EXTREME ENDOSCOPY: DIRECT JEJUNOSTOMY, ENDOSCOPIC RE-ANASTOMOSIS OF INTESTINES, PERCUTANEOUS ASSISTED TRANSPROSTHETIC THERAPY (PATENT) IN PATIENT ANASTOMOTIC DEHISCENCE AND COMPLEX PLEUROPERITONEAL ABSCESS AFTER PANCREATIC SURGERY

A 52-year old female with history of Roux-en-Y gastric bypass underwent resection of a huge pancreatic cystic tumor of the pancreas. Postoperatively an amylase-rich pleural and retroperitoneal fluid collection was noted, which was drained radiologically. Her clinical status was poor, she was septic and her albumin was 1.2 g/L (normal > 3.5). The patient was referred for double balloon (DEB)-ERCP for a suspected pancreatic duct leak. During endoscopy it became evident that the jejunogastric anastomosis was completely disrupted, communicating with a large peritoneo-pleural abscess.

At this moment change in plans became mandatory. First, a direct, DBE assisted-jejunostomy was performed after successfully finding a tiny communication to the jejunum within the disrupted anastomosis. Second, a large bore overtube was inserted per-orally into the abscess cavity and a gastroscope covered with a transparent cap was passed multiple times to remove copious amounts of pus, debris and food. Third, the disrupted bowel was re-anastomosed endoscopically using overtube-assisted technique to deliver a fully covered self-expanding metal stent (SEMS), which was then anchored to the esophagus using an over-the-scope clip to prevent distal migration. And finally, percutaneous assisted transprosthetic endoscopic therapy (PATENT) with another fully covered esophageal SEMS was performed after dilating the skin and muscle with an esophageal balloon. Subsequently Endovac therapy (Endosponge) was done to drain and close the abscessed cavity. The endoscopic interventions lasted 4 hours. On follow-up two months later, the endoscopic stent with its over-the-scope clip was removed and a small remnant anastomotic esophagopleural fistula was repaired using an over-the-scope-clip.