Abstract
Background and aim
Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9–15% of cases. Endoscopic strategies for management of pancreatic fistula, may allow to avoid reoperation and shorten times for fistula closure, but are still understudied and not widely performed. Aim of the present paper is to describe different endoscopic techniques used to treat such conditions.
Methods
It was a retrospective, single centre, study. All patients who underwent endoscopic treatment for pancreatic leaks following PD between 1st January 2013 and 31th May 2019 at our Centre were reviewed. Depending on the morphology and severity of the leak, four main endoscopic techniques were performed: (1) trans-anastomotic intraductal pancreatic stent insertion; (2) lumen-apposing metal stent between the jejunal loop and the retroperitoneum toward the pancreatic stump insertion (“yoyo-stent”); (3) large calibre nose-to-retroperitoneum drain insertion; (4) when a wide damage of the jejunal wall or a coexistent biliary-jejunal leak were observed, triple metal stent insertion was performed as follow in order to close the defect: enteral fully-covered SEMS in the jejunal stump, a pancreatic metal stent into the Wirsung duct and a fully-covered SEMS across the bilio-digestive anastomosis, through the meshes of the enteral stent. In all cases, surgical drain was simultaneously retracted.
Results
We identified 13 patients who underwent endoscopic treatment for POPF after PD. In total, 5 patients underwent “Yoyo stent insertion”, 3 with nose-to-collection drain placement and four patients were treated with triple-stent insertion; in only one patient intrapancreatic SEMS insertion was performed. Technical success was 100% and clinical success was 83.3%. Mean time for leak closure was 4.8 days (range 2–10). During the follow-up interval, no leak recurrences were observed.
Conclusions
Our experience confirms efficacy and safety of endoscopic management of POPF following pancreatoduodenectomy management. Endoscopy should play a central role in this clinical scenario.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M (2005) International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13
Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M (2017) International Study Group on Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 161(3):584–591
McMillan MT, Soi S, Asbun HJ, Ball CG, Bassi C, Beane JD, Behrman SW, Berger AC, Bloomston M, Callery MP, Christein JD, Dixon E, Drebin JA, Castillo CF, Fisher WE, Fong ZV, House MG, Hughes SJ, Kent TS, Kunstman JW, Malleo G, Miller BC, Salem RR, Soares K, Valero V, Wolfgang CL, Vollmer CM Jr (2016) Risk-adjusted outcomes of clinically relevant pancreatic fistula following pancreatoduodenectomy: a model for performance evaluation. Ann Surg 264(2):344–352
Nappo G, Capretti GL, Petitti T, Gavazzi F, Ridolfi C, Cereda M, Montorsi M, Zerbi A (2019) The evolution of post-operative pancreatic fistula (POPF) classification: a single-center experience. Pancreatology 19(3):449–455
El Nakeeb A, El Sorogy M, Hamed H, Said R, Elrefai M, Ezzat H, Askar W, Elsabbagh AM (2019) Biliary leakage following pancreaticoduodenectomy: prevalence, risk factors and management. Hepatobiliary Pancreat Dis Int 18(1):67–72
Burkhart RA, Relles D, Pineda DM, Gabale S, Sauter PK, Rosato EL, Koniaris LG, Lavu H, Kennedy EP, Yeo CJ, Winter JM (2013) Defining treatment and outcomes of hepaticojejunostomy failure following pancreaticoduodenectomy. J Gastrointest Surg 17(3):451–460
Luu AM, Krasemann L, Fahlbusch T, Belyaev O, Janot-Matuschek M, Uhl W, Braumann C (2020) Facing the surgeon’s nightmare: Incidence and management of postoperative pancreatic fistulas grade C after pancreaticoduodenectomy based on the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). J Hepatobiliary Pancreat Sci 27(4):171–181
Kazanjian KK, Hines OJ, Eibl G, Reber HA (2005) Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients. Arch Surg 140(9):849–54
Haddad LB, Scatton O, Randone B, Andraus W, Massault PP, Dousset B, Soubrane O (2009) Pancreatic fistula after pancreaticoduodenectomy: the conservative treatment of choice. HPB (Oxford) 11(3):203–209
Malleo G, Pulvirenti A, Marchegiani G, Butturini G, Salvia R, Bassi C (2014) Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg 399(7):801–810
Kwon YM, Gerdes H, Schattner MA, Brown KT, Covey AM, Getrajdman GI, Solomon SB, D’Angelica MI, Jarnagin WR, Allen PJ, Dimaio CJ (2013) Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage. Surg Endosc 27(7):2422–2427
Mutignani M, Forti E, Pugliese F, Tringali A, Cintolo M, Bonato G, Dioscoridi L (2018) Triple stenting to treat a complete Wirsung-to-jejunum anastomotic leak after pancreaticoduodenectomy. Endoscopy 50(2):E50–E51
Bobkiewicz A, Banasiewicz T, Drews M (2015) Postoperative pancreatic fistula successfully treated with “PEG-Like” endoscopic vacuum therapy. J LaparoendoscAdvSurg Tech A 25(4):314–8
Jürgensen C, Distler M, Arlt A, Brückner S, Ellrichmann M, Matthes K, Ludwig M, Sulk S, Romberg L, Zeissig S, Schafmayer C, Hinz S, Welsch T, Bahra M, Aselmann H, Weitz J, Klein F, Becker T, Hampe J (2019) EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video). Gastrointest Endosc 89(2):311-319.e1
Onodera M, Kawakami H, Kuwatani M, Kudo T, Haba S, Abe Y, Kawahata S, Eto K, Nasu Y, Tanaka E, Hirano S, Asaka M (2012) Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery. Surg Endosc 26(6):1710–1717
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Dr. Massimiliano Mutignani, Dr. Giulia Bonato, Dr. Lorenzo Dioscoridi, Dr. Roberto Rosa, Dr. Francesco Pugliese, Dr. Marcello Cintolo, Dr. Angelo Italia, Dr. Michele Mazzola, Dr. Giovanni Carlo Ferrari and Dr. Edoardo Forti have no conflicts of interest or financial ties to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary file1 (MP4 146413 KB)
Supplementary file2 (MP4 139779 KB)
Rights and permissions
About this article
Cite this article
Mutignani, M., Bonato, G., Dioscoridi, L. et al. Expanding endoscopic treatment strategies for pancreatic leaks following pancreato-duodenectomy: a single centre experience. Surg Endosc 35, 1908–1914 (2021). https://doi.org/10.1007/s00464-020-08199-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-020-08199-8