The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence

Abstract

Objectives: Although infrequent, Grade C postoperative pancreatic fistulae (POPF) following pancreaticoduodenectomy (PD) are morbid and potentially lethal. Traditional management of a disrupted pancreaticojejunostomy (PJ) anastomosis consists of either wide external drainage or completion pancreatectomy. The aim of this study is to describe an alternative management approach to PJ dehiscence after PD.

Methods: A bridge stent technique is employed in the setting of a disrupted PJ anastomosis. Upon re-exploration, a 5-Fr or 8-Fr silastic feeding tube stent is placed across a gap between the jejunal enterotomy and the pancreatic duct, and secured with an absorbable suture at both ends. Depending upon the degree of local inflammation, this may be externalized by coursing the stent downstream through the pancreaticobiliary drainage limb in a Witzel fashion.

Results: Over 8 years and 357 PDs with duct-to-mucosa PJ reconstruction, seven ISGPF (International Study Group on Pancreatic Fistula) Grade C fistulae occurred (2%). Two patients ultimately died secondary to POPF (neither anastomosis was dehisced). The described technique was used in the other five patients, all of whom had evidence of a dehisced PJ anastomosis. All originally had at least two or three recognized risk factors for POPF development (high-risk pathology, soft gland, duct diameter ≤ 3 mm, estimated blood loss ≥ 1000 ml). All patients survived this complication and were discharged from hospital. There have been no longterm external fistulae, nor any recognized PJ strictures or remnant atrophy (median follow-up: 10.7 months).

Conclusions: In the context of a dehisced pancreaticojejunal anastomosis, the bridge stent technique is a safe and effective method of management that contributes to diminished mortality and helps to salvage pancreatic function.

Figure 1

Axial computed tomography demonstrating peripancreatic gas with an associated ‘gap’ (arrows) between the jejunum and the pancreatic neck transaction margin

Figure 2

Computed tomography shows that a pancreatic anastomotic stent employed at the construction of the original anastomosis has migrated into the peritoneal cavity

Figure 3

(A) Dehiscence of the pancreatico-jejunal anastomosis is illustrated. Note the gap between the pancreatic remnant and the jejunum. (B) Bridge-Stent Technique with externalized stent, and external drain adjacent to gap. (C) Bridge-Stent Technique with internal stent and external drain adjacent to gap

Figure 4

Incidence and management of 78 cases of postoperative pancreatic fistulae (POPF) in 357 cases of pancreaticoduodenectomy. ^aNot mutually exclusive; ^bOne patient died prior to initiation of any definitive therapy