1383 Making It Work With the Tools at Hand: Use of a Biliary Stent to Repair a Pancreatic Leak

Abstract

INTRODUCTION: Pancreatic duct leaks (PDL) are primarily managed by advanced endoscopist, interventional radiologists, and sometimes by pancreatic surgeons. The mainstay of endotherapy for PDL is trans-papillary pancreatic duct stent placement bridging the PDL. Fully covered biliary metal stents are widely accepted in biliary leaks due to its radial force but there is no conventional fully covered metal stent (FCMS) in US for pancreatic duct for refractory PDL. We describe a patient with refractory PDL where biliary SEMS was used to successfully treat PDL. CASE DESCRIPTION/METHODS: Case Presentation A 43-year-old African American male presented to our hospital one month after admission for hemorrhagic pancreatitis attributed to dyslipidemia. Course was complicated by loculated retroperitoneal abscess tracking from pancreas to scrotum. Patient underwent exploratory laparotomy with pancreatic necrosectomy along with broad-spectrum antibiotics resulting in mild improvement in condition. Magnetic resonance cholangiopancreatography revealed PD injury confirmed on abdominal CT with contrast. ERCP confirmed PDL. A 5 F × 8 cm single pigtail plastic pancreatic stent (PPS) was placed. Unfortunately, PPS failed to maintain drainage and prevent leak as observed on contrasted abdominal CT 6 days later. PDL was confirmed again on repeat ERCP and an 8 mm × 6 cm biliary fully covered SEMS was placed in PD. Post stent placement, occlusion pancreatogram (OP) showed no leak. Four days later, repeat CT showed improving fluid collections without leak. After 4 weeks, third ERCP was performed, SEMS was removed with rat tooth forceps without complications, ERCP showed no PDL and a 7 F × 7 cm PPS was placed. Six weeks later, PPS was removed, ERCP showed no PDL and a 7 F × 4 cm PPS was placed. At this time, patient has continued to follow on outpatient basis without further incident. DISCUSSION: Discussion Endoscopic treatments for PDL have replaced surgical interventions in number of situations. Biflanged fully covered metal stents for PDL are only available outside US. In the meantime, cases like this emphasize the importance of considering alternative approaches in the treatment of PDL.