LAUSR

To the editor: We have read the technical note entitled ‘‘Restoration of Dehiscent Pancreaticojejunostomy Causing a Major Postoperative Pancreatic Fistula by Reinsertion of a Pancreatic Duct Tube Using the Rendezvous Technique’’by Suyama et al. [1] with great interest. Patients receiving duct-tomucosa pancreaticojejunostomy rarely develop exacerbation of postoperative pancreatic fistula (POPF) with partial dehiscence of the pancreaticojejunostomy due to spontaneous dislodgement of an external pancreatic duct (PD) stent placed during the surgery. Percutaneous reinsertion of a PD stent may help avoid the need for reoperation by resolving POPF and restoring the dehiscent pancreaticojejunostomy. We have also successfully performed percutaneous stent reinsertion in similar patients using two methods other than Suyama’s. We introduce them here as a reference material, as awareness of the existence of multiple methods may increase the success rate of this intervention. Institutional review board approval was obtained for this report. Our methods use two routes (Routes A and B) as also used in Suyama’s method: Route A is the tract of a surgical drain placed intraperitoneally near the pancreaticojejunostomy. Route B is from the epigastric surface to the elevated jejunal lumen. Route B can be obtained from the fistula tract through which the dislodged PD stent was placed, or created by a percutaneous jejunal puncture under fluoroscopy. Our methods facilitate reinsertion of a PD stent passing through Route B like with Suyama’s method. After stent reinsertion, a peritoneal drain is placed again near the pancreaticojejunostomy via Route A. Figures 1 and 2 show the detailed processes of our two methods. In the direct transjejunal method (Method 1), an angiography catheter is placed in the PD via Route A to create a target (Fig. 1B), and a stent tube is introduced in the PD transjejunally via Route B (Fig. 1D, E). In the loopcreating method (Method 2), a guidewire arc passing through Route B, the jejunum lumen, opening in the jejunal wall, and Route A is created (Fig. 2D, E), a stent tube is introduced in the PD via Route A (Fig. 2F, G), and the proximal end of the tube is advanced over the guidewire arc until it exits the body via Route B (Fig. 2H, I). Figure 3 shows digital radiograms during these procedures. We performed percutaneous reinsertion of a PD stent five times (Method 1, three times; Method 2, twice) in three patients who had received pancreaticoduodenectomy for pancreatic cancer (n = 2) or bile duct cancer (n = 1). Two developed stent dislodgement twice and underwent reinsertion twice. All patients had POPF grade B [2], which had been treated with long–term peripancreatic peritoneal drainage for nine to 25 weeks. Then they developed stent dislodgement that resulted in massively increased drainage and subsequent CT findings suggestive of partial dehiscence of pancreaticojejunostomy. After each stent reinsertion, the drainage volume that had increased immediately returned to the former level. Two patients were discharged free from POPF without reoperation. The other received total pancreatectomy due to exacerbation of POPF by bacterial infection. When comparing Suyama’s method and our two methods, Method 1 and Suyama’s reinsert a PD stent transjejunally from Route B, while in Method 2, the tip of the & Masayoshi Yamamoto [email protected]