
Received 16 June 2014; revised 6 July 2014; accepted 7 July 2014 DOI:10.1111/ases.12130
Introduction A postoperative pancreatic fistula (POPF) is the most common complication after pancreaticoduodenectomy (PD) (1). Traditionally, surgical management of POPF has included reconstruction of a previous anastomosis or partial/complete pancreatectomy (2). However, reoperative pancreatic surgery can be associated with significant morbidity (3). Fistulojejunostomy, a technically demanding procedure, has rarely been reported as a means of treating POPF (2,4). Here, we describe our successful experience of fistulojejunostomy using intraoperative gastrojejunoscopy for POPF.
Case Presentation A 69-year-old woman underwent subtotal stomachpreserving PD for pancreatic metastasis from renal cell carcinoma. A modified Child’s reconstruction was performed with an end-to-side binding pancreaticojejunostomy as previously described (Figure 1) (5). One week after the subtotal stomach-preserving PD, reoperation for
grade C POPF was performed (1). The pancreaticojejunostomy was resected by a linear stapler, and an external pancreatic duct drainage tube was then placed without reconstruction of the pancreatico-digestive anastomosis. In case of future reoperation to make a new anastomosis, the pancreatic duct drainage tube was passed near the stump of the jejunum. During the postoperative period, about 150-mL pancreatic juice was drained from the tube each day, and no obstructions occurred. Four months after subtotal stomach-preserving PD, the patient underwent reoperation to create a new pancreaticojejunostomy. During laparotomy, the fistula tract was identified surrounding the pancreatic duct drainage tube and transected circumferentially (Figure 2). Guided by the surgeon’s intraperitoneal manipulation, the endoscopist inserted a gastroscope (GIF-Q260, working length 1030 mm; Olympus, Tokyo, Japan) through the gastrojejunostomy to the stump of the jejunum. The pancreatic duct drainage tube, which was inserted into the jejunum, was held by a snare from the endoscope (Figure 3a,b). Whereas there was severe adhesion around the jejunum, the pancreatic duct drain-
Asian J Endosc Surg 7 (2014) 311–313 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
311
Endoscopy-assisted fistulojejunostomy
T Toihata et al.
Figure 1 The modified Child’s reconstruction after subtotal stomach-preserving pancreaticoduodenectomy.
Figure 3 (a) Gastrojejunoscopy was used to guide the pancreatic duct drainage tube. A gastroscope reached at the stump of the jejunum and held the pancreatic duct drainage tube inserted into the jejunum (arrow), (b) with a snare. Arrowheads, fistula tract; #, jejunal stump; ※, pancreatic stump.
Figure 4 Insertion and fixation of the fistula tract. The fistula tract was inserted into the jejunum and fixed by Witzel’s method.
Figure 2 The stumps of the pancreas and the fistula tract. During the fistulojejunostomy, the fistula tract (arrowheads) was identified surrounding the pancreatic duct drainage tube and transected circumferentially. ※, the pancreatic stump.
age tube was easily pulled to the afferent loop, with guidance from the gastroscope. The fistula tract was inserted into the jejunum and fixed by Witzel’s method (Figure 4). The pancreatic duct drainage tube was passed from the afferent loop and fixed as an external drainage tube. Thus, the fistulojejunostomy was completed. The external pancreatic drainage tube was removed 4 weeks after the fistulojejunostomy without any postoperative complication.
312
Discussion POPF from a pancreatico-digestive anastomosis is the most common cause of morbidity, and it contributes significantly to the prolonged hospitalization and mortality of patients undergoing PD (1). POPF is usually treated conservatively with external drainage of intra-abdominal fluid collection (6). However, once a pancreaticodigestive anastomosis is divided completely as in the present case, reoperation is needed to create a new anastomosis. Fistulojejunostomy has been previously performed for pancreatic fistula with pancreatitis rather than for POPF (2,4,6–9). To perform fistulojejunostomy, a substantial
Asian J Endosc Surg 7 (2014) 311–313 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Endoscopy-assisted fistulojejunostomy
T Toihata et al.
period is needed so that a fibrous fistula tract can develop surrounding an external drainage tube (2). Bassi et al. recommended constructing a fistulojejunostomy at least 1.5–3 months after fistula onset (4). A fistula formation also depends on a patient’s condition. Severe adhesion exists in reoperative pancreatic surgery or around a fistula (3). Adhesiolysis has a large impact on the risk of bowel injury (10). As previous cases did not employ endoscopy during the procedure (2,4,6,7,9), we would like to emphasize the benefit of intraoperative gastrojejunoscopy in guiding the external pancreatic duct tube to the afferent loop and in avoiding extensive adhesiolysis around the pancreatic stump and the jejunal stump in the present case. In addition to sufficient preoperative simulation, careful surgical technique, and perioperative management to reduce and avoid mortality and high morbidity rates (2,4,6,7), we believe that fistulojejunostomy offers an effective treatment. It is applicable even in patients whose pancreatic duct and jejunal stump are relatively far apart.
Acknowledgments The authors received no financial support for this report.
2. Nair RR, Lowy AM, McIntyre B et al. Fistulojejunostomy for the management of refractory pancreatic fistula. Surgery 2007; 142: 636–642 discussion#. 3. Ahmed SA, Wray C, Rilo HL et al. Chronic pancreatitis: Recent advances and ongoing challenges. Curr Probl Surg 2006; 43: 127–238. 4. Bassi C, Butturini G, Salvia R et al. A single-institution experience with fistulojejunostomy for external pancreatic fistulas. Am J Surg 2000; 179: 203–206. 5. Hashimoto D, Hirota M, Yagi Y et al. End-to-side pancreaticojejunostomy without stitches in the pancreatic stump. Surg Today 2013; 43: 821–824. 6. Voss M, Ali A, Eubanks WS et al. Surgical management of pancreaticocutaneous fistula. J Gastrointest Surg 2003; 7: 542–546. 7. Howard TJ, Rhodes GJ, Selzer DJ et al. Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis. Surgery 2001; 130: 714–719 discussion 7. 8. Calu V, Dutu M, Pârvuletu R et al. Persistent pancreatic fistula after surgical necrosectomy for severe pancreatitis. Chirurgia (Bucur) 2012; 107: 796–801. 9. Shibuya T, Shioya T, Kokuma M et al. Cure of intractable pancreatic fistula by subcutaneous fistulojejunostomy. J Gastroenterol 2004; 39: 162–167. 10. ten Broek RP, Strik C, Issa Y et al. Adhesiolysis-related morbidity in abdominal surgery. Ann Surg 2013; 258: 98–106.
References 1. Bassi C, Dervenis C, Butturini G et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005; 138: 8–13.
Asian J Endosc Surg 7 (2014) 311–313 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
313
