Percutaneous Trans-Jejunal Pancreatic Duct Drainage to Treat a Post-Operative Pancreatico-Cutaneous Fistula
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LETTER TO THE EDITOR
NON-VASCULAR INTERVENTIONS
Percutaneous Trans-Jejunal Pancreatic Duct Drainage to Treat a Post-Operative Pancreatico-Cutaneous Fistula Ali Alsafi1
•
Zaynab A. R. Jawad2 • Long R. Jiao2
Received: 2 May 2020 / Accepted: 9 June 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
To the Editor, We report the case of a post-operative pancreatic fistula/leak secondary to pancreaticojejunal anastomotic dehiscence managed successfully by percutaneous transjejunal pancreatic duct drainage. A 64-year-old man with a pancreatic head adenocarcinoma had an attempt at resection by another surgeon thirteen months earlier. At the time of the initial surgery, the pancreatic tumour was deemed unresectable after dissection for pancreaticoduodenectomy as it infiltrated the superior mesenteric vein (SMV). A palliative choledochojejunostomy and a rouxen-y gastric bypass was formed leaving the tumour in situ. After six cycles of chemotherapy with FOLFIRINOX with stable disease, the patient was referred to the lead pancreatic surgeon (LRJ) for pancreaticoduodenectomy with possible resection and reconstruction of the SMV. The distorted anatomy and extensive fibrosis secondary to previously attempted dissection around the pancreas and post-chemotherapy changes precluded pancreatic duct stenting at the time of forming a pancreaticojejunal anastomosis as the pancreatic duct was not visualised. The postoperative period was complicated by increasing right-sided abdominal pain and worsening inflammatory markers (WCC: 29 9 109/l and CRP: 260) prompting a CT at the second post-operative day. This showed a peripancreatic & Ali Alsafi [email protected] 1
Imaging Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0HS, UK
2
Department Surgery and Cancer, HPB Surgical Unit, Hammersmith Hospital, Imperial College London, London W12 0HS, UK
collection and dehiscence of the pancreaticojejunal anastomosis (Fig. 1). The collection was drained percutaneously under ultrasound and fluoroscopy guidance using a 12Fr SkaterTM drain (Argon Medical, Frisco, Tex), but the patient’s abdominal pain continued to worsen. In order to divert pancreatic fluid, pancreatic duct drainage was considered. A 5Fr multipurpose catheter (Cordis, Florida, USA) and a 0.03500 , 150-cm angled glide wire (Terumo, Japan) were introduced through the pre-existing peripancreatic drain tract, subsequently catheterising the pancreatic duct. The catheter was then changed over an 0.03500 straight guidewire for a 5Fr straight flush catheter (Cordis, Florida, USA) (Fig. 2). After a few days, the patient returned in order to convert his external pancreatic drain into an internal one. The roux loop was accessed using a 21 Gauge Chiba needle under a combination of ultrasound and fluoroscopy guidance allowing the introduction of a Neff-set introducer (Cook Medical, Bloomington, USA), which was exchanged ove
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