How to prevent the postoperative pancreatic fistula with an ethylene vinyl alcohol copolymer (Onyx®): A proposal of a new technique

Abstract

Backgrounds/aims: Despite the advances in identifying risk factors, improving operative technique, and postoperative patient care, pancreatic leakage after pancreatic resection remains a highly debated topic. The aim of this study is to describe our technique and our initial experience with the intraoperative embolization of the main pancreatic duct with an Ethylene Vinyl Alcohol Copolymer (Onyx®).

Methods: Two patients of 63 and 64 years underwent pancreaticoduodenectomy for a cholangiocarcinoma of the extrahepatic bile duct and a pancreatic adenocarcinoma, respectively. At the time of pancreatic parenchyma resection, a Wirsung duct was identified and catheterized. A wirsungography was done and then, embolization with Onyx® was carried out under fluoroscopic control.

Results: Neither of the patients developed a postoperative pancreatic fistula. They were discharged to home on the 17^th and 18^th postoperative day, respectively. At the last follow-up, no recurrence was found. The two patients became diabetics; both needed the support of supplementary pancreatic enzymes.

Conclusions: To our knowledge, we are the first to describe this technique, which seems safe and reliable. Studies on this subject with more patients are needed to confirm the validity of this procedure.

Keywords: Onyx®; Pancreaticoduodenectomy; Postoperative pancreatic fistula.

Fig. 1. Intraoperative fluoroscopy: the procedure begins with the embolization of the distal part of the duct (A), continues to the body (B) and up to the stump (C). The final angiographic control shows the Wirsung mold, with evidence of all secondary pancreatic branches (D).

Fig. 2. (A) X-ray and (B) abdominal computed tomography scan at the 7^th postoperative day shows the pancreatic mold, correlatable to successful embolization of the main pancreatic duct and its secondary branches.