Introduction: Internal drainage of a persistent pancreatic fistula following necrosectomy for severe acute pancreatitis can be accomplished by fistulojejunostomy roux-en-y (FJ) or pancreaticojejunostomy roux-en-y (PJ). Drainage procedures are favored over resection in this setting to preserve pancreatic parenchyma and function. While effective in the short term, long-term patency of these anastomoses is unknown. The aim of this study is to provide long-term follow-up on 22 patients treated by FJ or PJ for a persistent pancreatic fistula following necrosectomy.
Methods: Between July 1996 and February 2006, 95 patients with severe acute pancreatitis were treated by pancreatic necrosectomy. Fifty-three patients (56%) developed post necrosectomy pancreatic fistulas of which 22 (42%) were persistent (> 3 months) and treated by internal drainage. Seventeen patients (77%) had FJ and 5 patients (23%) had PJ using a duct to mucosal anastomosis. Eight patients (36%) had diabetes mellitus. Three patients had unrelated deaths during follow-up in the FJ group (2 cardiac, one malignancy) and one related death in the PJ group (pseudoaneurysm). All patients were contacted by telephone or clinic visit with a mean follow-up of 72 months (range 11- 120 months).
Results: Of the 17 patients following FJ, 6 (35%) had recurrent symptoms and were found on imaging to have a pancreatic pseudocyst a mean of 24 months (range 13-36 months) following drainage. All 6 patients with recurrent pseudocysts had a disconnected pancreatic remnant identified on imaging and 4 of the 6 patients (67%) had diabetes mellitus. Five of 6 were treated by distal pancreatic resection and one had a PJ. All remained symptom free at a mean follow-up of 57 months. Of the 5 patients treated primarily by PJ, all had a disconnected pancreatic remnant. One patient died two months postop from a splenic artery pseudoaneurysm. The remaining 4 patients are well without symptoms at a mean follow-up of 33 months.
Conclusions: PJ, when feasible, is a durable drainage procedure to treat persistent pancreatic fistulas following necrosectomy. FJ, while technically easier, has a 35% symptomatic recurrence rate during long-term follow-up particularly in the setting of a disconnected pancreatic remnant. Diabetes mellitus may be an indicator of a poorly drained pancreatic remnant following FJ.