The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence.
OBJECTIVE
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.
Kent
Tara S
TS
Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA. tkent@bidmc.harvard.edu
Callery
Mark P
MP
Vollmer
Charles M
CM
D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001900:Boston; D003131:Combined Modality Therapy; D004322:Drainage / Q000295:instrumentation*; D006801:Humans; D010185:Pancreatic Fistula / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality; D010193:Pancreaticojejunostomy / Q000009:adverse effects* / Q000401:mortality; D010288:Parenteral Nutrition; D018570:Risk Assessment; D012307:Risk Factors; D016879:Salvage Therapy; D015607:Stents; D013529:Surgical Wound Dehiscence / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents