Megan Sippey, MD, Jeffrey Hardacre, MD, FACS, Jeffrey Marks, MD, FACS, FASGE. Case Western Reserve University
Abdominal drains are frequently used as a surgeon’s surveillance tool, with the benefit of serving a potential therapeutic role, for high risk anastomoses. Although rare, surgical drains can erode into nearby intraabdominal organs. We report two cases of abdominal surgical drain erosion into small bowel.
Case 1: A 17yo male underwent pancreaticoduodenectomy for a near-complete transection of the pancreatic head and a perforation of the duodenum sustained in a motor vehicle collision. A flat Jackson-Pratt drain was placed anterior to the pancreaticojejunostomy. After 3 months, the drain continued to produce approximately 100cc daily. A fluoroscopic drain study confirmed filling of the jejunum (Figure 1). With suspicion for a pancreaticojejunostomy leak, the patient underwent enteroscopy with intention of endoscopically clipping or oversewing the suspected fistula. On endoscopic inspection, however, the drain was visualized intraluminally in close vicinity to an intact pancreatic anastomosis (Figure 2). The drain was removed and the tract healed spontaneously.
Case 2: A 62yo female underwent Billroth II distal gastrectomy for a Stage IIIb gastric adenocarcinoma. On post-operative day 6, she developed peritonitis and was found to have a leak at the duodenal staple line on abdominal re-exploration. This was repaired with a Graham patch type repair using a mobilized piece of fat from the anterior aspect of the hepatic artery, and covered by a serosal patch using the efferent limb of the gastrojejunostomy. Two 3/16 inch round Jackson-Pratt drains were placed, one inferior and one superior to the repair. One drain had cessation of output and was removed. After 5 months, the second drain had persistent bilious output of 20-30cc daily, despite being taken off of suction. A fluoroscopic drain study showed communication with small bowel in the left upper quadrant, and contrast passing through the gastrojejunostomy to fill the residual stomach (Figure 3). Interestingly, the area of communication was not at the site of the initial duodenal leak. The drain was slowly backed out over 6 weeks. She had intermittent drainage from the former tube site, which resolved spontaneously.
Drain erosion, with an otherwise intact surgical anastomosis, should be kept in mind in patients with persistent drainage despite a recuperating clinical picture. The advanced endoscopist is uniquely equipped to confirm this diagnosis and manage the residual fistula tract should spontaneous closure fail.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92312
Program Number: P425
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster