ENDOSCOPIC AND PERCUTANEOUS MANAGEMENT OF AN IATROGENIC DISTAL PANCREATIC FISTULA DURING VASCULAR SURGERY

Abstract

Abstract Introduction Traumatic pancreatic fistulas are, normally, secondary to a partial or complete rupture of the pancreatic duct. Pancreatic surgery is associated with high morbidity and mortality, thus a step-up approach, with priorization of a conservative or endoscopic management, is useful in selected cases. Clinical case A 74-year-old man underwent resection of a thoraco-abdominal aneurysm with placement of a vascular graft and reimplantation of visceral arteries. In the immediate postoperative period, he presented with febrile syndrome and abdominal pain. Abdominal CT was performed, observing a retroperitoneal collection of 7cm. Ultrasound-guided percutaneous drainage of the collection was performed. Amylase levels in the drainage were analyzed, which were compatible with a pancreatic fistula. Pancreatomagnetic resonance imaging confirmed partial disruption of the pancreatic duct. In successive radiological studies, the persistence of the collection was observed, and the removal of the drain was prevented. ERCP was performed with insertion of a pancreatic stent (photo 1) and papillotomy with good clinical evolution. In subsequent ambulatory CT, the progressive decrease of the retroperitoneal collection was evident. The percutaneous drainage was removed. After 3 months, the pancreatic stent was removed. Discussion Diagnosis of iatrogenic traumatic pancreatic injury is difficult and requires a high degree of caution. Pancreatoresonance is the gold-standard for imaging. The transpapillary placement of pancreatic stents, in selected patients, has a high success rate.