Patrick J Sweigert, MD, Kamthorn Yollsuriyanwong, MD, Gerard Abood, MD, FACS, Bipan Chand, MD, FACS, FASMBS, FASGE. Loyola University Medical Center
Background: Pancreaticoduodenectomy (PD) remains the mainstay of surgical treatment of malignant periampullary disorders. Despite technological advances, the procedure continues to be associated with relatively high complication rates, including leakage from the pancreaticojejunostomy (PJ) and resultant abdominal fluid collections. Given the morbidity associated with early reoperation, fluid collections are commonly managed with percutaneous drainage. However, complex complications that include gastroenteric leakage frequently require operative re-exploration. Endoscopic therapies for such early postoperative complications present a less invasive opportunity to improve morbidity associated with reoperation.
Methods: We present the case of a 67 year-old male who developed sepsis from complex intra-abdominal abscess and post-operative pancreatic fistula 2 weeks following PD. Diagnostic workup including axial imaging and endoscopy confirmed pancreaticojejunal disruption and gastric staple line dehiscence. The patient underwent 5 endoscopic sessions over 60 days, which led to complete resolution of symptoms. Therapeutic techniques included endoscopic vacuum assisted abscess debridement, placement of a distal feeding percutaneous endoscopic jejunostomy (PEJ), as well as use of a covered enteric stent from his gastric staple line dehiscence to the afferent jejunal limb, thus creating a neo-gastrojejunostomy.
Results: Nonoperative management of this severe complication status post PD led to complete healing of the patients external fistula, endoscopic resolution of his complex abdominal abscess, creation of a functional communication between the gastric staple line disruption and the afferent jejunum, and return of normal gastrointestinal function. Following treatment, the patient quickly advanced to his baseline oral diet and activity, without gastrointestinal symptoms or necessity for supplemental PEJ tube feedings.
Conclusions: Early endoscopy is becoming incorporated into the treatment algorithm for post-operative complications following PD with increasing frequency and novel techniques may allow for improved outcomes. Although we recognize risks to the patient following our novel treatment, including potential for future reflux of gastric contents into the pancreaticobiliary system and the possibility of an inappropriately draining pancreatic duct, we are reassured by the patients dramatic and sustained clinical improvement. Our case represents a rare and severe complication that was successfully managed endoscopically.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88325
Program Number: V143
Presentation Session: Flexible Endoscopy Videos Session
Presentation Type: Video