Enteric Drainage of Pancreatic Fistulas with Onlay Roux-en-Y Limb

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Enteric Drainage of Pancreatic Fistulas with Onlay Roux-en-Y Limb

Peter Shamamian, Stuart Marcus

Introduction

The majority of pancreatic fistulae will resolve with conservative measures, including improving pancreatic duct drainage through the ampulla, nutritional support, and somatostatin analogues. When pancreatic fistulae result from pancreatic ductal disrup- tion and pancreatic secretions produced in a portion of the pancreas do not flow into the GI tract, operative intervention is indicated.

Indications and Contraindications

Indications in ^■

Pancreatic ductal disruption secondary to pancreatic trauma

Non-Resolving Fistulae ^■

Fistulae following debridement of pancreatic necrosis

■

Fistulae from complications of pancreatic surgery (i.e., enucleation of endocrine neoplasms)

■

Fistulae from pancreatic injury during surgery on juxtapancreatic organs (i.e., stomach, colon, left kidney, left adrenal, spleen)

■

Fistulae secondary to external drainage of pancreatic pseudocysts

■

Fistulae associated with pancreatic ascites

■

Pancreato-pleural ﬁstulae

Contraindications ^■

Ongoing acute pancreatic inﬂammation

■

Pancreatic abscess

■

Undrained peri-pancreatic ﬂuid collection

Preoperative Investigation and Preparation for the Procedure

History: Pancreatitis, pancreatic trauma, pancreatic pseudocyst, prior pancreatic surgery, prior non-operative therapy with internal or external drains; exclude alcohol abuse, cirrhosis, portal hypertension Clinical evaluation: Quantify ﬁstula output, optimize nutritional status, provide adequate

external drainage, protect the skin from pancreatic secretions Laboratory tests: Serum electrolytes, amylase, lipase, and liver chemistries, bacterial

culture, cytology and amylase of any drained peritoneal or pleural ﬂuid

Preoperative Imaging ^■

CT: exclude presence of undrained collections or abscess

■

ERCP: delineate pancreatic ductal anatomy, site of duct disruption, obstructing strictures or calculi

■

Fistulogram: anatomy of pancreatic segment from which ﬁstulous tract originates;

adequate external preoperative drainage is essential.

■

Angiogram: if suspicion of a pseudoaneurysm

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STEP 1

Access: incision, midline or bilateral subcostal depending on patient habitus (see Sect.1, chapter “Positioning and Accesses”).

The ﬁrst step involves exposure to the lesser sac and installation of the mechanical retractor (see Sect.1, chapter “Positioning and Accesses”).

The preoperative ﬁstulogram helps to locate the disrupted pancreatic duct.

Carefully trace the external drainage catheter into the lesser sac; dissection continues through the peripancreatic inﬂammatory tissue to the anterior surface of the pancreas (A-1).

It is often possible to directly visualize the ﬁstulous tract as it exits the pancreas parenchyma.

Intraoperative secretin (SecreFlo, ChiRhoClin, Inc. Silver Springs, MD, USA) 0.2mg/kg (after a 0.2-mg test dose) given intravenously stimulates pancreatic secretion and assists identiﬁcation of the ductal disruption when it is not visualized clearly (A-2).

A-1

A-2

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STEP 2

If possible, a catheter or probe is passed through the ﬁstulous tract into the pancreatic duct.

If the pancreatic duct is identiﬁed, opening the anterior wall (spatulating the duct) increases the effective diameter of the anastomosis and facilitates the conduct of the anastomosis.

Pancreatography can be obtained if not done already.

The pancreatic duct should be imaged proximally and distally.

The jejunum is transected about 15 cm distal to the ligament of Treitz.

The blind end of the jejunum is closed by a stapling device or sutures.

Enteric continuity is reestablished by end-to-side jejunojejunostomy at least 60cm from the closed end of the Roux limb.

The anastomosis is constructed by suturing the side of the jejunum to the pancreatic

duct or the rim of scarred tissue at the ﬁstulous tract at its point of origin on the

pancreas. For details of construction of the Roux-en-Y limb see Sect.2, chapter “Subtotal

Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision

in Complicated Gastric Ulcers.”

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A posterior row of Lembert-type sutures is placed using 4-0 silk.

Next a row of absorbable sutures (4-0 or 5-0 polyglycolic acid) are placed full thickness through the pancreatic duct and the jejunum.

A catheter can be left as a stent through the anastomosis and brought out of the

anterior abdominal wall, allowing the anastomosis to be studied postoperatively

through the catheter if indicated.

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STEP 4

If the pancreatic duct cannot be identified definitively, the jejunum can be sewn over the fistulous tract as an onlay anastomosis to the pancreatic parenchyma; it would be optimal to keep a stent across this onlay anastomosis.

A soft closed suction drain is placed adjacent to the anastomosis.

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■

Hemodynamic and respiratory monitoring in intensive or intermediate care unit.

■

Measure daily drain output; note changes after beginning oral intake. Drains are removed after resumption of oral intake and output is <50ml/day.

■

Measure drain amylase if persistent signiﬁcant drainage >50ml/day. If ﬂuid is amylase rich, convert drains from closed suction drains to passive drains after 7days, then advanced 1–2cm/day.

Local Postoperative Complications

■

Anastomotic leak, possible recurrent ﬁstula

■

Abscess

■

Pancreatitis

■

Pancreatic pseudocyst

■

Intra-abdominal hemorrhage

Tricks of the Senior Surgeon

■

Patience, adequate drainage, and complete pre- or intraoperative imaging is paramount for deﬁnition of the ﬁstula and associated ductal anatomy; should marked disease remain in the duct, an alternative procedure, e.g., resection or lateral pancreaticojejunostomy, might be a better choice.

■

One goal of ﬁstula drainage is to preserve pancreatic endocrine and exocrine function. If the ﬁstula arises from the tail of the pancreas, resection of the distal pancreas may be the best option if minimal loss of functional pancreatic tissue is anticipated.

■

Spontaneous closure of the pancreatic ﬁstula can be aided with a somatostatin analogue; success may be predictable based on radiographic evaluation. Fistulae that arise from a divided duct will not resolve.

■

Closure of ﬁstulae that radiographically connect to the GI tract may be facilitated by transpapillary pancreatic stents and by ensuring that strictures and

obstructing calculi are addressed.

■

Internal drainage of the ﬁstulous tract into the stomach is not suggested; rather a defunctionalized Roux limb of jejunum is preferred when resection is not the best option.

■

Sew to the pancreatic parenchyma at the point of origin of ﬁstula and not to the ﬁstulous tract; the parenchyma is usually thickened and scarred.

■

If internal drainage is not possible (high operative risk or anatomic considera- tions), chronic external drainage is the best option.

■

Amylase-rich ﬂuid in the drain signiﬁes breakdown of the anastomosis; manage- ment is considerably easier if a stent is placed across anastomosis at operation.

The anastomosis can be evaluated radiographically; as the output decreases, the stent is converted from closed suction to passive drainage and then advanced 1cm/day.

■

Enteric Drainage of Pancreatic Fistulas with Onlay Roux-en-Y Limb

Enteric Drainage of Pancreatic Fistulas with Onlay Roux-en-Y Limb

Introduction

Indications and Contraindications

Pancreatic ductal disruption secondary to pancreatic trauma

Fistulae following debridement of pancreatic necrosis

Fistulae from complications of pancreatic surgery (i.e., enucleation of endocrine neoplasms)

Fistulae from pancreatic injury during surgery on juxtapancreatic organs (i.e., stomach, colon, left kidney, left adrenal, spleen)

Fistulae secondary to external drainage of pancreatic pseudocysts

Fistulae associated with pancreatic ascites

Pancreato-pleural ﬁstulae

Ongoing acute pancreatic inﬂammation

Pancreatic abscess

Undrained peri-pancreatic ﬂuid collection

Preoperative Investigation and Preparation for the Procedure

History: Pancreatitis, pancreatic trauma, pancreatic pseudocyst, prior pancreatic surgery, prior non-operative therapy with internal or external drains; exclude alcohol abuse, cirrhosis, portal hypertension Clinical evaluation: Quantify ﬁstula output, optimize nutritional status, provide adequate

external drainage, protect the skin from pancreatic secretions Laboratory tests: Serum electrolytes, amylase, lipase, and liver chemistries, bacterial

culture, cytology and amylase of any drained peritoneal or pleural ﬂuid

CT: exclude presence of undrained collections or abscess

ERCP: delineate pancreatic ductal anatomy, site of duct disruption, obstructing strictures or calculi

Fistulogram: anatomy of pancreatic segment from which ﬁstulous tract originates;

adequate external preoperative drainage is essential.

Angiogram: if suspicion of a pseudoaneurysm

Access: incision, midline or bilateral subcostal depending on patient habitus (see Sect.1, chapter “Positioning and Accesses”).

The ﬁrst step involves exposure to the lesser sac and installation of the mechanical retractor (see Sect.1, chapter “Positioning and Accesses”).

The preoperative ﬁstulogram helps to locate the disrupted pancreatic duct.

Carefully trace the external drainage catheter into the lesser sac; dissection continues through the peripancreatic inﬂammatory tissue to the anterior surface of the pancreas (A-1).

It is often possible to directly visualize the ﬁstulous tract as it exits the pancreas parenchyma.

Intraoperative secretin (SecreFlo, ChiRhoClin, Inc. Silver Springs, MD, USA) 0.2mg/kg (after a 0.2-mg test dose) given intravenously stimulates pancreatic secretion and assists identiﬁcation of the ductal disruption when it is not visualized clearly (A-2).

If possible, a catheter or probe is passed through the ﬁstulous tract into the pancreatic duct.

If the pancreatic duct is identiﬁed, opening the anterior wall (spatulating the duct) increases the effective diameter of the anastomosis and facilitates the conduct of the anastomosis.

Pancreatography can be obtained if not done already.

The pancreatic duct should be imaged proximally and distally.

The jejunum is transected about 15 cm distal to the ligament of Treitz.

The blind end of the jejunum is closed by a stapling device or sutures.

Enteric continuity is reestablished by end-to-side jejunojejunostomy at least 60cm from the closed end of the Roux limb.

The anastomosis is constructed by suturing the side of the jejunum to the pancreatic

duct or the rim of scarred tissue at the ﬁstulous tract at its point of origin on the

pancreas. For details of construction of the Roux-en-Y limb see Sect.2, chapter “Subtotal

Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision

in Complicated Gastric Ulcers.”

A posterior row of Lembert-type sutures is placed using 4-0 silk.

Next a row of absorbable sutures (4-0 or 5-0 polyglycolic acid) are placed full thickness through the pancreatic duct and the jejunum.

A catheter can be left as a stent through the anastomosis and brought out of the

anterior abdominal wall, allowing the anastomosis to be studied postoperatively

through the catheter if indicated.

If the pancreatic duct cannot be identified definitively, the jejunum can be sewn over the fistulous tract as an onlay anastomosis to the pancreatic parenchyma; it would be optimal to keep a stent across this onlay anastomosis.

A soft closed suction drain is placed adjacent to the anastomosis.

Hemodynamic and respiratory monitoring in intensive or intermediate care unit.

Measure daily drain output; note changes after beginning oral intake. Drains are removed after resumption of oral intake and output is <50ml/day.

Measure drain amylase if persistent signiﬁcant drainage >50ml/day. If ﬂuid is amylase rich, convert drains from closed suction drains to passive drains after 7days, then advanced 1–2cm/day.

Local Postoperative Complications

Anastomotic leak, possible recurrent ﬁstula

Abscess

Pancreatitis

Pancreatic pseudocyst

Intra-abdominal hemorrhage

Tricks of the Senior Surgeon

Patience, adequate drainage, and complete pre- or intraoperative imaging is paramount for deﬁnition of the ﬁstula and associated ductal anatomy; should marked disease remain in the duct, an alternative procedure, e.g., resection or lateral pancreaticojejunostomy, might be a better choice.

One goal of ﬁstula drainage is to preserve pancreatic endocrine and exocrine function. If the ﬁstula arises from the tail of the pancreas, resection of the distal pancreas may be the best option if minimal loss of functional pancreatic tissue is anticipated.

Spontaneous closure of the pancreatic ﬁstula can be aided with a somatostatin analogue; success may be predictable based on radiographic evaluation. Fistulae that arise from a divided duct will not resolve.

Closure of ﬁstulae that radiographically connect to the GI tract may be facilitated by transpapillary pancreatic stents and by ensuring that strictures and

obstructing calculi are addressed.

Internal drainage of the ﬁstulous tract into the stomach is not suggested; rather a defunctionalized Roux limb of jejunum is preferred when resection is not the best option.

Sew to the pancreatic parenchyma at the point of origin of ﬁstula and not to the ﬁstulous tract; the parenchyma is usually thickened and scarred.

If internal drainage is not possible (high operative risk or anatomic considera- tions), chronic external drainage is the best option.

Amylase-rich ﬂuid in the drain signiﬁes breakdown of the anastomosis; manage- ment is considerably easier if a stent is placed across anastomosis at operation.

The anastomosis can be evaluated radiographically; as the output decreases, the stent is converted from closed suction to passive drainage and then advanced 1cm/day.

Early intra-abdominal hemorrhage is best treated by reoperation and direct

vessel ligation. Late hemorrhage may be a sentinel bleed from a pseudoa-

neurysm; immediate angiography and vessel embolization are indicated.