A case of intractable pancreatic fistula after pancreatoduodenectomy, successfully cured by fistulo-jejunostomy directly under the abdominal wall

われわれは膵頭十二指腸切除後に発生した難治性膵液瘻に対し,皮下レベルでの瘻孔空腸吻合を施行し治癒可能となった症例を経験したので報告する.症例は56歳女性,膵頭部に対して膵頭十二指腸切除を施行した.消化管再建はChild変法にて行い,膵空腸吻合は端側吻合を行った.術後16日目より膵液漏を認め,絶食･TPN･ソマトスタチンアナログ投与などの保存加療を行ったが難治性であった.その後も膵液漏は持続したため,術後64日目に再手術を施行した.腹壁直下の瘻孔腔に挙上空腸を吻合しsplint tubeを吻合部に挿入した.Tubeは空腸内より腹腔外へ誘導して膵液を外瘻させた.これまで術後合併症はなく瘻再発および膵炎再燃は認められていない.この術式は従来の方法に比し,瘻孔の腹腔内までの追求剥離操作を行わないため,手技的に簡便で副損傷の可能性が少ない.また空腸と腹壁筋膜の一部とを固定するため瘻孔との空腸の確実な吻合を行うことができる.術後難治性膵液瘻に対する有効な治療法であると考えられるものの,長期的な成績は不明であるため症例を蓄積した上で検討していく必要がある.

We experienced a case of intractable pancreatic fistula after pancreatoduodenectomy, successfully cured by fistulo-jejunostomy directly under the abdominal wall. A 56-year-old woman underwent pancreatoduodenectomy for carcinoma of pancreatic head. After removal of the drainage tube of anastomosis of pancreato-jejunostomy, pancreatic juice started to discharge from the median wound. Conservative therapy such as fasting, TPN, and administration of somatostatin analogue failed to achieve complete healing of pancreatic fistula. The patient underwent surgical treatment 64 days after pancreatoduodenectomy. At laparotomy, fistulo-jejunostomy was performed directly under the abdominal wall. A splint tube was inserted into the anastomosed site and the jejunum and abdominal wall were sutured for fixation, and drainage was made externally via the splint tube. Postoperative course was uneventful and she had no recurrence of pancreatic fistula until now. This surgical procedure is easily and safety and make a certain fixation of jejunum to fistula, so it might be a useful treatment of intractable pancreatic fistula after pancreatoduodenectomy. Because long-term results of its procedure is unknown, further consideration should be needed after collecting cases.

膵頭十二指腸切除

膵液瘻

膵瘻孔空腸吻合