Two-Staged Pancreatoduodenectomy Including Interventional Pancreatic Fistulo-Jejunostomy in a High-Risk Patient

JOP. J Pancreas (Online) 2016 Nov 08; 17(6):671-674. CASE REPORT Two-Staged Pancreatoduodenectomy Including Interventional Pancreatic Fistulo-Jejunostomy in a High-Risk Patient Hisashi Gunji, Akihiro Cho, Hiroshi Yamamoto, Matsuo Nagata, Nobuhiro Takiguchi, Osamu Kainuma, Hiroaki Souda, Atsushi Ikeda, Akinari Miyazaki Department of Gastroenterological Surgery, Chiba Cancer Center Hospital, Chiba, Japan ABSTRACT Context followed by later pancreatojejunostomy in the second operation is a safe method for high-risk patients. But this procedure requires twice laparotomy. It has Here been we reported report anthat improved two-staged method pancreatoduodenectomy to avoid the second includingoperation the using first interventional operation without technique. pancreatoenteric Case report anastomosis A Seventy- one-year-old man with a lower bile duct carcinoma who had repeated hemorrhage by duodenal ulcer and deterioration in the liver function underwent pancreatoduodenectomy. Because of the high risk situation, we selected the complete exteriorization of pancreatic juice without pancreatoenteric anastomosis to avoid pancreatic fistula. Three months after operationConclusion we performed No complication interventional occurred pancreatic during andfistulo-jejunostomy after procedure. by puncturing the pancreatic fistula into the jejunal loop under endoscopic observation followed by insertion of 8Fr. internal drainage tube between pancreatic fistula and jejunum using double guide wires. INTRODUCTION obstru Despite decreases in operative mortality after duct withoutctive jaundice. passing Serum the obstructivetotal bilirubin site. level Emergency was 11.3 pancreatoduodenectomy (PD) due to improved surgical gastroduodenalmg/dL, and PTBD endoscopic tube was examination inserted into revealed common bleeding bile from a duodenal ulcer as a result endoscopic clipping and methods and perioperative care [1, 2, 3, 4], life-threatening three times angiographic coil embolization for pancreatic arterial arcade were performed. Hemostasis was obtained especiallycomplications in the such elderly as patientspancreatic with leakage poor liver [5, function6] and and subsequent cholangiography using contrast medium orconsequent in emergency arterial situations. bleeding [7, 8] are of great concern An effective surgical method to avoid these complications, two-staged PD followed by later tomographyvia a PTBD tube showed revealed no metastasis stenosis inof other the lower organs. bile duct compatible with bile duct cancer. The enhanced computed pancreatojejunostomy was previously advocated by Although he had just recovered from shock status, he Miyagawa et al underwent surgery because the laboratory data showed safety in high risk cases, but could be improved further. his liver function and jaundice was getting worse. PD . [9]. This procedure has already improved was performed in a standard manner except complete two-staged PD and propose a new strategy for PD in high exteriorization of the pancreatic juice was performed by In an effort to improve on the procedure we modified jejunostomy.risk cases; here we report our findings in a successful keyinserting to this a procedure 6 Fr.pancreatic is the arrangementtube into the ofmain the pancreatic tubeduct two-staged PD including interventional pancreatic fistulo- adjacentand the pancreatic to the jejunal remnant loop during was covered gastrojejunal with a condom.anastomosis The CASE REPORT A Seventy-one-year-old male patient was rushed to jejunostomy is easy to perform. our hospital in a state of shock induced by melena and as this insures subsequent interventional pancreatic fistulo- pat Bim tublar adenocarcinoma, moderately differentiated The pathological findings were confirmed as follows; a hemorrhage caused by a PTBD tube inserted to treat Received July 5th, 2016 - Accepted July 26th, 2016 panc 1b, du 2, pv 0, a0, hm0, dm0, em0. Keywords Pancreatoduodenectomy; Jejunostomy type, intermediated, INF β, ly1, v1, pn3β, si, h-inf 0, g-inf 0, Correspondence Hisashi Gunji No complication occurred after operation. He was Department of Gastroenterological Surgery Nitona 666-2, Chuo-ku days later, interventional internal drainage was carried discharged on 28th post-operative day. One hundred Tel out as follows. Before the second stage procedure, FaxChiba 260-8717, Japan E-mail + 81 [email protected] 243 264 5431 phyconⓇ + 81 043 262 8680 the 6Fr. pancreatic tube was substituted for the 16Fr. JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 17 No. 6 – Nov 2016. [ISSN drainage 1590-8577] tube (Fuji Systems Corporation, Japan)671 JOP. J Pancreas (Online) 2016 Nov 08; 17(6):671-674. and pancreatic At this point internal drainage was still incomplete because the drainage tube was placed from the remnant fistulography followed by computed tomography with reconstructing 3D imaging was performed. This revealed the spatial relation between gastric lumen through the pancreatic fistula and out of the pancreatic fistula and the jejunal loop. We simulated (Figure 1). radiographicthe abdominal technique cavity. Five (Figure days 4) later. the drainage tube puncturing the pancreatic fistula into the jejunum with werewas substituted separated; onewith in athe T-tube remnant using gastric the lumeninterventional another this 3D image to facilitate internal drainage The ends of the T-tube (FigureThe pancreatic2). Endoscopy fistula was was necessary punctured to intoensure the jejunumthat the in the pancreatic fistula. Seven days later the final step was needlewith a was EUS-FNB pushing needle against underand sticking endoscopic to the jejunalobservation wall. drainage tube, which enabled the pancreas juice to drain to replace the T-tube with a “lost tube” made of 8Fr. internal After penetration a guide wire was inserted into the jejunal completely into the jejunal or gastric lumen (Figure 5). lumen via the needle. After this step both endoscopy and without leakage or any peri-procedural complications. guide-wire was caught and held with endoscopic forceps until The internal drainage of pancreatic juice was completed radiography were simultaneously performed. Then the procedure. He has been free of recurrence in 5 years, and Ⓡ heHe neverwas discharged suffered from on anythe pancreatic13th day afterdisorder interventional during this followingthe needle dilation was replaced through with the guide-wirean 8Fr. internal (Figure drainage 3). tube period. (Cliny Internal Drainage Tube , CREATE MEDIC CO.LTD) Figure 1 Ⓡ Arrow shows. Preoperative the simulation image of of puncturing computed direction.tomography and its 3D reconstruction shows the spatial relation between pancreatic fistula and jujunal loop. The white tube is the’16Fr.phycon drainage tube which is placed along the fistula made inside the condom. Figure 2 . Jejunal loop was punctured via pancreatic fistula under endoscopic observation as the scheme shows. JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 17 No. 6 – Nov 2016. [ISSN 1590-8577] 672 JOP. J Pancreas (Online) 2016 Nov 08; 17(6):671-674. Figure 3 Ⓡ . The needle was replaced by an 8Fr. internal drainage tube (Cliny Internal Drainage Tube , CREATE MEDIC CO., LTD) using a guidewire. Figure 4 Figure 5 external drainage. T-tube was inserted into pancreatic fistula and jejunal lumen. A 8Fr. internal drainage tube was inserted as a ‘lost tube’ without DISCUSSIONArrow shows pancreatic fistula, arrow head shows jejunal loop. and subsequent pancreatojejunostomy in the second Pancreatoenteric anastomosis is still considered to be dangerous especially in high risk patients because it is fatal operation. This method is highly effective in performing if a major pancreatic leakage occurs. In particular the major orPD in without emergency pancreatic patients, anastomosis subsequent during anastomosis the first can stage. be arterial bleeding following pancreatic leakage is a crucial carriedIn risky outcases after such liver as concomitantfunction and major the general hepatectomy condition [15] of element in postoperative mortality. Although, it might be the patient normalizes. But this technique imposes twice acceptable that operative mortality decreased to less than laparotomy on patients, and as there is a need for a second et al. very carefully. A further drawback of this technique is that usefulness4% in high-volume of using centersan occlusion as Yeo balloon[10]. catheter Reported, during we itoperation requires it pancreatojejunostomy is essential that the pancreatic performed fistula by is suturing handled laparotomyshould have saferto controlprocedure intra-abdominal for PD in high risk hemorrhage cases. The in the second operation. Kubota et al . [16] reported in 4 related to PD was reported [11], but it is essential that operation. occlusion of the remnant pancreatic duct with ligature or of 24 patients (16.7%) leakage occurred after the second pancreatic leakage is avoided. Total pancreatectomy and risk, but these procedures were shown to result in the loss ofprolamine exocrine [12, and 13,endocrine 14] have functions been employed of the pancreas. to reduce Hence the On the other hand, interventional internal drainage Miyagawa et al for post-operative intractable pancreatic fistula [17, 18, drainage of pancreatic knowledge,19] has been i nestablished previous reportsas a useful interventional technique related internal to . [9] devised two-staged PD with external obvious progress in interventional radiography. To our juice during the first operation JOP. Journal of

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