Elsevier

Journal of Surgical Education

Volume 64, Issue 4, July–August 2007, Pages 220-223
Journal of Surgical Education

Case report
Late Pancreaticojejunostomy Stent Migration and Hepatic Abscess after Whipple Procedure

https://doi.org/10.1016/j.jsurg.2007.03.002Get rights and content

A previously unreported late complication of a transanastomotic stent across a pancreaticotojejunostomy is described. The stent migrated distally into the jejunal lumen, through the biliary anastomis into the bile duct and proximally into the liver where it served as a nidus for infection with abscess formation. A percutaneous transhepatic interventional radiologic approach both drained the abscess and pushed the stent out of the liver and biliary tree and into the bowel, with complete recovery. The decision by the surgeon to use a stent in these patients is discussed, and the complications associated with stenting a pancreaticojejunostomy are reviewed.

Introduction

The complexity of pancreaticoduodenectomy (PD) relates in part to the creation of 3 separate anastomoses required to reconstruct the continuity and drainage of the remaining pancreas, biliary tree, and upper gastrointestinal tract. Although associated operative mortality rates have diminished significantly over the last 20 years, complication rates continue to range as high as 50%,1 and they are often related to problems with one of the anastomoses, most often the pancreaticojejunostomy. Various techniques have been used to facilitate anastomosis of the remaining pancreas to the gastrointestinal tract and to attempt to diminish the chance for leakage with its resulting morbidity. Stenting of the pancreaticojejunostomy is one option. A previously unreported complication of stenting of a pancreaticojejunostomy is described: migration of the stent into the liver and abscess formation that occurred 4 years postoperatively. The efficacy of stenting, as well as its associated complications, are reviewed.

Section snippets

Case History

A 61-year-old woman presented with obstructive jaundice and was found to have a pancreatic mass. A temporary silastic stent was placed endoscopically to decompress the obstructed biliary tree. During exploratory laparotomy and PD, the endoscopically placed biliary stent was removed and reconstruction was carried out using a surgically placed internal stent across the pancreaticojejunostomy (Fig. 1). The postoperative course was complicated by delayed gastric emptying, which resolved.

Pathologic

Discussion

Despite reductions in operative mortality rates for PD over the last few decades, the rate of significant complications remains high and is often related to the creation of the pancreaticojejunostomy.2, 3 Leakage of pancreatic juice with its digestive enzymes can cause autolysis of normal tissues and lead to further disruption of healing anastomoses and surgical wounds. Pancreatic fistulas have been reported in 8% to 29% of patients and can lead to abscess, sepsis, bleeding, additional

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