Ann Surg Treat Res.  2022 Oct;103(4):217-226. 10.4174/astr.2022.103.4.217.

Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy

• Lee SJ
• Choi IS
• Moon JI

• KMID: 2534121
• DOI: http://doi.org/10.4174/astr.2022.103.4.217

Abstract

Purpose
This study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).
Methods
This single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy.
Results
A total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months.
Conclusion
Conversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.

Keyword

Pancreatic fistula; Pancreaticoduodenectomy; Pancreaticogastrostomy; Pancreaticojejunostomy

Figure

• 

  Fig. 1 Axial computed tomography image taken after the index operation. Disrupted pancreaticojejunostomy with peripancreatic fluid collection and an associated “gap” (arrows) between the jejunum and the remnant pancreas margin is visible.

• 

  Fig. 2 Schematic drawing of the pancreaticogastrostomy technique. (A) The pancreatic stump with an internal stent was placed in the stomach through the posterior gastrostomy. (B) A continuous suture was placed between the remnant pancreas and the posterior wall of the stomach in 2 layers through the anterior gastrostomy.

• 

  Fig. 3 Axial computed tomography image taken after the pancreaticogastrostomy. The pancreatic stump with internal stent (arrow) is visibly protruding into the stomach lumen after conversion to pancreaticogastrostomy.

• 

  Fig. 4 Incidence and management of postoperative pancreatic fistulae (POPF) in the study population according to International Study Group on Pancreatic Fistula grade. BL, biochemical leak.

Reference

1. Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006; 10:1199–1211. PMID: 17114007.

2. Gilsdorf RB, Spanos P. Factors influencing morbidity and mortality in pancreaticoduodenectomy. Ann Surg. 1973; 177:332–337. PMID: 4540286.

3. Kawai M, Yamaue H, Jang JY, Uesaka K, Unno M, Nakamura M, et al. Propensity score-matched analysis of internal stent vs external stent for pancreatojejunostomy during pancreaticoduodenectomy: Japanese-Korean cooperative project. Pancreatology. 2020; 20:984–991. PMID: 32680728.

4. Panni RZ, Panni UY, Liu J, Williams GA, Fields RC, Sanford DE, et al. Re-defining a high volume center for pancreaticoduodenectomy. HPB (Oxford). 2021; 23:733–738. PMID: 32994102.

5. Cameron JL, He J. Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg. 2015; 220:530–536. PMID: 25724606.

6. Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017; 161:584–591. PMID: 28040257.

7. Ma T, Bai X, Chen W, Lao M, Jin G, Zheng K, et al. Surgical management and outcome of grade-C pancreatic fistulas after pancreaticoduodenectomy: a retrospective multicenter cohort study. Int J Surg. 2019; 68:27–34. PMID: 31195148.

8. Zhou YM, Zhou X, Wan T, Xu D, Si XY. An evidence-based approach to the surgical interventions for severe pancreatic fistula after pancreatoduodenectomy. Surgeon. 2018; 16:119–124. PMID: 28864156.

9. Kent TS, Callery MP, Vollmer CM Jr. The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence. HPB (Oxford). 2010; 12:577–582. PMID: 20887326.

10. Paye F, Lupinacci RM, Kraemer A, Lescot T, Chafaï N, Tiret E, et al. Surgical treatment of severe pancreatic fistula after pancreaticoduodenectomy by wirsungostomy and repeat pancreatico-jejunal anastomosis. Am J Surg. 2013; 206:194–201. PMID: 23706258.

11. Garnier J, Ewald J, Marchese U, Delpero JR, Turrini O. Standardized salvage completion pancreatectomy for grade C postoperative pancreatic fistula after pancreatoduodenectomy (with video). HPB (Oxford). 2021; 23:1418–1426. PMID: 33832833.

12. Bachellier P, Oussoultzoglou E, Rosso E, Scurtu R, Lucescu I, Oshita A, et al. Pancreatogastrostomy as a salvage procedure to treat severe postoperative pancreatic fistula after pancreatoduodenectomy. Arch Surg. 2008; 143:966–971. PMID: 18936375.

13. Mayhew D, Mendonca V, Murthy BV. A review of ASA physical status: historical perspectives and modern developments. Anaesthesia. 2019; 74:373–379. PMID: 30648259.

14. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007; 142:761–768. PMID: 17981197.

15. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007; 142:20–25. PMID: 17629996.

16. Lee YC, Wang HP, Yang CS, Yang TH, Chen JH, Lin CC, et al. Endoscopic hemostasis of a bleeding marginal ulcer: hemoclipping or dual therapy with epinephrine injection and heater probe thermocoagulation. J Gastroenterol Hepatol. 2002; 17:1220–1225. PMID: 12453283.

17. Pottier E, Ronot M, Gaujoux S, Cesaretti M, Barbier L, Sauvanet A, et al. Endovascular management of delayed post-pancreatectomy haemorrhage. Eur Radiol. 2016; 26:3456–3465. PMID: 26815369.

18. Fuks D, Piessen G, Huet E, Tavernier M, Zerbib P, Michot F, et al. Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors. Am J Surg. 2009; 197:702–709. PMID: 18778804.

19. Malleo G, Pulvirenti A, Marchegiani G, Butturini G, Salvia R, Bassi C. Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg. 2014; 399:801–810. PMID: 25173359.

20. Balzano G, Pecorelli N, Piemonti L, Ariotti R, Carvello M, Nano R, et al. Relaparotomy for a pancreatic fistula after a pancreaticoduodenectomy: a comparison of different surgical strategies. HPB (Oxford). 2014; 16:40–45. PMID: 23458209.

21. Groen JV, Smits FJ, Koole D, Besselink MG, Busch OR, den Dulk M, et al. Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis. Br J Surg. 2021; 108:1371–1379. PMID: 34608941.

22. Bouras AF, Marin H, Bouzid C, Pruvot FR, Zerbib P, Truant S. Pancreas-preserving management in reinterventions for severe pancreatic fistula after pancreatoduodenectomy: a systematic review. Langenbecks Arch Surg. 2016; 401:141–149. PMID: 26586034.

23. Ribero D, Amisano M, Zimmitti G, Giraldi F, Ferrero A, Capussotti L. External tube pancreatostomy reduces the risk of mortality associated with completion pancreatectomy for symptomatic fistulas complicating pancreaticoduodenectomy. J Gastrointest Surg. 2013; 17:332–338. PMID: 23207684.

24. Govil S. Salvage pancreaticogastrostomy for pancreatic fistulae after pancreaticoduodenectomy. Indian J Gastroenterol. 2012; 31:263–266. PMID: 22923318.