Open access peer-reviewed chapter
Abstract
Pancreaticoduodenectomy is still the only treatment option that offers a chance to cure patients with pancreatic cancer and malignant periampullary tumors. Pancreaticojejunal anastomosis is the preferred method of reconstruction after pancreaticoduodenectomy. However, because of the high incidence of anastomotic leak and subsequent severe consequences, pancreaticojejunal anastomosis still remains the Achilles’ heel of the operation. Several technical modifications of pancreaticojejunal anastomosis exist, but none completely eliminates anastomotic leak, postoperative pancreatic fistula, or severe complications. Therefore, considerable efforts have been made to study and develop surgical options that can mitigate the severity and avoid fatal consequences of postoperative pancreatic fistula. This chapter presents and discusses some of the existing and emerging surgical strategies devoted to mitigating the catastrophic consequences of pancreatic anastomotic leaks.
Keywords
- pancreaticoduodenectomy
- anastomotic leak
- pancreatic fistula
- pancreaticojejunostomy
- pancreatic cancer
- falciform ligament
- transanastomotic external stent
- coronary stent
1. Introduction
Pancreaticoduodenectomy (PD) is still the only treatment option that offers a chance to cure patients with pancreatic cancer and malignant periampullary tumors. Regarding the constantly growing incidence of pancreatic ductal adenocarcinoma [1, 2], the demand for PD worldwide is expected to increase as well. Pioneer surgeons such as Codivilla in 1898 and Kausch in 1909 performed the first pancreatic head resections without pancreatic anastomosis [3, 4]. Whipple also performed his first PD without reconstruction of pancreatico-enteric continuity [5], but in his subsequent 36 pancreatic head resections reconstructed the drainage of the pancreatic duct by pancreaticojejunal anastomosis (PJA), which is now the preferred method to reestablish pancreatic ductal drainage.
Currently, PD remains a complex and risky surgical intervention, requiring substantial surgeon experience despite advances in surgical techniques and technology [6, 7]. With the refinement of the surgical technique of PD, the main problems with intraoperative bleeding and early postoperative mortality were gradually resolved, and a series of more than a hundred consecutive operations with no postoperative mortality were published for the first time in the 90s from the leading centers [8, 9]. However, compared to other abdominal operations, the complication rate of PD is still high, mainly due to PJA leak and subsequent severe consequences that remain the Achilles’ heel of the operation. It becomes obvious that searching for a no-leak PJA technique is unrealistic, and it is considered that an individual surgeon’s mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low PJA leak rate [10, 11, 12].
2. Surgical techniques to mitigate the consequences of PJA leak
The main problem of a leaked PJA comes from the extravasation of pancreatic enzyme-rich juice into the perianastomotic region, which can cause severe morbidity due to the development of intra-abdominal abscesses leading to sepsis or pseudoaneurysms leading to severe hemorrhage and even mortality. Surgical techniques devoted to mitigating the fatal consequences of PJA leak aim to control/reduce pancreatic juice extravasation into the abdomen or to prevent the contact of dissected peripancreatic vascular structures with leaked pancreatic enzymes, decreasing the incidence and grade of postoperative pancreatic fistula (POPF) (Figure 1).
Figure 1.
International Study Group of Pancreatic Surgery (ISGPS) grading of postoperative pancreatic fistula (modified by [
2.1 Transanastomotic external pancreatic duct stent
The goal of transanastomotic external stenting is to control pancreatic juice leakage by diverting the pancreatic secretion through the PJA outside the body by exteriorization of the stent from the jejunal lumen through a Witzel tunnel (Figure 2).
Figure 2.
Pancreaticoduodenectomy. Transanastomotic stent placement. (A) Positioning the stent after completion of the posterior row sutures of the PJA. (B) Stent covered by anterior, first row, and duct-to-mucosa sutures. (C) Exteriorization of the stent from the jejunal lumen [original photograph].
From a technical standpoint, we performed duct-to-mucosa PJA in two layers and opened the jejunum corresponding to the pancreatic duct after completion of the external layer of the posterior row sutures of the anastomosis. The posterior duct-to-mucosa sutures are then easily placed, and the chosen transanastomotic stent is introduced through a small opening in the jejunal limb at a distance of approximately 10 cm from the PJA. We left the uncut and used at least one of the tied posterior row duct-to-mucosa sutures to secure the stent in the desired position. The PJA is completed then, and the stent is secured at a second point in the Witzel tunnel. It is also important to note that some measures have to be taken in order to divert or reduce the flow of the pancreatic juice in the operative field after transection of the gland, as it might cause intraperitoneal saponification around the pancreas due to pancreatic lipase-induced lipolysis, and has been shown to negatively impact anastomotic healing [14]. As a preventive measure, we temporarily placed the external stent in the remnant pancreatic duct (Figure 3) and/or covered the cut surface of the pancreas with gauze.
Figure 3.
Pancreaticoduodenectomy. Stent (arrow) is placed in the pancreatic duct immediately after transection of the gland to divert the pancreatic juice from the operative field during the resection [original photograph].
The use of transanastomotic external stents after PD has been a matter of debate and controversy due to conflicting results published from single-institution retrospective and/or nonrandomized studies. However, initial randomized trials on the subject clearly demonstrated the ability of the technique to reduce morbidity and the incidence of clinically relevant PJA leaks, especially in patients at high risk of developing POPF [15, 16, 17]. Further research and high-quality evidence from systematic reviews and meta-analyses have confirmed the efficacy of transanastomotic external stents in reducing the incidence and grade of POPF in both randomized and nonrandomized settings [18, 19, 20, 21]. The largest systematic review to date with meta-analysis of the POPF-related mortality rate includes 60,739 patients and undoubtedly confirmed that external transanastomotic stents decreased the POPF-related mortality rate [22].
The main problems with the use of external stents are stent malfunction and/or migration. Stent migration can be prevented by securing the stent at least at two points: at the anastomosis and at the Witzel tunnel, and by leaving the ample length of the stent between the Witzel tunnel and abdominal wall to compensate for the tension of the fixation point at the anastomosis in a case of abdominal distension during the postoperative period. Malfunction of nondisplaced stents is rare and is a result of clotting (which can be resolved by stent irrigation) or of use of a stent with just 1–2 distal openings that could impact the pancreatic duct if positioned too distally from the PJA. To prevent the latter, additional holes can be made in the stent tube to secure drainage of the duct close to the PJA. However, we consider that even the displaced from the pancreatic duct external stent can still be beneficial by reducing the intraluminal pressure of the jejunal limb in cases of PJA leak.
2.2 Transanastomotic internal pancreatic duct stent
The internal transanastomotic stent seems theoretically superior to the external stent, as it eliminates the exteriorized part of the drain. However, the results of numerous randomized trials, systematic reviews, and meta-analyses failed to prove the benefit of internal PJA stents versus no-stent in terms of the incidence and severity of POPF, morbidity, and mortality after PD [18, 19, 21, 22, 23, 24, 25]. The use of internal stents is associated with a high rate of stent migration, and, contrary to an external stent, the malfunction of an internal stent in place cannot be assessed.
As the theoretical benefits of internal PJA stents cannot be neglected, recent research has focused on the options to find/develop an internal stent that can be safely positioned and secured in place, especially in a patient with a soft pancreas and very small duct size, in whom the use of an external stent is impractical because of the very narrow lumen of the fitting stent or even impossible. To overcome these limitations in patients with a small pancreatic duct size that cannot fit the external stent, since November 2016 we started to use as an internal PJA stent a commercially available, covered, and balloon-expandable coronary artery stent (Figure 4).
Figure 4.
Pancreaticoduodenectomy. Postoperative computed tomography showing pancreaticojejunal anastomosis with covered coronary artery stent (arrow) in place [original photograph].
We positioned the stent using the over-the-wire technique after completion of the posterior row sutures of the PJA. Briefly, the jejunal limb was punctured at a chosen point opposite the transected pancreatic duct with the needle passing through both the lateral and medial bowel walls. A guidewire was inserted through the needle into the pancreatic duct. The coronary artery stent is positioned under intraoperative ultrasound guidance over the wire in the anastomosis and the pancreatic duct and expanded enough to be self-impacted in the duct. Anastomosis was then completed using anterior row sutures. A similar use of an uncovered coronary artery stent with positioning under X-ray guidance was recently reported by Huscher et al. [26], and the use of biodegradable stents in 10 patients was reported by Sulieman et al. [27]. Although the use of expandable internal PJA stents is still in its infancy, the initial results of their use are promising in terms of reducing the clinically relevant POPF rate and major morbidity with no stent-related complications [26, 27].
2.3 Peripancreatic vessel wrap
Irrespective of the anastomotic technique and use of transanastomotic stents, the risk of high-grade POPF is not negligible, especially for International Study Group of Pancreatic Surgery (ISGPS) grade C-D anastomoses (Figure 5).
Figure 5.
Clinically relevant postoperative pancreatic fistula (POPF) rates for ISGPS A-D grades of pancreaticojejunal anastomoses (modified by [
The most dramatic and life-threatening complication of PJA leak is grade C POPF with severe postoperative hemorrhage caused by erosion of a major peripancreatic vessel from the leaked pancreatic juice and accompanying local infection. Different surgical options can be used to wrap the peripancreatic vessels in an attempt to prevent contact with aggressive leakage content in the case of POPF, thus preventing vessel erosion and severe hemorrhage. For this purpose, we routinely use the teres/falciform ligament of the liver (Figure 6), which is carefully preserved and tailored during laparotomy at the beginning of the surgery. Alternatively, omental or peritoneal patches can be used to protect the vessels in the case of a sacrificed or small teres ligament. The chosen wrap is carefully positioned to cover the major arteries and veins and secured in place with nonabsorbable sutures. From the above options for the protection of divided or skeletonized vessels, the use of a teres/falciform ligament has become the most frequently applied technique due to evidence for its effectiveness in published case series [29, 30, 31, 32, 33], systematic reviews [34, 35, 36], and a recent randomized clinical trial [37].
Figure 6.
Pancreaticoduodenectomy. (A–C) Wrapping the retroperitoneal vessels with the teres/falciform ligament flap [original photograph].
2.4 Prophylactic abdominal drainage
Historically, abdominal drains are routinely placed at the time of pancreatic resection to allow postoperative evacuation of intra-abdominal secretions, lymphatic fluid, blood, bile, and pancreatic juice. Theoretically, the use of drains should reduce the incidence of intra-abdominal collections and the need for re-intervention after PD. However, the routine use of prophylactic abdominal drains after PD has been questioned in the past decade and remains a matter of debate and controversy [38, 39, 40, 41]. Further randomized clinical trials on the subject also reported conflicting results and did not resolve this issue. The PANDRA trial concluded that clinically important POPF was significantly reduced in patients without drainage, although there was no significant difference in overall morbidity [38]. However, the next randomized trial was prematurely closed because patients without prophylactic intraperitoneal drainage had a higher mortality rate than those with drainage [39]. Subsequent systematic reviews and meta-analyses also reported that patients without prophylactic drainage after PD had a higher mortality rate despite a similar or lower rate of overall major complications and readmissions [40, 41]. Regarding the above data, although the use of prophylactic abdominal drains in PD is associated with a higher rate of POPF compared to no drain abandoning, its routine use is not justified. Moreover, there is still room for research, and not well-studied options, to achieve more benefits from prophylactic drains to reduce the incidence and grade of clinically relevant POPF after PD. For this purpose, a few groups have reported promising results with prophylactic saline irrigation around a PJA after PD and around the pancreatic stump after distal pancreatectomy [42, 43, 44].
We routinely place prophylactic drains parallel to the upper and lower borders of the remnant pancreas, passing the drains to the right, beneath the PJA, and hepaticojejunostomy. In the case of a biochemical leak, we started intermittent drain irrigation (2–3 times daily with 20–30 ml saline solution per drain with no suction) to dilute the aggressive content of the subclinical leak. In our experience, this strategy was always effective in controlling the leak and maintaining the drain patent.
3. Conclusion
The constant evolution of pancreatic surgery makes PD a widespread intervention, which is now performed routinely even outside specialized centers. Although there are several reports of reduced intra-abdominal complications and mortality, POPF remains the most common unavoidable and life-threatening complication of PD. It becomes obvious that no single measure could be effective enough to eliminate POPF or to reduce its severity to the level of clinically irrelevant postoperative events. However, the combined use of the existing and emerging surgical strategies proved to mitigate the catastrophic consequences of pancreatic anastomosis leak and might be more successful in attempts to achieve this goal.
Based on available clinical evidence, we routinely used a combination of the above-mentioned surgical measures (transanastomotic drain plus vessel wrap plus abdominal drains) in more than a hundred pancreatic resections. Our postoperative protocol included daily measurement of drain fluid amylase levels and prompt start of drain irrigation in a case of biochemical leak, as mentioned above. We proceeded with irrigation of the drain until normalization of the drain fluid amylase (less than 3× the upper limit of normal serum amylase), but no longer after the second postoperative week. A systemic antibiotic is started if the patient develops a clinically apparent PJA leak, body temperature >37.5°C, or had prior chemotherapy. The biochemical leak rate was 17% and the ISGPS grade B POPF rate was 11%, with no POPF-related mortality. Notably, none of the patients in this series developed ISGPS grade C POPF nor required image-guided intervention or reoperation. Although none of the surgical techniques can completely eliminate the occurrence of PJA leak after PD, the simultaneous use of measures proven to reduce the risk and/or severity of POPF can effectively mitigate the catastrophic consequences of pancreatic anastomosis leak and should be implemented in PD management protocols.
Abbreviations
| PD | pancreaticoduodenectomy |
| PJA | pancreaticojejunal anastomosis |
| POPF | postoperative pancreatic fistula |
| ISGPS | International Study Group of Pancreatic Surgery |
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