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Fistulojejunostomy versus Distal Pancreatectomy for the Management of Disconnected Duct and Distal Pancreas
Vikrom K. Dhar*, Jeffrey M. Sutton, Brent T. Xia, Nick C. Levinsky, Gregory C. Wilson, Jeffrey Sussman, Michael Edwards, Syed Ahmad, Daniel E. Abbott
Surgery, University of Cincinnati, Cincinnati, OH
Background:
A disconnected distal pancreas as a result of pancreatic duct disruption (PDD) is a morbid sequelae of necrotizing pancreatitis, frequently resulting in ductal stricture and/or a persistent pancreatic leak. Surgical management of these patients is often challenging secondary to a hostile retroperitoneum, with definitive intervention accomplished by either distal pancreatectomy (DP) or fistulojejunostomy (FJ). We sought to contrast these surgical approaches for PDD in terms of both short and long-term outcomes.
Methods:
Between 2002-2014, 42 patients undergoing either FJ or DP for PDD were retrospectively identified from an institutional database. Patient demographics, operation type, post-operative complications and development of endocrine or exocrine insufficiency were evaluated.
Results:
Overall, 64% (n=27) of patients were male, with a median age of 52 years (range 26-75 years) at the time of surgery. The etiologies of pancreatitis were gallstones (36%), idiopathic (31%), alcohol (21%), post endoscopic intervention (7%), and trauma (5%). The chosen surgical intervention for PDD was FJ (n=21) or DP (n=21). Preoperatively, roughly half of each cohort was diabetic (FJ, n=9, 43%; DP, n=12, 57%). There were no significant differences in the overall lengths of stay (FJ 6.7d, DP 8.2d), pancreatic leak rates (FJ n=4/21, DP n=3/21), 30-day readmission rates (FJ 29%, DP 38%), or bouts of recurrent pancreatitis between the groups (FJ n=8/21, DP n=8/21). With regards to diabetes, 33% of patients undergoing FJ (n=3/9), required an increase in their preoperative diabetes medication regimen, compared to 50% (n=6/12) of patients who underwent DP, indicated by increasing insulin or oral hyperglycemic agent doses. Of patients who were not diabetic preoperatively, 17% of the FJ cohort developed new onset diabetes postoperatively, compared to 44% (n=4/9) of the DP cohort. Exocrine dysfunction developed in 33% of each cohort (n=7 for both). In the FJ cohort, 29% (n=4/14) of patients developed new onset exocrine insufficiency postoperatively compared to 14% (n=2/14) of patients in the DP cohort. Equal numbers (n=7, 33%) of each cohort required additional surgical or endoscopic intervention for management of PDD on most recent follow-up.
Conclusions:
Fistulojejunostomy and distal pancreatectomy provide comparable short and long-term outcomes for patients requiring surgical intervention for management of PDD, though DP was associated with a slightly increased rate of new-onset diabetes. With similar rates of postoperative complications and exocrine/endocrine insufficiency, the optimal surgical approach for PDD must be tailored to individual patient characteristics and risk tolerance.
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