CASE 16788 Published on 15.06.2020

Percutaneous management of complicated pancreatitis  by pacreatico-gastric fistula formation, portal vein and biliary recanalization

Section

Interventional radiology

Case Type

Clinical Cases

Authors

M. Mizandari, T. Azrumelashvili

Tbilisi State Medical University, New Hospitals LTD, 12, Krtsanisi st, Tbilisi, 0144, Georgia

Patient

54 years, female

Categories
Area of Interest Gastrointestinal tract ; Imaging Technique CT, Ultrasound
Clinical History

54 years old female patient presented with severe abdominal pain. The history was mild abdominal discomfort and slowly advancing diabetes only, revealed a few years ago; no previous abdominal pain attacks were reported.  Laboratory data revealed leukocytosis and increased lipase concentration.  

Imaging Findings

CT revealed giant unenhanced mass, PD dilation, PV non-obstructing thrombus. Two drainage procedures (by  June 11, 2015) collapsed the mass completely and documented PD connection with it. Balloon Assisted Percutaneous Descending Litholapaxy (BAPDL procedure – stone evacuation in duodenum) attempted using mass drain track - July 17, 2015.  PD percutaneous drainage  (completed on second attempt  Aug.13,2015) was performed for BAPDL technical prerequisites creation; transgastric route was selected for pancreatic-gastric fistula creation in case of BAPDL failure.

    After  BAPDL failed attempts (August 27 and Sept 14, 2015)  endoscopy documented the mature pancreatic-gastric fistula creation.

   Later portal vein thrombus became symptomatic and December 21, 2015 PV percutaneous US&Fluoroscopy guided recanalisation by 14 mm diameter vascular stent implantation was performed. Because of CBD stricture related jaundice patient underwent PTBD November 15, 2016, followed by biliary dilatation (in January 16, 2017) and biliary stenting (March 24, 2017).

Discussion

PD obstruction related chronic recurrent pancreatitis is a life-threatening condition, which may lead to significant morbidity and even mortality. Persistent high pressure in PD leads to acinar cells atrophy, islets aggregation and pancreatic parenchymal fibrotic changes which engender exocrine and endocrine insufficiency [1,2,3] Complications, such as peripancreatic fluid collection formation, portal vein thrombosis, biliary stricture with jaundice and cholangitis may develop in such patients. The main idea of adequate treatment of primary problem in such patients is the reestablishment of  PD and GI tract normal connection; the traditional way of it is surgery, including pancreatic duct surgical drainage, cysto-entero or pancreatic-enteroanastomosis [9, 13, 14].  In cases of concomitant complications, such as peripancreatic infected or painful cystic collections formation, PVT and biliary stricture, surgery is associated with high morbidity and low-invasive techniques should be widely used [15,17]. Low-invasive treatment means endoscopic techniques, including recently established EUS guided PD interventions [10, 11,12] and  image-guided percutaneous techniques  [16, 18]

   The reported case shows percutaneous management of PD stone obstruction induced pancreatitis and it’s complications.  Although the drainage of  peripancreatic mass (it happened to be a hemorrhagic pseudocyst, which most likely became symptomatic after internal bleeding) improved the situation regarding pancreatitis , only PD and GI tract reconnection by pancreatic-gastric fistula creation enabled to finally withdraw the drainage catheters. Good clinical result regarding pancreatitis has been achieved shortly after successful drainages; in few weeks improvement has been achieved regarding pancreatic atrophy related diabetes also. PV and biliary stenting helped to manage pancreatitis complications.  The main problem-solving intervention is PD percutaneous drainage, which is a novel approach and is performed in our clinic routinely in selected cases. In literature this procedure is reported as sporadic cases only [4,5,6,7,8]; the total number of reported cases is 8.

On follow-up studies, patient was in a good general condition, presented with no pancreatitis, improved blood sugar level, open PV and biliary tree. She was lost for follow up after June 2018

Differential Diagnosis List
The main pancreatic duct obstruction related pancreatitis
Cystic tumor of the head of pancreas
Pancreatic pseudocyst
Hemorrhagic pancreatic pseudocyst
Peripancreatic abscess
Echinococcal cyst
Final Diagnosis
The main pancreatic duct obstruction related pancreatitis
Case information
URL: https://www.eurorad.org/case/16788
ISSN: 1563-4086