Wirsungostomy as a salvage procedure after pancreaticoduodenectomy.
BACKGROUND
Mortality rates associated with postoperative peritonitis or haemorrhage secondary to pancreatic fistula (PF) after pancreaticoduodenectomy (PD) remain high. This study analysed the results of an alternative management strategy for these life-threatening complications.


METHODS
All patients undergoing PD between January 2004 and April 2011 were identified. Patients who underwent further laparotomy for failure of the pancreatico-digestive anastomosis were identified. Since 2004, this problem has been managed by dismantling the pancreatico-digestive anastomosis and cannulating the pancreatic duct remnant with a thin polyethylene tube (Escat tube), which is then passed through the abdominal wall. Main outcome measures were mortality, morbidity and longterm outcome.


RESULTS
From January 2004 to April 2011, 244 patients underwent a PD. Postoperatively, 21 (8.6%) patients required re-laparotomy to facilitate a wirsungostomy. Two patients were transferred from another hospital with life-threatening PF after PD. Causes of re-laparotomy were haemorrhage (n= 12), peritonitis (n= 4), septic shock (n= 4) and mesenteric ischaemia (n= 1). Of the 21 patients who underwent wirsungostomy, six patients subsequently died of liver failure (n= 3), refractory septic shock (n= 2) or mesenteric ischaemia (n= 1) and nine patients suffered complications. The median length of hospital stay was 42 days (range: 34-60 days). The polyethylene tube at the pancreatic duct was removed at a median of 4 months (range: 2-11 months). Three patients developed diabetes mellitus during follow-up.


CONCLUSIONS
These data suggest that preservation of the pancreatic remnant with wirsungostomy has a role in the management of patients with uncontrolled haemorrhage or peritonitis after PF.
Department of Digestive Surgery, Haut-Lévêque Hospital, University of Bordeaux Hospital Centre (Centre Hospitalier Universitaire de Bordeaux), Bordeaux, France. denostquentin@hotmail.fr
Quentin
Q
Denost
Arnaud
A
Pontallier
Alexandre
A
Rault
Jacques Andre
JA
Ewald
Denis
D
Collet
Bernard
B
Masson
Antonio
A
Sa-Cunha
D000368:Aged; D002404:Catheterization; D004067:Digestive System Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010183:Pancreatic Ducts / Q000601:surgery*; D010185:Pancreatic Fistula / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality; D010538:Peritonitis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome