Iatrogenic Jejunal Perforation during Duodenal Stricture Dilatation Secondary to Groove Pancreatitis

Abstract

A 35 y/o female with a history of alcoholic chronic pancreatitis was transferred for open surgical repair of an iatrogenic, proximal jejunal perforation during endoscopic balloon dilatation of a presumed benign duodenal stricture. Three months previously, she had undergone gastrojejunostomy secondary to duodenal obstructive symptoms. The stricture was located in the duodenal c-sweep and perforation occurred just distal to the stricture in the afferent jejunal limb while attempting retrograde dilation. Following primary closure, the patient underwent an MRI to evaluate the stricture and a focal 1.5 cm fluid collection was found in the pancreatic head adjacent to the second portion of the duodenum with associated pancreatic head enlargement. EUS revealed mass-like enlargement of the pancreatic head with a focal 1.5 cm fluid collection and chronic inflammatory changes in the body and tail. EUS-FNA of the fluid collection and surrounding pancreatic parenchyma revealed cell block portions featuring spindle cell proliferation with nuclear atypia, marked cellularity and high mitotic activity. Based on subsequent immunohistochemistry, the pancreatic head lesion appeared to be a malignant spindle cell neoplasm with smooth muscle differentiation. Uneventful pancreaticoduodenectomy was performed three months following her perforation. Pathology revealed fibrosis of the adjacent pancreas, Brunner's gland hyperplasia, and bundles of smooth muscle within the duodenum that were interspersed with dilated ducts containing inspissated secretions. All findings were consistent with a diagnosis of paraduodenal pancreatitis, or groove pancreatitis. Groove pancreatitis is a rare form of segmental chronic pancreatitis that involves the anatomic space between the head of the pancreas, the duodenum, and the common bile duct. It has been associated with alcoholic chronic pancreatitis and its etiology is thought secondary to disruption of normal pancreatic secretory flow via the minor papilla. The differential diagnosis of patients with external duodenal compression, chronic pancreatitis, and pancreatic head fullness should include groove pancreatitis. This is the first reported case of iatrogenic perforation during endoscopic treatment of a duodenal stricture secondary to groove pancreatitis.