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Acute pancreatitis after pancreatectomy: Inside the dilemma pancreatitis-pancreatic fistula

2020; Elsevier BV; Volume: 169; Issue: 4 Linguagem: Inglês

10.1016/j.surg.2020.10.011

1532-7361

Antonio Manenti, Gianrocco Manco, Alberto Farinetti, Luca Roncati,

Gastrointestinal disorders and treatments

The interesting paper by Ikenaga et al about acute pancreatitis after pancreatic resections merits some patho-physiological observations. 1 Ikenaga N. Ohtsuka T. Nakata K. Watanabe Y. Mori Y. Nakamura M. Clinical significance of postoperative acute pancreatitis after pancreatoduodenectomy and distal pancreatectomy. Surgery. 2020; 169: 732-737 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Besides pathogenic elements in common with other abdominal operations, we identify as a specific factor the acute postoperative stasis of pancreatic juice, leading to a subsequent acute pancreatitis. In case of distal pancreatectomy, and independently from the techniques of pancreatic stump sealing, this factor induces an acute pancreatitis in the area surrounding the section rim, possibly evolving into a diffuse pancreatitis or in a Wirsung duct fistula. Similarly, after a pancreatoduodenectomy, a malfunctioning anastomosis of the Wirsung duct, always through the same mechanism of a pancreatic juice stasis, can cause a secondary pancreatitis, often followed by a more dangerous leakage of pancreatic juice mixed with gastric or jejunal content, depending on the technique employed. 2 Manenti A. Farinetti A. Simonini E. Calderoni S. The Wirsung duct in acute pancreatitis: its morphoclinical relevance. J Am Coll Surg. 2015; 220: 254 Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar ,3 Lee P.J. Papachristou G.I. New insights into acute pancreatitis. Nat Rev Gastroenterol Hepatol. 2019; 16: 479-496 Crossref PubMed Scopus (84) Google Scholar On the basis of current knowledge, of observed cases of limited acute pancreatitis around penetrating injuries of the Wirsung duct or traumatic contusions of the pancreatic body, and of histologic documents proving focal pancreatitis secondary to neoplastic obstruction of the Wirsung duct, typically in the pancreatic intraductal neoplasms, we developed the concept of "acute localized pancreatitis." 4 Saluja A. Dudeja V. Dawra R. Sah R.P. Early intra-acinar events in pathogenesis of pancreatitis. Gastroenterology. 2019; 156: 1979-1993 Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Clearly, this disease can worsen from an early stage to a diffuse form, mainly when the other 2 adverse factors, the pancreatic juice stasis and the failed Wirsung duct anastomosis, are not removed. This agrees with the pancreas anatomy, where a segmental subdivision based on sure landmarks of its vascular and ductal excretory networks cannot be drawn. 5 Zhu C. Jia Z. Zhang X. Yu Q. Qin X. Anatomical segmentectomy of the pancreatic head along the embryological fusion plane: a case series and a literature review. Medicine (Baltimore). 2018; 97e0623 PubMed Google Scholar ,6 Renard Y. de Mestier L. Perez M. Avisse C. Lévy P. Kianmanesh R. Unraveling pancreatic segmentation. World J Surg. 2018; 42: 1147-1153 Crossref PubMed Scopus (4) Google Scholar This pancreatitis, recalling a "focal" disease, can be suspected on the basis of laboratory signs but more precisely diagnosed on computed tomography or magnetic resonance cholangiopancreatography that can demonstrate the 2 key signs: an intraparenchymal area of necrosis and a dilation/obstruction of the Wirsung duct or of its main branches. 7 Khurana A. Nelson L.W. Myers C.B. et al. Reporting of acute pancreatitis by radiologists-time for a systematic change with structured reporting template. Abdom Radiol (NY). 2020; 45: 1277-1289 Crossref PubMed Scopus (4) Google Scholar The same radiological tools are preoperatively useful in detecting inherent risk factors secondary to anatomic variations in the pancreas vascular anatomy or to pre-existing lesions of the Wirsung duct, such as segmental obstruction or pancreatoliths. 7 Khurana A. Nelson L.W. Myers C.B. et al. Reporting of acute pancreatitis by radiologists-time for a systematic change with structured reporting template. Abdom Radiol (NY). 2020; 45: 1277-1289 Crossref PubMed Scopus (4) Google Scholar At surgery, all this invites a careful tailoring of the Wirsung duct anastomosis according to its anatomy, eventually spatulating a narrowed outlet, and to privilege its temporary external/internal stenting. 8 Andrianello S. Marchegiani G. Malleo G. et al. Pancreaticojejunostomy with externalized stent vs pancreaticogastrostomy with externalized stent for patients with high-risk pancreatic anastomosis: a single-center, phase 3, randomized clinical trial. JAMA Surg. 2020; 155: 313-321 Crossref PubMed Scopus (22) Google Scholar , 9 Manenti A. Farinetti A. Pavesi E. Zizzo M. Improving treatment of the pancreatic stump after pancreaticoduodenectomy. J Am Coll Surg. 2016; 222: 324 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar , 10 Sato H. Ishida M. Motoi F. et al. Combination of longitudinal pancreaticojejunostomy with coring-out of the pancreatic head (Frey procedure) and distal pancreatectomy for chronic pancreatitis. Surg Today. 2019; 49: 137-142 Crossref PubMed Scopus (3) Google Scholar Clinical significance of postoperative acute pancreatitis after pancreatoduodenectomy and distal pancreatectomySurgeryVol. 169Issue 4PreviewThe definition of postoperative acute pancreatitis as a specific complication of pancreatic surgery was proposed in 2016. Its presence and relevance have not been established, especially after a distal pancreatectomy. Full-Text PDF