Ann Hepatobiliary Pancreat Surg.  2020 May;24(2):228-233. 10.14701/ahbps.2020.24.2.228.

Management of intractable pancreatic leak from iatrogenic pancreatic duct injury following resection of choledochal cyst in an adult patient

• Choi JU
• Hwang S
• Chung YK

• KMID: 2500811
• DOI: http://doi.org/10.14701/ahbps.2020.24.2.228

Abstract

Iatrogenic pancreatic duct injury can occur during resection of the choledochal cyst (CC). We herein present a case of postoperative pancreatic fistula (POPF) developed after resection of the CC in an adult patient with variant anomalous union of pancreatobiliary duct. The 55-year-old female patient underwent surgery after the diagnosis of CC-associated gallbladder cancer. During surgery, the CC mass was accidentally pulled out, by which the intrapancreatic CC portion was torn out from the main pancreatic duct. Since the pancreatic duct stump was not identified due to its small size, repair was not possible. The excavated defect at the pancreas head was closed securely combined with insertion of multiple drains. Postoperative POPF and peripancreatic fluid collection developed and the patient had to be fasted for 4 weeks. She was first discharged at 6 weeks after surgery. At 10 weeks, she was readmitted due to progression of peripancreatic fluid collection, which was controlled by percutaneous drain insertion. At 6 months, she was readmitted again due to repeated progression of peripancreatic fluid collection, which were controlled by endoscopic transmural duodenocystostomy. It took 8 months to resolve the pancreatic duct injury-associated pancreatitis. The experience in this case suggests that iatrogenic pancreatic duct injury during resection of CC can induce catastrophic complications, thus special attention should be paid to prevent pancreatic duct injury.

Keyword

Pancreatic leak; Iatrogenic injury; Resection; Anomalous union of pancreatobiliary duct

Figure

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  Fig. 1 Preoperative radiologic findings. The computed tomography scan showed highly suspected gallbladder cancer arising from the intracystic papillary neoplasm with underlying choledochal cyst (A). Magnetic resonance cholangiopancreatography showed choledochal cyst combined with anomalous union of pancreatobiliary duct (B).

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  Fig. 2 The extent of resection overlapped at the magnetic resonance cholangiopancreatography image. A green bidirectional arrow was the preplanned transection line. The red thick dotted line indicates the main pancreatic duct and the blue thin dotted line indicates the accessory pancreatic duct. The yellow dotted area indicates the actual extent of resection.

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  Fig. 3 Gross photographs of the resected specimen. There was a 6 cm-sized adenocarcinoma arising in the intracystic papillary neoplasm (A). The choledocal cyst was free of malignant changes (B).

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  Fig. 4 Postoperative computed tomography (CT) findings. (A) The 5-day CT showed pancreatitis with peripancreatic fluid collection. (B) The 10-day CT showed exacerbation of acute pancreatitis. (C) The 4-week CT scan showed progressive resolution of pancreatitis and peripancreatic fluid collection. (D) The 6-week CT scan showed further improvement of pancreatitis.

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  Fig. 5 Postoperative computed tomography (CT) and magnetic resonance imaging findings. (A) The 10-week CT showed progression of peripancreatic necrotic collection. (B) The 14-week CT scan showed liver abscess at the left liver (arrow). (C) Magnetic resonance cholangiopancreatography image showed no abnormality at the intrahepatic bile duct and dilation of the remnant accessory pancreatic duct. (D) The 17-week CT showed resolution of liver abscess and improvement of peripancreatic necrosis.

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  Fig. 6 Postoperative computed tomography (CT) findings. (A) The 6-month CT scan showed increased complicated fluid collection. (B) Endoscopic ultrasonography-guided transmural duodenocystostomy was performed to drain the peripancreatic fluid collection (arrow). (C) The 8-month CT scan showed marked decrease of pancreatic pseudocyst with further dilation of the pancreatic duct and atrophy of the pancreatic parenchyma. (D) The 12-month CT scan showed complete resolution of pancreatitis.

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