Diario del páncreas Acceso abierto

Abstracto

Biflanged Fully Covered Metal Stents to Treat Pancreatic Leaks and Fistulae after Duodenopancreatectomy: A New Effective Endoscopic Therapy

Massimiliano Mutignani, Lorenzo Dioscoridi, Edoardo Forti, Francesco Pugliese, Marcello Cintolo, Alberto Tringali, Stefanos Dokas

Background Pancreatic leak is one the most feared complications after duodenopancreatectomy. Treatment depends on the leak’s severity. Conservative treatment is usually effective for leaks of lesser severity. However, conservative treatment prolongs hospital stay, thus increasing hospital cost and decreasing the patient’s quality of life. Surgical treatment is reserved for persistent, high output fistulae but, it is a high risk procedure, often with poor results. There is a plethora of endoscopic methods and devices used to address pancreatic leaks in general. However, in current literature, there is a lack of papers specifically about endoscopic treatment options for pancreatic leaks after duodenopancreatectomy. Methods We present our small series of 4 patients with pancreatic fistula after duodenopancreatectomy and duct-to-mucosa anastomosis. Our patients were treated by implanting a biflanged, fully covered metal stent. The rationale of the treatment, not yet described in the literature, is explained hereafter. Results During the postoperative days, we always documented a significant reduction of the fistula’s output. In all cases, the surgical drain’s output stopped within a few days (range: 2-5 days). One patient died because of severe, preexisting sepsis from multi-resistant Klebsiella pneumoniae five days after the endoscopic procedure. At the time of death, the fistula had already dried out. The remaining three patients had a complete fistula’s healing and no early complication was noted at first follow-up visit (1 month). One patient had a spontaneous yet uneventful migration of the stent, a few weeks after fistula’s healing. The mean follow-up is 24 months. Conclusions The endoscopic interventions were performed successfully rather late in our small study group. This complication is better treated as soon as possible so as to avoid forming a mature fistula or allow for establishment of sepsis. The present method could be a reasonable alternative in selected patients and tertiary referral endoscopic centers.