Gastrointestinal perforation caused by a pancreaticojejunal anastomotic stent: a postoperative case report following pancreaticoduodenectomy

Introduction

Postoperative pancreatic fistula (POPF) is a common complication following pancreaticoduodenectomy (PD), with an incidence ranging from 10–20% in large medical centers (1). However, the incidence of POPF is higher in patients with a soft pancreatic texture and no significant dilation of the main pancreatic duct (2,3). In such cases, if the main pancreatic duct is not significantly dilated, surgeons often employ a selective internal stent that corresponds to the internal diameter of the duct. This approach aims to reduce the incidence of POPF during the PD procedure by decreasing ductal pressure and directing pancreatic fluid flow, thereby mitigating the risk of anastomotic fistulas.

However, the use of these stents is associated with both immediate and long-term complications. It is well-documented that the prolonged presence of a pancreatic duct stent can lead to pancreatitis and the formation of pancreatic duct stones. Displacement of the stent may also cause additional complications, such as biliary obstruction, intestinal obstruction, biliary tract infection, and bile duct stones (4-8). These complications are primarily a result of the stent’s displacement as a foreign body. While such issues are frequently discussed, there are relatively few reports of perioperative organic injuries, such as perforation, induced by the stent (6,7).

We reported a case of retroperitoneal effusion caused by intestinal perforation due to a stent, which did not undergo significant migration within two weeks after PD. We present this article in accordance with the CARE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-51/rc).

Case presentation

A 59-year-old woman presented to our hospital with epigastric pain and a history of well-controlled hypertension, managed with regular doses of nifedipine and irbesartan. There was no history of other chronic diseases or prior abdominal surgeries.

The patient’s laboratory tests were normal. Tumor indicators were normal. An enhanced computed tomography (CT) scan revealed a moderately enhanced tumor in the head of the pancreas, measuring 3.8 cm × 2.0 cm (Figure 1A). The tumor was located near the superior mesenteric vein (SMV), with possible invasion of the vessel wall. A 3.0 cm × 2.0 cm lesion with calcification was observed posteriorly, at the level of the duodenum (Figure 1B). There was no significant dilatation of the bile or pancreatic ducts.

Figure 1 Enhanced preoperative CT images. (A) The tumor is located in the head of the pancreas near the wall of the SMV. The main pancreatic duct was dilated and thickened. (B) A 3 cm × 2 cm mass was present posterior to the level of the duodenum, which was suspected to be an enlarged lymph node prior to surgery. CT, computed tomography; SMV, superior mesenteric vein.

The preliminary diagnosis was a malignant tumor of the pancreatic head. The patient underwent a radical PD, including SMV resection for reconstruction and resection of the retroperitoneal lesions.

Reconstruction was performed using the Child method. For the reconstruction of the SMV, continuous closure was achieved with polypropylene (4/0) sutures. The pancreaticojejunostomy was constructed using a duct-to-mucosa technique, with a combination of Vicryl (4/0) and polydioxanone (PDS) (5/0) sutures. We chose this anastomotic technique for high-risk patients with a soft pancreatic texture and no significant dilation of the main pancreatic duct.

The posterior wall anastomosis between the jejunum and pancreas was first performed with seven interrupted Vicryl (4/0) sutures (Figure 2A). Subsequently, the pancreatic duct was anastomosed to the jejunal mucosa using four interrupted Vicryl (4/0) sutures. An 8 Fr silicone tube was placed in the Wirsung duct as a support tube (Figure 2B). Serial suturing of the pancreatic duct to the jejunal mucosa was then carried out using polydioxanone (4/0) sutures (Figure 2C). Finally, the anterior wall anastomosis between the jejunum and pancreas was completed with seven interrupted Vicryl (4/0) sutures (Figure 2D), finalizing the pancreatojejunostomy.

Figure 2 Demonstrates the surgical procedure for performing a pancreaticojejunal anastomosis during surgery, taking the approach of duct to the mucosa. (A) After placing the pancreatic duct support tube, 7 interrupted sutures were placed between the posterior wall of the pancreas and the jejunum. (B) The posterior pancreatic duct was sutured to the jejunal mucosa in an interrupted fashion. (C) The anterior inner layer of the duct to mucosa was then performed with a continuous suture with 4/0 polydioxanone. (D) The same 7 interrupted sutures were used to suture the anterior outer wall of the pancreas to the jejunum.

An end-to-side hepaticojejunostomy was performed with continuous absorbable PDS (5/0) sutures. The lateral anastomosis between the stomach and jejunum was completed serially using Vicryl (4/0) sutures.

Pathological examination revealed a moderately to poorly differentiated pancreatic adenocarcinoma (T2N0M0), with invasion of the entire duodenum, involvement of adjacent nerves, and a margin of 1 mm from the portal groove. The venous margins were negative. Additionally, the pathology of an enlarged lymph node in group 16, identified on preoperative enhanced CT, was consistent with a nerve sheath tumor.

The patient’s postoperative drainage fluid amylase was elevated, exceeding the upper limit of the triple serum amylase (110 U/L). On postoperative day (POD) 1, the drainage amylase level peaked at 15,198 IU/L, gradually decreasing thereafter. However, on POD8, the patient developed low back pain, and by POD9, a fever manifested, with a maximum temperature reaching 39 ℃. The amylase level in the drainage fluid increased dramatically to 58,450 IU/L. On POD10, laboratory results indicated a marked increase in inflammatory markers: C-reactive protein (CRP) 169.82 mg/L, white blood cell count (WBC) 16.13×10⁹/L, neutrophils (NE) 15.42×10⁹/L, NE% 95.6%, hemoglobin (HB) 84 g/L, platelet count (PLT) 297×10¹²/L, albumin (ALB) 31.9 g/L. Enhanced abdominal CT imaging revealed a perforated intramural pancreatic duct, with a supporting tube extending from the jejunum, continuing to drain pancreatic fluid into the abdominal cavity. This led to the formation of a localized encapsulated effusion (Figure 3A,3B). An enhanced CT scan on POD6, performed as part of the routine protocol, showed no significant perforation or fluid accumulation at that time (Figure 3C,3D).

Figure 3 Postoperative CT scan of the surgical area. (A,B) Enhanced CT images of the post-operative review, routinely performed on day 7 after PD. It was suspicious to see that the pancreatic duct support tube was not significantly displaced or dropped and punctured out of the jejunum. However, the support tube placed on the jejunal side is perpendicular to the mucosal surface of the jejunum. (C,D) The support tube remained in the pancreas on one side, but the other side had penetrated out of the jejunum and formed a localised effusion in the abdominal cavity. CT, computed tomography; PD, pancreaticoduodenectomy.

The patient underwent an emergency exploration laparotomy, during which the pancreatic duct support tube was removed, and the jejunal perforation was repaired with sutures (Figure 4A-4D). An abdominal drain was placed, with 20 mL of fluid drained on POD20, followed by 5 mL daily from POD21. The drain was removed on POD27.

Figure 4 Emergency surgery was performed following gastrointestinal perforation. The images show the perforation site and the location of the pancreatic duct support tube. (A) Localised perforation of the jejunal wall is seen posteriorly on the contralateral side of the pancreaticojejunal anastomosis. (B) The pancreatic duct support tube is gradually removed and is seen to be filled with clear pancreatic fluid. (C) Localised perforation of the small bowel is seen after removal of the support tube. (D) Photograph of the support tube being withdrawn. The tip with the lateral hole is the support tube placed in the pancreatic duct.

After six months of follow-up, the patient experienced no complications related to the surgery and continued regular chemotherapy.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Pancreatic fistula, a common complication following pancreatic surgery, can lead to several serious issues such as abdominal infections, blood vessel erosion leading to bleeding, and irritation causing gastroparesis (2,9). As a result, surgeons have explored various anastomotic techniques to minimize the occurrence of such complications. Despite these efforts, pancreatic fistula continues to arise, particularly in patients with narrow main pancreatic ducts, even in major medical centers (2,3).

To reduce the risk of POPF, surgeons often place a pancreatic duct stent intraoperatively (10). A silicone tube with side holes is inserted into the main pancreatic duct and the small intestine during the anastomosis. This tube helps drain pancreatic fluid, reducing irritation at the anastomotic site while also lowering pressure in the pancreatic duct. Additionally, the stent serves as a temporary guide during the anastomosis, preventing inadvertent closure of the pancreatic duct by facilitating the proper alignment of the pancreatic tissue and jejunum (11-13).

The use of a support tube during PD to prevent POPF in patients without significant dilation of the pancreatic duct has been supported by several studies (10). However, pancreatic duct stenting carries risks, including the development of pancreatic duct stones, infections, gastrointestinal perforation, and cholangitis. Given these potential complications, several questions arise regarding the necessity of stent placement, the fixation of the stent, and the removal of the stent postoperatively. In this case, we believe there are three possible causes: (I) intraoperatively, a nerve sheath tumor was resected posterior to the horizontal part of the duodenum, which created a local cavity, allowing pancreatic fluid to collect and irritate the intestinal canal, leading to perforation. (II) This patient had undergone SMV reconstruction, and the lack of venous blood return resulted in oedema of the intestinal wall, which was irritated by the stent, leading to perforation. (III) In this case, we used a duct to mucosa pancreaticojejunostomy, and we didn’t fix the support tube intraoperatively, which may have led to greater mobility of the support tube postoperatively, exerting more pressure on the contacting intestinal lumen, leading to perforation. The excessively long pancreatic duct support tube pressed against the bowel wall for a prolonged period of time, and the bowel became irritated and violently peristaltic, leading to local perforation. As intraoperative exploration did not reveal any significant detachment of the pancreaticojejunal anastomosis, the perforation was repaired surgically.

At our center, we employ a non-fixation method for some patients with dilated pancreatic ducts. Following the completion of the anterior wall suture, the support tube is actively removed before the knot is tied. Alternatively, the support tube may be allowed to fall off naturally after surgery, which typically occurs within three months due to the absence of suture fixation. For patients requiring long-term support, we use Vicryl water-soluble absorbable sutures for fixation, which dissolve and are absorbed in approximately 56–70 days. As a result, the pancreatic support tubes in our center are expelled earlier than those reported by Park et al., who used 5/0 PDS sutures with a dissolution time of 454 days (8). In most cases, the tubes are expelled between the 4th and 6th months after surgery. In addition to the suture material, the material of the support tube also influences the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF). The “Huscher technique” using the coronary artery stent (CAS) for support was reported by Huscher et al. (14). The incidence of CR-POPF and support tube displacement was reduced. We hypothesise that this method reduces suture damage to the pancreatic duct and anastomotic irritation by reducing the number of sutures in the pancreatic section. The material is also secured with its own balloon, which prevents fistula and perforation.

Therefore, we need to further investigate the immediate and long-term complications caused by stents and make a trade-off between reducing pancreatic fistula and these complications in high-risk patients.

Conclusions

This case highlights a rare postoperative complication of PD: jejunal perforation associated with a pancreatic duct support tube. Although support tubes help to prevent pancreatic fistula, they may also pose a risk of mechanical injury, particularly in patients with a softer pancreas and undilated pancreatic ducts. The decision to place a support tube, its immobilisation, and the choice of tube type must be individualised. Close monitoring and early recognition are essential for effective management of these complications.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-51/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-51/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-51/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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