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