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Erschienen in: Journal of Gastrointestinal Surgery 7/2017

10.04.2017 | Original Article

Fistulojejunostomy Versus Distal Pancreatectomy for the Management of the Disconnected Pancreas Remnant Following Necrotizing Pancreatitis

verfasst von: Vikrom K. Dhar, Jeffrey M. Sutton, Brent T. Xia, Nick C. Levinsky, Gregory C. Wilson, Milton Smith, Kyuran A. Choe, Jonathan Moulton, Doan Vu, Ross Ristagno, Jeffrey J. Sussman, Michael J. Edwards, Daniel E. Abbott, Syed A. Ahmad

Erschienen in: Journal of Gastrointestinal Surgery | Ausgabe 7/2017

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Abstract

Background

A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes.

Methods

Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated.

Results

Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15).

Conclusions

Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ.
Literatur
1.
Zurück zum Zitat Banks PA. Infected necrosis: morbidity and therapeutic consequences. Hepatogastroenterology 1991;38:116–119PubMed Banks PA. Infected necrosis: morbidity and therapeutic consequences. Hepatogastroenterology 1991;38:116–119PubMed
2.
Zurück zum Zitat Imrie CW. Underdiagnosis of acute pancreatitis. Adv Acute Pancreatitis 1997;1:3–5 Imrie CW. Underdiagnosis of acute pancreatitis. Adv Acute Pancreatitis 1997;1:3–5
3.
Zurück zum Zitat Ramia, J. M., de la Plaza, R., Quiñones-Sampedro, J. E., Ramiro, C., Veguillas, P., & García-Parreño, J. Walled-off pancreatic necrosis. Netherlands Journal of Medicine 2012; 70(4), 168–171. doi: 10.3748/wjg.v16.i14.1707 PubMed Ramia, J. M., de la Plaza, R., Quiñones-Sampedro, J. E., Ramiro, C., Veguillas, P., & García-Parreño, J. Walled-off pancreatic necrosis. Netherlands Journal of Medicine 2012; 70(4), 168–171. doi: 10.​3748/​wjg.​v16.​i14.​1707 PubMed
4.
Zurück zum Zitat Kozarek, R. A., & Traverso, L. W. Pancreatic fistulas: etiology, consequences, and treatment. Gastroenterologist 1996; 4(4), 238–244.PubMed Kozarek, R. A., & Traverso, L. W. Pancreatic fistulas: etiology, consequences, and treatment. Gastroenterologist 1996; 4(4), 238–244.PubMed
5.
Zurück zum Zitat Howard, T. J., Rhodes, G. J., Selzer, D. J., Sherman, S., Fogel, E., & Lehman, G. A. Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis. Surgery 2001; 130(4), 714–721. doi: 10.1067/msy.2001.116675 CrossRefPubMed Howard, T. J., Rhodes, G. J., Selzer, D. J., Sherman, S., Fogel, E., & Lehman, G. A. Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis. Surgery 2001; 130(4), 714–721. doi: 10.​1067/​msy.​2001.​116675 CrossRefPubMed
6.
Zurück zum Zitat Tann, M., Maglinte, D., Howard, T. J., Sherman, S., Fogel, E., Madura, J. A, & Lehman, G. A. Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients. Journal of Computer Assisted Tomography 2003; 27(4), 577–582. doi: 10.1097/00004728-200307000-00023 CrossRefPubMed Tann, M., Maglinte, D., Howard, T. J., Sherman, S., Fogel, E., Madura, J. A, & Lehman, G. A. Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients. Journal of Computer Assisted Tomography 2003; 27(4), 577–582. doi: 10.​1097/​00004728-200307000-00023 CrossRefPubMed
7.
Zurück zum Zitat Neoptolemos, J. P., London, N. J., & Carr-Locke, D. L. Assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography in patients with acute pancreatitis. The British Journal of Surgery 1993; 80(1), 94–9.CrossRefPubMed Neoptolemos, J. P., London, N. J., & Carr-Locke, D. L. Assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography in patients with acute pancreatitis. The British Journal of Surgery 1993; 80(1), 94–9.CrossRefPubMed
8.
9.
Zurück zum Zitat Irani, S., Gluck, M., Ross, A., Gan, S. I., Crane, R., Brandabur, J. J., Hauptmann, E., Fotoohi, M., & Kozarek, R. A. Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: Using rendezvous techniques to avoid surgery (with video). Gastrointestinal Endoscopy 2012. doi: 10.1016/j.gie.2012.05.006 Irani, S., Gluck, M., Ross, A., Gan, S. I., Crane, R., Brandabur, J. J., Hauptmann, E., Fotoohi, M., & Kozarek, R. A. Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: Using rendezvous techniques to avoid surgery (with video). Gastrointestinal Endoscopy 2012. doi: 10.​1016/​j.​gie.​2012.​05.​006
10.
Zurück zum Zitat Lawrence, C., Howell, D. A., Stefan, A. M., Conklin, D. E., Lukens, F. J., Martin, R. F., Landes, A., & Benz, B. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointestinal Endoscopy 2008; 67(4), 673–679. doi: 10.1016/j.gie.2007.07.017 CrossRefPubMed Lawrence, C., Howell, D. A., Stefan, A. M., Conklin, D. E., Lukens, F. J., Martin, R. F., Landes, A., & Benz, B. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointestinal Endoscopy 2008; 67(4), 673–679. doi: 10.​1016/​j.​gie.​2007.​07.​017 CrossRefPubMed
11.
13.
Zurück zum Zitat Bassi, C., Butturini, G., Salvia, R., Contro, C., Valerio, A., Falconi, M., & Pederzoli, P. A single-institution experience with fistulojejunostomy for external pancreatic fistulas. American Journal of Surgery 2000; 179(3), 203–206. doi: 10.1016/S0002-9610(00)00291-9 CrossRefPubMed Bassi, C., Butturini, G., Salvia, R., Contro, C., Valerio, A., Falconi, M., & Pederzoli, P. A single-institution experience with fistulojejunostomy for external pancreatic fistulas. American Journal of Surgery 2000; 179(3), 203–206. doi: 10.​1016/​S0002-9610(00)00291-9 CrossRefPubMed
14.
Zurück zum Zitat Murage, K. P., Ball, C. G., Zyromski, N. J., Nakeeb, A., Ocampo, C., Sandrasegaran, K., & Howard, T. J. Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis. Surgery 2010; 148(4), 847–857. doi: 10.1016/j.surg.2010.07.039 CrossRefPubMed Murage, K. P., Ball, C. G., Zyromski, N. J., Nakeeb, A., Ocampo, C., Sandrasegaran, K., & Howard, T. J. Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis. Surgery 2010; 148(4), 847–857. doi: 10.​1016/​j.​surg.​2010.​07.​039 CrossRefPubMed
18.
Zurück zum Zitat Pelaez-Luna, M., Vege, S. S., Petersen, B. T., Chari, S. T., Clain, J. E., Levy, M. J., Pearson, R.K., Topazian, M.D., Farnell, M.B., Kendrick, M.L., & Baron, T. H. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointestinal Endoscopy 2008; 68(1), 91–97. doi: 10.1016/j.gie.2007.11.041 CrossRefPubMed Pelaez-Luna, M., Vege, S. S., Petersen, B. T., Chari, S. T., Clain, J. E., Levy, M. J., Pearson, R.K., Topazian, M.D., Farnell, M.B., Kendrick, M.L., & Baron, T. H. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointestinal Endoscopy 2008; 68(1), 91–97. doi: 10.​1016/​j.​gie.​2007.​11.​041 CrossRefPubMed
20.
Zurück zum Zitat Sandrasegaran, K., Tann, M., Jennings, S. G., Maglinte, D. D., Peter, S. D., Sherman, S., & Howard, T. J. Disconnection of the pancreatic duct: an important but overlooked complication of severe acute pancreatitis. Radiographics: A Review Publication of the Radiological Society of North America, Inc. 2007; 27(5), 1389–1400. doi: 10.1148/rg.275065163 CrossRef Sandrasegaran, K., Tann, M., Jennings, S. G., Maglinte, D. D., Peter, S. D., Sherman, S., & Howard, T. J. Disconnection of the pancreatic duct: an important but overlooked complication of severe acute pancreatitis. Radiographics: A Review Publication of the Radiological Society of North America, Inc. 2007; 27(5), 1389–1400. doi: 10.​1148/​rg.​275065163 CrossRef
21.
Zurück zum Zitat Solanki, R., Koganti, S. B., Bheerappa, N., & Sastry, R. A. Disconnected duct syndrome: Refractory inflammatory external pancreatic fistula following percutaneous drainage of an infected peripancreatic fluid collection. A case report and review of the literature. Journal of the Pancreas 2011; 12(2), 177–180.PubMed Solanki, R., Koganti, S. B., Bheerappa, N., & Sastry, R. A. Disconnected duct syndrome: Refractory inflammatory external pancreatic fistula following percutaneous drainage of an infected peripancreatic fluid collection. A case report and review of the literature. Journal of the Pancreas 2011; 12(2), 177–180.PubMed
22.
Zurück zum Zitat Kozarek, R. A., Ball, T. J., Patterson, D. J., Raltz, S. L., Traverso, L. W., Ryan, J. A., & Thirlby, R. C. Transpapillary stenting for pancreaticocutaneous fistulas. Journal of Gastrointestinal Surgery 1997; 1(4), 357–361.CrossRefPubMed Kozarek, R. A., Ball, T. J., Patterson, D. J., Raltz, S. L., Traverso, L. W., Ryan, J. A., & Thirlby, R. C. Transpapillary stenting for pancreaticocutaneous fistulas. Journal of Gastrointestinal Surgery 1997; 1(4), 357–361.CrossRefPubMed
23.
Zurück zum Zitat Howard, T. J., Stonerock, C. E., Sarkar, J., Lehman, G. A., Sherman, S., Wiebke, E. A., Madura, J.A., & Broadie, T. A. Contemporary treatment strategies for external pancreatic fistulas. Surgery 1998; 124(4), 627–633. doi: 10.1067/msy.1998.91267 CrossRefPubMed Howard, T. J., Stonerock, C. E., Sarkar, J., Lehman, G. A., Sherman, S., Wiebke, E. A., Madura, J.A., & Broadie, T. A. Contemporary treatment strategies for external pancreatic fistulas. Surgery 1998; 124(4), 627–633. doi: 10.​1067/​msy.​1998.​91267 CrossRefPubMed
24.
Zurück zum Zitat Stahl, C. C., Moulton, J., Vu, D., Ristagno, R., Choe, K., Sussman, J. J., Shah S. A., Ahmad S. A., & Abbott, D. E. Routine use of U-tube drainage for necrotizing pancreatitis: A step toward less morbidity and resource utilization. Surgery 2015; 158(4), 919–928. doi: 10.1016/j.surg.2015.07.006 CrossRefPubMed Stahl, C. C., Moulton, J., Vu, D., Ristagno, R., Choe, K., Sussman, J. J., Shah S. A., Ahmad S. A., & Abbott, D. E. Routine use of U-tube drainage for necrotizing pancreatitis: A step toward less morbidity and resource utilization. Surgery 2015; 158(4), 919–928. doi: 10.​1016/​j.​surg.​2015.​07.​006 CrossRefPubMed
25.
Zurück zum Zitat da Costa, D. W., Boerma, D., van Santvoort, H. C., Horvath, K. D., Werner, J., Carter, C. R., Bollen T. L., Gooszen H. G., Besselink M. G., & Bakker, O. J. Staged multidisciplinary step-up management for necrotizing pancreatitis. The British Journal of Surgery 2014; 101(1), e65–79. doi: 10.1002/bjs.9346 CrossRefPubMed da Costa, D. W., Boerma, D., van Santvoort, H. C., Horvath, K. D., Werner, J., Carter, C. R., Bollen T. L., Gooszen H. G., Besselink M. G., & Bakker, O. J. Staged multidisciplinary step-up management for necrotizing pancreatitis. The British Journal of Surgery 2014; 101(1), e65–79. doi: 10.​1002/​bjs.​9346 CrossRefPubMed
26.
Zurück zum Zitat Trikudanathan, G., Arain, M., Attam, R., & Freeman, M. L. Interventions for necrotizing pancreatitis: an overview of current approaches. Expert Review of Gastroenterology & Hepatology 2013; 7(5), 463–475. JOUR. doi: 10.1586/17474124.2013.811055 CrossRef Trikudanathan, G., Arain, M., Attam, R., & Freeman, M. L. Interventions for necrotizing pancreatitis: an overview of current approaches. Expert Review of Gastroenterology & Hepatology 2013; 7(5), 463–475. JOUR. doi: 10.​1586/​17474124.​2013.​811055 CrossRef
27.
Zurück zum Zitat Freeman, M. L., Werner, J., van Santvoort, H. C., Baron, T. H., Besselink, M. G., Windsor, J. A., Horvath K. D., VanSonnenberg E., Bollen T. L., Vege, S. S. Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference. Pancreas 2012; 41(8), 1176–94. doi: 10.1097/MPA.0b013e318269c660 CrossRefPubMed Freeman, M. L., Werner, J., van Santvoort, H. C., Baron, T. H., Besselink, M. G., Windsor, J. A., Horvath K. D., VanSonnenberg E., Bollen T. L., Vege, S. S. Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference. Pancreas 2012; 41(8), 1176–94. doi: 10.​1097/​MPA.​0b013e318269c660​ CrossRefPubMed
28.
Zurück zum Zitat Lahey FH, Lium R. Cure of pancreatic fistula by pancreati- cojejunostomy: report of a case with review of the literature. Surgery Gynecology Obstetrics 1937;64:78–81. Lahey FH, Lium R. Cure of pancreatic fistula by pancreati- cojejunostomy: report of a case with review of the literature. Surgery Gynecology Obstetrics 1937;64:78–81.
Metadaten
Titel
Fistulojejunostomy Versus Distal Pancreatectomy for the Management of the Disconnected Pancreas Remnant Following Necrotizing Pancreatitis
verfasst von
Vikrom K. Dhar
Jeffrey M. Sutton
Brent T. Xia
Nick C. Levinsky
Gregory C. Wilson
Milton Smith
Kyuran A. Choe
Jonathan Moulton
Doan Vu
Ross Ristagno
Jeffrey J. Sussman
Michael J. Edwards
Daniel E. Abbott
Syed A. Ahmad
Publikationsdatum
10.04.2017
Verlag
Springer US
Erschienen in
Journal of Gastrointestinal Surgery / Ausgabe 7/2017
Print ISSN: 1091-255X
Elektronische ISSN: 1873-4626
DOI
https://doi.org/10.1007/s11605-017-3419-9

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