Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy.
Department of Oncologic and Minimally Invasive Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
Surg Endosc. 2021 Apr;35(4):1908-1914. doi: 10.1007/s00464-020-08199-8. Epub 2021 Jan 5.
Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9-15% of cases. Endoscopic strategies for management of pancreatic fistula, may allow to avoid reoperation and shorten times for fistula closure, but are still understudied and not widely performed. Aim of the present paper is to describe different endoscopic techniques used to treat such conditions.
It was a retrospective, single centre, study. All patients who underwent endoscopic treatment for pancreatic leaks following PD between 1st January 2013 and 31th May 2019 at our Centre were reviewed. Depending on the morphology and severity of the leak, four main endoscopic techniques were performed: (1) trans-anastomotic intraductal pancreatic stent insertion; (2) lumen-apposing metal stent between the jejunal loop and the retroperitoneum toward the pancreatic stump insertion ("yoyo-stent"); (3) large calibre nose-to-retroperitoneum drain insertion; (4) when a wide damage of the jejunal wall or a coexistent biliary-jejunal leak were observed, triple metal stent insertion was performed as follow in order to close the defect: enteral fully-covered SEMS in the jejunal stump, a pancreatic metal stent into the Wirsung duct and a fully-covered SEMS across the bilio-digestive anastomosis, through the meshes of the enteral stent. In all cases, surgical drain was simultaneously retracted.
We identified 13 patients who underwent endoscopic treatment for POPF after PD. In total, 5 patients underwent "Yoyo stent insertion", 3 with nose-to-collection drain placement and four patients were treated with triple-stent insertion; in only one patient intrapancreatic SEMS insertion was performed. Technical success was 100% and clinical success was 83.3%. Mean time for leak closure was 4.8 days (range 2-10). During the follow-up interval, no leak recurrences were observed.
Our experience confirms efficacy and safety of endoscopic management of POPF following pancreatoduodenectomy management. Endoscopy should play a central role in this clinical scenario.
胰十二指肠切除术后（PD），临床相关的空肠-胰吻合口漏发生在 9-15%的病例中。内镜策略管理胰瘘，可能避免再次手术和缩短瘘管闭合时间，但仍在研究中，并未广泛应用。本文旨在描述用于治疗此类情况的不同内镜技术。
这是一项回顾性、单中心研究。对 2013 年 1 月 1 日至 2019 年 5 月 31 日期间在我中心接受内镜治疗 PD 后胰漏的所有患者进行了回顾。根据漏的形态和严重程度，采用了四种主要的内镜技术：（1）经吻合口内置入胰管内支架；（2）将空肠袢与后腹膜之间的吻合金属支架（“yoyo 支架”）插入胰腺残端；（3）大口径鼻-后腹膜引流管插入；（4）当观察到空肠壁广泛损伤或并存胆肠漏时，采用三重金属支架插入以闭合缺陷：肠内全覆膜 SEMS 插入空肠残端、胰金属支架插入 Wirsung 导管和全覆膜 SEMS 穿过胆肠吻合口，穿过肠内支架的网眼。在所有情况下，同时撤回外科引流。
我们共识别出 13 例 PD 后接受内镜治疗的 POPF 患者。共有 5 例患者接受了“yoyo 支架插入”，3 例接受了鼻-引流管放置，4 例接受了三重支架插入，仅 1 例患者接受了胰内 SEMS 插入。技术成功率为 100%，临床成功率为 83.3%。漏口关闭的平均时间为 4.8 天（范围 2-10）。在随访期间，未观察到漏口复发。
我们的经验证实了内镜治疗 PD 后 POPF 的有效性和安全性。在这种临床情况下，内镜应发挥核心作用。
