ENDOSCOPIC MULTIPLE STENTING FOR THE TREATMENT OF ENTERAL LEAKS NEAR THE BILIO-PANCREATIC ORIFICE: AN EXPERIENCE FROM A SINGLE CENTER

Aims To evaluate the clinical outcome of a new endoscopic procedure for complex enteral leaks involving the bilio-pancreatic orifice, inducing the healing through the isolation of the leak and the diversion of all the secretions (biliary and pancreatic).

Methods A fully covered SEMS was placed to seal the leak. Subsequentely bile and pancreatic juice were drained away from the leak, inside the lumen of the enteral metal stent, by placing biliary and pancreatic stents through the meshes of the enteral stent.

Results Between April 2013 and June 2019, 16 consecutive patients (11 M/5 F) treated with this multiple stenting technique were included. In 9 patient with normal upper gastrointestinal anatomy, the leaks involved the second portion of the duodenum near the biliopancreatic orifice (2 Roux-en-Y reconstruction after duodenal diverticulization, 7 surgical primary repair after surgical/endoscopic duodenal perforation), in 7 patient, after Whipple-Child pancreaticoduodenectomy the leaks involved the bilio and/or pancreatico-jejunal anastomosis with perianastomotic jejunal necrosis. A re-do surgery and/or a percutaneous drainage placement were attempted firstly in all the patients. Technical success was 100%, clinical success (healing of the leak) was 94%. The leak healed in 15 patients, one patient died few days after the procedure because of septic shock and massive dehiscence of the duodenum. Stents removal was scheduled 6 weeks after the procedure. An abdominal CT scan was always performed before stents removal to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. Two cases of spontaneous migration of the enteral stent were reported, in two patients that missed the scheduled removal appointment, causing small bowel obstruction treated surgically with enterotomy and removal of the stent complexes.

Conclusions Endoscopic biliary-pancreatic-enteral fluids’ compartmentalization to treat complex enteral leaks is an effective, safe and minimally invasive endoscopic procedure for post-surgical duodenal/jejunal leaks in tertiary referral endoscopic centers.