C. W. Jensen1, S. Friedland2, P. J. Worth1, G. A. Poultsides1, J. A. Norton1, W. G. Park2, B. C. Visser1, M. M. Dua1 1Stanford University,Surgery,Palo Alto, CA, USA 2Stanford University,Gastroenterology,Palo Alto, CA, USA
Introduction: Severe necrotizing pancreatitis may result in mid-body necrosis and ductal disruption. When a significant portion of the tail remains viable but cannot drain into the proximal pancreas, the “unstable anatomy” that results is often deemed an indication for distal pancreatectomy. The transgastric approach to pancreatic drainage/debridement has been shown to be effective for retrogastric walled-off collections. A subset of these cases are performed in patients with an isolated viable tail. The purpose of this study was to characterize the outcomes among patients with an isolated pancreatic tail remnant who underwent trangastric drainage or necrosectomy (endoscopic or surgical) and determine how often they required subsequent operative management.
Methods: Patients with necrotizing pancreatitis and retrogastric walled-off collections that were treated by either surgical transgastric necrosectomy or endoscopic cystgastrostomy +/- necrosectomy between 2009-2017 were identified by retrospective chart review. Clinical and operative details were obtained through the medical record. All available pre- and post-procedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants.
Results: A total of 75 patients were included in this study (41 surgical and 34 endoscopic). All of the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 27 patients that underwent pseudocyst drainage and 7 that underwent necrosectomy. Median follow-up for the entire cohort was 13 months and there was one death. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and 9 endoscopic). After the surgical or endoscopic creation of an internal fistula (“cystgastrostomy”), there were no external fistulas despite the viable tail. Of the 22 patients, there were 5 (23%) patients that developed symptoms at a median of 23 months from the index procedure (3-recurrent episodic pancreatitis and 2-intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 6 and 24 months after index procedure.
Conclusion: Patients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly “unstable anatomy,” the creation of an internal fistula via surgical or endoscopic “cystgastrostomy” avoids external fistulas/drains and the short term (near to initial pancreatitis) necessity of surgical distal pancretectomy. A very small subset require intervention for late symptoms. In our series, the patients that ultimately required distal pancreatectomy had initially undergone an endoscopic rather than a surgical approach; however, whether there is a difference between the two approaches in the outcome of the isolated pancreatic remnant is difficult to conclude due to small sample size.