Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy [1]. Disruption of the pancreaticojejunal anastomosis after pancreatoduodenectomy is reported to occur in as many as 15% of cases, and treatment of the dehiscent pancreatojejunostomy is through relaparotomy or catheter drainage [2]. Although a few recent reports have described the successful endoscopic ultrasound-guided internalization of external pancreatic fistula [3, 4], there has been no report to date of restoration of a dehiscent pancreaticojejunostomy. Here, we report a case of endoscopic restoration of a dehiscent pancreatojejunostomy after pancreatoduodenectomy.
A 72-year-old man, who underwent pancreatoduodenectomy 2 months earlier for cholangiocarcinoma, was referred for treatment of an intractable external pancreatic fistula resulting from pancreatojejunostomy dehiscence. Fistulogram through a remaining surgical drainage tube demonstrated a pancreatocutaneous fistula connecting to the pancreatic duct (Fig. 1). Endoscopic treatment with a short-type single-balloon enteroscope (SIF-H290S; Olympus, Tokyo, Japan), which has a 1,520-mm working length and a 3.2-mm working channel, was then undertaken to recanalize the dehiscent pancreatojejunostomy. A transparent cap was attached to the tip of the scope to facilitate insertion of the endoscope and cannulation through the anastomosis. After identification of the pancreaticojejunal anastomosis, a 0.025-in guidewire (VisiGlide 2; Olympus Medical Systems, Tokyo, Japan) was manipulated through the dehiscent anastomosis into the pancreatic duct, and a 7-Fr, 5-cm straight stent with proximal and distal flaps (Flexima; Boston Scientific Japan, Tokyo, Japan) was placed across the dehiscent anastomosis for internal drainage (Fig. 2; online suppl. Video 1, see www.karger.com/doi/10.1159/000516946 for all online suppl. material). The surgical drainage tube was removed 2 days after the endoscopic treatment, and the patient was discharged without further complications; on a follow-up CT performed 2 months after the endoscopic treatment, complete resolution of the pancreatic fistula with spontaneous dislodgement of the pancreatic stent was confirmed.
Fig. 1.
Fistulogram through a surgical drainage tube (arrow) showing a pancreatocutaneous fistula connecting to the pancreatic duct (arrowhead) in a 72-year-old man who presented with an intractable external pancreatic fistula resulting from pancreatojejunostomy dehiscence.
Fig. 2.
a Endoscopic image showing the pancreaticojejunal anastomosis. b Fluoroscopic image showing a catheter manipulated through the dehiscent anastomosis into the pancreatic duct with a retrograde filling of the bile duct through the hepaticojejunostomy. c Endoscopic image showing a 7-Fr, 5-cm straight stent placed across the dehiscent anastomosis for internal drainage. d Fluoroscopic image showing the pancreatic stent after endoscopic recanalization.
Statement of Ethics
Patient consent was obtained for publication of this report, including the images.
Conflict of Interest Statement
The authors have no conflict of interests to declare.
Funding Sources
No financial support was received for this work.
Author Contributions
S.K. is the article guarantor and wrote this paper.
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Supplementary data
References
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