PMC4560123_01
Pancreatic pseudocyst. Acute pancreatitis repeatedly occurred 1 month after the first operation, and a pancreatic pseudocyst developed at the same site. Enhanced computed tomography (CT) showed a cyst with a diameter of 29 mm in the body of the pancreas
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Fig1
About 1 month after the operation, a PPC developed as a consequence of grade B postoperative pancreatic fistula (POPF) and acute pancreatitis (Fig. 1).
Endoscopic approach for pancreatic pseudocyst. a Two drainage tubes were inserted into the pancreatic pseudocyst and main pancreatic duct through the ampulla of Vater. b Enhanced CT showed that acute pancreatitis and pancreatic pseudocyst had recurred 1 month after endoscopic drainage
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Fig2
Endoscopic drainage was subsequently performed, and two endoscopic nasopancreatic drainage (ENPD) tubes were placed into the PPC and main pancreatic duct (Fig. 2a). One month later, the PPC worsened again (Fig. 2b).
Migration of the ERPD tube into the main pancreatic duct. Endoscopic nasopancreatic drainage (ENPD) tubes were placed again into the main pancreatic duct side by side with the migrated ERPD tube
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Fig3
ERPD tube had migrated into the main pancreatic duct and could not be removed endoscopically. ENPD tubes were placed again into the main pancreatic duct side by side with the migrated ERPD tube (Fig. 3).
Distal pancreatectomy and pancreatojejunostomy (R-Y reconstruction). a The position of the endoscopic retrograde pancreatic drainage tube was checked with US, and the pancreatic body and tail were resected. b The pancreatic drainage tube was inserted from the tail to the duodenum. c Pancreatojejunostomy was performed to drain the pancreatic body and tail followed by R-Y reconstruction
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Fig4
The position of the endoscopic retrograde pancreatic drainage tube was checked with ultrasonography (US) during the operation, and the pancreatic body and tail were resected on the position (Fig. 4a). The migrated ERPD tube was removed smoothly from the cut end (Fig. 4a). Insertion of an external pancreatic drainage stent tube from the cut end into the duodenum through the ampulla of Vater was needed to drain the PPC because we considered the drainage of the pancreatic body to be insufficient (Fig. 4b). A pancreaticojejunostomy was then made between the pancreatic cut end and the jejunum with Roux-Y reconstruction (Fig. 4c).
Disappearance of pancreatic pseudocyst. a The pancreatic pseudocyst was seen on pancreatography through the pancreatic drainage tube. b Enhanced CT showed that the pancreatic pseudocyst had disappeared 4 weeks after the second operation
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Fig5
One month after discharge, the PPC had disappeared completely (Fig. 5a, b), and the external drainage stent was removed.