Abstract
The patient was an 82-year-old man who had undergone pancreaticoduodenectomy (PD-IIA-2, D1) for intraductal papillary mucinous neoplasm in the pancreatic head in September 2013. Intraoperative findings were that the pancreas was soft without dilatation of the main pancreatic duct, and the postoperative course was uneventful including the absence of a pancreatic fistula.
In December 2013, he was admitted to our hospital because of acute cholangitis with disseminated intravascular coagulation (DIC). When he started to take foods orally after conservative treatment of DIC, the serum amylase level became elevated.
Abdominal CT and MRCP showed fluid collections within the jejunal wall and also dilatation of the remnant main pancreatic duct at the level of the pancreatojejunostomy. We considered that the both findings indicated anastomotic site occlusion. Although the site of anastomosis was difficult to identify, a single-balloon enteroscopy revealed a submucosal bleb consisting of the intramural fluid collection. After performing direct puncture at the submucosal bleb, the anastomotic stricture and the remnant pancreatic duct could be radiologically visualized with contrast injection. Then, the stricture was resolved with a balloon dilation following a needle knife incision. The serum amylase and the diameter of the remnant main pancreatic duct were normalized soon after the treatment. Single balloon enteroscopy enabled the anastomosis site to be endoscopically accessed even in a patient with surgically altered anatomy after pancreaticojejunostomy. Also, the anastomotic stricture could be resolved with the combination of incision and balloon dilatation.
