A 68-year old female patient, who had an asymptomatic space-occupying pancreatic lesion that was identified during routine check-up, was admitted to our hospital two years ago. She had hypertension for about 10 years, and her blood pressure was maintained at approximately 130/80 mmHg using oral antihypertensives. The patient had no relevant history of other diseases, surgery, or trauma. No abnormality was found on physical examination. Contrast-enhanced computed tomography revealed a cystic low-density mass with a clear boundary in the pancreatic head that measured approximately 3.1 × 5.0 × 3.4 cm in size and was slightly enhanced. Magnetic Resonance Cholangiopancreatography (MRCP) revealed a cystic long T1 and long T2 signal mass in the body of the pancreas, with thin division walls in the cyst. The pancreatic duct ran at the edge of the mass and was slightly compressed and tortuous. All laboratory examinations including tumor markers were normal.
Since the tumor could become malignant and the patient strongly requested for surgery, central pancreatectomy was performed. During the operation, the gastrocolonic ligament was opened using an ultrasonic scalpel to explore the pancreas. A tumor with a diameter of 5.0 cm was found in the pancreatic body. The splenic artery and vein were dissected 2 cm to the right of the pancreatic mass. The pancreatic neck was incised using a cutting-closure device. The splenic artery and vein were also incised and clamped using hemo-lock clamps. The pancreatic body was dissected using an ultrasonic scalpel at the left edge of the mass, and the main pancreatic duct was revealed. The specimen was removed from the abdominal cavity, and frozen sections showed that the tumor was benign. Subsequently, the section of the pancreatic head was closed using a linear stapler and bridge catheter internal drainage—a novel pancreatic reconstruction technique proposed by our team—was performed (5). During the anastomosis, a silicone pancreatic stent with a length of 20 cm was selected, and two non-absorbable strings were tied at both ends. At the pancreatic tail side, the tube was inserted into the main pancreatic duct (MPD) for 5 cm, and a U-suture parallel to the pancreatic section was placed to buttress the pancreas. Afterwards, the string of the tube was knotted with the U-suture in an interlocking manner for fixation. On the intestinal side, the jejunum was lifted to the ligament of Treitz. A corresponding hole was made on the jejunum, and a purse-string suture was placed around the hole. The catheter was inserted into the intestinal lumen for 5 cm, and the purse-string suture was tightened to close the anastomotic stoma. For further fixation of the pancreatic stent, the string of the catheter was knotted with the purse-string suture. Thus, the bridge catheter internal drainage was successfully created. Finally, an abdominal drainage tube was placed at the pancreatic section and the surgery was completed. Intraoperative bleeding was 100 mL and blood transfusion was not required. Postoperative pathology examination showed that the tumor was a cystadenoma. Routine treatment was administered, and the patient was discharged 10 days postoperatively.
However, 6 months later, the patient was hospitalized again with a chief complain of exudation from the incision site. The patient had noticed consistent exudation from the abdominal incision 1 month after she was discharged. The fluid was colorless, odorless, and transparent with an approximate volume of 30 mL daily. The abdominal wall drainage tube was indwelling at the local hospital. Nonetheless, after conservative treatment for more than half a year, her symptoms persisted. Physical examination showed that a sinus had formed at the abdominal incision, and the surrounding skin was red and edematous. The amylase level in the fluid was 12,311 U/L. Contrast-enhanced computed tomography revealed an encapsulated effusion between the pancreatic head and the abdominal wall. The pancreatic duct at the pancreatic tail was also dilated. The pancreatic parenchyma was atrophic while the pancreatic head was enlarged, which suggested the possibility of pancreatitis. MRCP also revealed a cystic long T1 and long T2 signal shadow in front of the pancreas measuring approximately 2.9 × 1.8 cm, which was attached to the pancreatic neck and the distal pancreatic duct.
To relieve the patient’s symptoms and treat complications, an exploratory laparotomy was performed. After accessing the abdominal cavity through the original incision, a 4 × 4 cm cyst was exposed at the anastomotic stoma of the pancreas. A sinus was formed between the cyst and the abdominal wall. After opening the cyst, the pancreatic duct stent, suture strings, and multiple free hemo-lock clips were found. We considered that the patient was intolerant to these surgical materials, and an exogenous rejection reaction had occurred in the abdominal cavity. The cystic contents were cleared, and the pancreatic stent was pulled out. We injected water along one end of the tube, and several stones measuring 0.3–0.5 cm in size were discharged. A diagnosis of postoperative pancreatic stent stone formation complicated by pancreatic pseudocyst and pancreatitis was made. Subsequently, the jejunum was lifted to the pancreas, and the cyst was anastomosed to the jejunum. During the procedure, another short support tube (5 cm in length) was placed in the MPD of the pancreatic tail in case a stricture develops; however, it was not fixed. Finally, a drainage tube was placed nearby, and the operation was completed. The patient recovered well after surgery and was discharged 7 days postoperatively.
The patient was followed up for half a year. The sinus was closed, and the abdominal incision healed adequately. There were no gastrointestinal complications, such as fatty diarrhea. Furthermore, the patient’s blood glucose level was not elevated, and there was no significant weight loss.