clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

STEP 2

If possible, a catheter or probe is passed through the fistulous tract into the pancreatic duct.

If the pancreatic duct is identified, opening the anterior wall (spatulating the duct) increases the effective diameter of the anastomosis and facilitates the conduct of the anastomosis.

Pancreatography can be obtained if not done already.

The pancreatic duct should be imaged proximally and distally.

The jejunum is transected about 15 cm distal to the ligament of Treitz. The blind end of the jejunum is closed by a stapling device or sutures.

Enteric continuity is reestablished by end-to-side jejunojejunostomy at least 60cm from the closed end of the Roux limb.

The anastomosis is constructed by suturing the side of the jejunum to the pancreatic duct or the rim of scarred tissue at the fistulous tract at its point of origin on the pancreas. For details of construction of the Roux-en-Y limb see Sect.2, chapter “Subtotal Gastrectomy, Antrectomy, Billroth II and Roux-en-Y Reconstruction and Local Excision in Complicated Gastric Ulcers.”

STEP 3

A posterior row of Lembert-type sutures is placed using 4-0 silk.

Next a row of absorbable sutures (4-0 or 5-0 polyglycolic acid) are placed full thickness through the pancreatic duct and the jejunum.

A catheter can be left as a stent through the anastomosis and brought out of the anterior abdominal wall, allowing the anastomosis to be studied postoperatively through the catheter if indicated.

STEP 4

If the pancreatic duct cannot be identified definitively, the jejunum can be sewn over the fistulous tract as an onlay anastomosis to the pancreatic parenchyma; it would be optimal to keep a stent across this onlay anastomosis.

A soft closed suction drain is placed adjacent to the anastomosis.

Local Postoperative Complications

■Anastomotic leak, possible recurrent fistula

■Abscess

■Pancreatitis

■Pancreatic pseudocyst

■Intra-abdominal hemorrhage

Tricks of the Senior Surgeon

■Patience, adequate drainage, and complete preor intraoperative imaging is paramount for definition of the fistula and associated ductal anatomy; should marked disease remain in the duct, an alternative procedure, e.g., resection or lateral pancreaticojejunostomy, might be a better choice.

■One goal of fistula drainage is to preserve pancreatic endocrine and exocrine function. If the fistula arises from the tail of the pancreas, resection of the distal pancreas may be the best option if minimal loss of functional pancreatic tissue is anticipated.

■Spontaneous closure of the pancreatic fistula can be aided with a somatostatin analogue; success may be predictable based on radiographic evaluation. Fistulae that arise from a divided duct will not resolve.

■Closure of fistulae that radiographically connect to the GI tract may be facilitated by transpapillary pancreatic stents and by ensuring that strictures and obstructing calculi are addressed.

■Internal drainage of the fistulous tract into the stomach is not suggested; rather a defunctionalized Roux limb of jejunum is preferred when resection is not the best option.

■Sew to the pancreatic parenchyma at the point of origin of fistula and not to the fistulous tract; the parenchyma is usually thickened and scarred.

■If internal drainage is not possible (high operative risk or anatomic considerations), chronic external drainage is the best option.

■Amylase-rich fluid in the drain signifies breakdown of the anastomosis; management is considerably easier if a stent is placed across anastomosis at operation. The anastomosis can be evaluated radiographically; as the output decreases, the stent is converted from closed suction to passive drainage and then advanced 1cm/day.

■Early intra-abdominal hemorrhage is best treated by reoperation and direct vessel ligation. Late hemorrhage may be a sentinel bleed from a pseudoaneurysm; immediate angiography and vessel embolization are indicated.

Sphincteroplasty for Pancreas Divisum

Andrew L. Warshaw

Indications and Contraindications

Preoperative Investigation and Preparation for the Procedure

delayed return of principal pancreatic duct to normal size after hyperstimulation of pancreatic secretion.

Impaired emptying through stenotic accessory papilla results in persistent (15to 30-min) duct dilation.

Extensive mobilization of the duodenum and the head of the pancreas (extended Kocher maneuver) facilitates exposure.

Cholecystectomy is performed if the gallbladder is still present; passage of a biliary Fogarty® catheter via the cystic duct or common duct through the major ampulla into the duodenum aids localization of the accessory papilla.

A transverse duodenotomy is made just proximal to the papilla of Vater, which can usually be felt transduodenally or with the aid of the biliary Fogarty® catheter.

Fine traction sutures are placed at the distal margins of the accessory papilla; the papilla is incised over a probe in the duct. Pancreatic juice should gush forth, and a dilated vestibule proximal to the papillary membrane should be immediately apparent. The smooth light pink mucosa lining the pancreatic duct is easily distinguished from the duodenal mucosa.

The incision is extended about 1cm, only as far as necessary to lay the duct vestibule widely open.

Local Postoperative Complications

■Short term:

–Acute pancreatitis

–Duodenal obstruction

–Duodenal leak

■Long term:

–Recurrent papillary stenosis

–Recurrent symptoms, pancreatitis

–Failure to cure preoperative pain syndrome

Tricks of the Senior Surgeon

■The major papilla (ampulla) of Vater is often palpable through the duodenal wall even without a transcholedochal (e.g., via cystic duct) catheter through the Ampulla of Vater.

■The accessory papilla is proximal in the duodenum, perhaps only 3cm from the pylorus; a prominent vessel on the lateral duodenal wall is often noted at this point.

■The transverse duodenotomy provides adequate exposure and is less likely to cause postoperative duodenal stenosis than a longitudinal suture line.

■The accessory papilla may be difficult to find by visual inspection, it is often small, protrudes minimally from the duodenal surface and is located more easily by gentle palpation of the medial wall of the duodenum. It feels like a small “bump” or nipple.

■Application of methylene blue to the duodenal mucosa may help to locate the pancreatic duct orifice; pancreatic secretions, especially after secretin, wash off the blue dye at the orifice.

■After cannulating the orifice, do not remove the probing instrument until the incision into the papilla has been completed. Local trauma may make rediscovery of a small, traumatized orifice very difficult.

■The dorsal duct of Santorini follows a perpendicular course through the duodenal wall (in contrast to the oblique path of the duct of Wirsung); the sphincteroplasty is therefore necessarily short. Going past the thin membrane of the first centimeter makes the apex of the sphincteroplasty difficult to suture.