Pankreatojejunostomie bei der Pankreaskopfresektion unter Verwendung eines resorbierbaren monofilen Fadens zur inneren Schienung der Anastomose – klinische Erfahrungen und perioperative Ergebnisse

Zusammenfassung

Hintergrund: Insuffizienzen der Pankreasanastomose sind bedeutend für Morbidität und Mortalität der Pankreaskopfresektion. Wir untersuchten den potenziellen Nutzen einer einfachen Technik der inneren Pankreasgangschienung mit einem resorbierbaren monofilen Faden bei Anlage der Pankreatojejunostomie nach Warren-Cattell. Patienten und Methodik: Im Zeitraum von 2006–2010 wurden 139 Pankreaskopfresektionen (124 pyloruserhaltend, 15 klassischer Whipple) durchgeführt. Indikationen waren: Malignome (n = 97), chronische Pankreatitis (n = 24) oder andere (n = 18). Bei 64 Patienten erfolgte die Schienung der Pankreasanastomose wie beschrieben. Die Erfassung aller perioperativen Daten erfolgte prospektiv in einer SPSS-Datenbank. Der perioperative Verlauf wurde nach ISGPF (International Study Group for Pancreatic Fistula, Schweregrad A–C) und Accordion (Klassifikation postoperativer Komplikationen nach Schweregrad 1–6) klassifiziert. Ergebnisse: Die Rekonstruktion nach Pankreaskopfresektion erfolgte durch 99 Pankreatojejunostomien und 41 Pankreatogastrostomien. Die Morbidität (Accordion 1–6) war 48 %, die Mortalität betrug 5,8 %. Pankreasfisteln (A–C) traten in 27 (19,4 %) Fällen auf. Nur eine Patientin verstarb an den direkten Folgen einer Pankreasfistel (Typ-C-Fistel nach pyloruserhaltender Pankreaskopfresektion und Pankreatogastrostomie). In der Untergruppe mit 2-reihiger Duct-to-Mucosa-Anastomose (Warren-Cattell) der Pankreatojejunostomie und innerer Gangschienung mit resorbierbarem monofilen Faden (n = 64) betrug die Fistelrate (A–C) 20,3 % (n = 13). Entsprechend der ISGPF-Klassifikation handelte es sich um Fisteln nach Typ A (n = 10), Typ B (n = 2) und Typ C (n = 1). Die Morbidität (Accordion 1–6) betrug 55 % (n = 35) und die Mortalität (Accordion 6) 6,2 % (n = 4). Komplikationen durch die Pankreasgangdrainage selbst wurden nicht beobachtet. Schlussfolgerung: Die Methode der inneren Gangschienung mit resorbierbarem monofilen Material ist technisch einfach und sicher durchführbar. Pankreasfisteln traten sowohl in der Gesamtgruppe als auch in den Subgruppen mit/ohne Pankreasgangdrainage in etwa 20 % auf. Eine Senkung der Fistelrate konnte durch die Anastomosenschienung nicht erreicht werden.

Abstract

Background: Pancreatic fistulas are relevant in perioperative outcome, morbidity and mortality after pancreatic head resection. We analysed the potential benefit of an internal pancreatic duct draining technique by a resorbable monofilament suture if performing a two-layer duct-to-mucosa pancreatojejunostomy. Patients and Methods: From 2006 to 2010, 139 pancreatic head resections were performed in our department (124 pylorus-preserving, 15 Whipple). Indications for surgery were malignancies (n = 97), chronic pancreatitis (n = 24) or others (n = 18). In 64 cases, internal drainage of the pancreatic anastomosis was performed as described. Perioperative results were evaluated by the ISGPF classification (International Study Group for Pancreatic Fistula, type A–C) and Accordion classification (degree 1–6). Results: Pancreatic anastomosis was performed in 99 cases as pancreatojejunostomy and in 41 cases as pancreatogastrostomy. Morbidity (Accordion 1–6) was 48 %, and mortality was 5.8 %. Pancreatic fistulas (A–C) occurred in 27 (19.4 %) cases. Only one patient died as a direct consequence of a pancreatic fistula (type C fistula after pylorus-preserving pancreatic head resection and pancreatogastrostomy). In the subgroup of patients with a two-layer duct-to-mucosa pancreatojejunostomy with internal pancreatic duct drainage by a resorbable monofilament suture (n = 64), a pancreatic fistula occurred in 20.3 % (n = 13). According to the ISGPF classification, they were type A (n = 10), type B (n = 2) and type C fistulas (n = 1). In this subgroup with pancreatic duct drainage, morbidity (Accordion 1–6) was 55 % (n = 35) and mortality (Accordion 6) was 6.2 % (n = 4). Complications due to the pancreatic duct drainage were not observed. Conclusion: Internal drainage of the duct-to-mucosa pancreatojejunostomy using monofilament suture material is a safe and feasible method. Pancreatic fistula occurred in 20 % both in the entire group as well as in subgroups with or without pancreatic duct drainage. A reduction of the rate of pancreatic fistula could not be achieved by internal drainage of the pancreatojejunostomy.

Schlüsselwörter

Pankreasgangdrainage - Anastomoseninsuffizienz - Pankreaschirurgie - Pankreaskopfresektion - Pankreasfistel

Key words

pancreatic duct drainage - anastomotic insufficiency - pancreatic surgery - pancreatic head resection - pancreatic fistula

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