Hariruk Yodying, MD. Department of surgery, HRH Princess Maha Chakri Sirindhorn Medical Center (MSMC) Hospital, Srinakharinwirot University
BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD) is a complex procedure that has been cautiously regarded as feasible and safe for resection and reconstruction. Postoperative pancreatic fistula (POPF) remains the major complication after pancreaticoduodenectomy. Risk factors commonly reported to increase the risk of pancreatic anastomotic failure include a soft pancreas and a small duct. We present our experience of pancreaticojejunostomy reconstruction in small pancreatic duct during totally laparoscopic pancreaticoduodenectomy.
CASE PRESENTATION: A 55-year-old female with a history of choledocholithiasis. She underwent ERCP with stones removal one year ago. Six months later she developed jaundice and abnormal weight loss. Abdominal ultrasound showed dilatation of common bile duct (CBD) without evidence of choledocholithiasis. CT scan demonstrated dilatation of common bile duct and abrupt change of ductal caliber at the intrapancreatic bile duct with ductal enhancement. The ERCP was failed to cannulate through this lesion. Malignancy was suspected from a brush cytology. The patient was diagnosed as cholangiocarcinoma at distal CBD. CA 19-9 was 928. Then PTBD was performed to relieve the obstruction
OPERATION AND OUTCOME: The patient underwent laparoscopic pancreaticoduodenectomy. During laparoscopic exploration, There was dense adhesion at the subhepatic area due to the previous infection. A standard dissection of pancreaticoduodenectomy resection and lymphadenectomy was performed. The pancreatic stump founded small pancreatic duct less than 1mm. with failed stent cannulation. The pancreaticojejunostomy was constructed by invagination (end to side) technique without stenting. The operation time was 480 mins. The postoperative course was uneventful and the patient was discharged postoperative day 6.
Pathological examination revealed adenocarcinoma at distal CBD with free resection margin and positive of lymph node metastasis.
The patient received adjuvant chemotherapy. There was no evidence of recurrent tumor or stricture on the 7th-month follow-up.
CONCLUSION: Pancreaticojejunostomy by invagination (end to side) without stenting technique is a simple and safe reconstruction procedure after LPD, especially for patients with a small pancreatic duct.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92252
Program Number: V028
Presentation Session: HPB Videos
Presentation Type: Video