Can the Realization of an External Wirsungostomy be an Option for High‐Risk Pancreatic Anastomosis After Pancreaticoduodenectomy?

Abstract

AbstractBackgroundClinically relevant postoperative pancreatic fistula (POPF) occurs in 15–20% of patients after pancreaticoduodenectomy (PD) and reintervention in the setting of Grade C POPF remains associated with a mortality rate of up to 25%. In patients at high risk of POPF, PD with external wirsungostomy (EW) could be a safe alternative that avoids pancreatico‐enteric anastomosis while preserving the remnant pancreas.MethodsOf the 155 consecutive patients who underwent PD from November 2015 to December 2020, 10 patients were managed using an EW, all with a fistula risk score (FRS) ≥ 7 and BMI ≥30 kg/m2, and/or major associated abdominal surgery. The pancreatic duct was cannulated with a polyethylene tube to allow good external drainage of the pancreatic fluid. We retrospectively analyzed postoperative complications and endocrine and exocrine insufficiencies.ResultsThe median alternative FRS was 36.9% [22.1–45.2]. There was no postoperative death. The 90‐day overall severe complication (grade  ≥3) rate was 30% (n = 3 patients), no patient required reoperation, and 2 hospital readmissions occurred. 3 patients experienced Grade B POPF (30%), managed using image‐guided drainage for 2 patients. The external pancreatic drain was removed after a median drainage time of 75 days [63–80]. Two patients presented with late symptoms (> 6 months) warranting interventional management (pancreaticojejunostomy and transgastric drainage). Six patients experienced significant weight loss (> 2 kg) 3 months after surgery. One year after surgery, 4 patients still complained of diarrhea and were treated with transit‐delaying drugs. One patient presented new‐onset diabetes one year after surgery, and 1 of the 4 patients with preexisting diabetes experienced worsening disease.ConclusionEW after PD might be a solution to reduce post‐operative mortality following PD in high‐risk patients.