Postoperative pancreatic fistula successfully treated with "PEG-Like" endoscopic vacuum therapy.

Abstract

One of the latest methods for management of pancreaticogastrostomy (PG) leakage after pancreaticoduodenectomy (PD) is endoscopic vacuum therapy. PD was performed on a 72-year-old man suffering from a nonfunctioning pancreatic neuroendocrine tumor of the head of the pancreas. On postoperative Day 6 after the primary surgery, postoperative pancreatic fistula (POPF) of the PG was revealed. Based on the International Study Group of Pancreatic Fistula recommendations, total parenteral nutrition, a regimen of somatostatin analogs, and intravenous antibiotics were implemented. The patient was qualified for a re-exploration because of the doubtful safety of percutaneous drainage of fluid collection detected in the ultrasonography scan. However, this management was not efficient. Endoscopic vacuum treatment (E-VAC) was initiated. The E-VAC was placed directly into the POPF site using a modified "percutaneous endoscopic gastrostomy (PEG)-like" technique. Over the next few days, the E-VAC was started. The volume of fluid collection from percutaneous drainage rapidly decreased, whereas the volume of E-VAC the following day after vacuum therapy was approximately 1000 mL. There were no signs of leakage of PG confirmed with endoscopy, and there was no fluid collection from peripancreatic drainage. The E-VAC therapy was stopped after 6 days. The patient's general condition improved significantly. There were no abnormalities observable in both clinical and imaging examinations. In selected patients, the "PEG-like" modification can be used successfully in the management of POPF. This technique allows the E-VAC to be placed directly in the POPF site under the endoscopic camera, which is what makes this method safe and efficient.