Decubitus sign of the stent

Small Bowel Perforation Caused by Pancreaticojejunal Anastomotic Stent Migration after Pancreaticoduodenectomy for Periampullary Carcinoma

Giulio Mari, Andrea Costanzi, Nicola Monzio, Angelo Miranda, Luca Rigamonti, Jacopo Crippa, Paola Sartori, Dario Maggioni


Context Pancreaticoduodenectomy is the gold standard for patients with resectable periampullary carcinoma. The protection of the anastomosis by positioning of an intraluminal stent is a technique used to lower the frequency of anastomotic fistulas. However the use of anastomotic stents is still debated and stent related complications are reported. Case report A fifty-three-year old male underwent pancreaticoduodenectomy (PD) for a T2N0 periampullary carcinoma with a pancreaticojejunal (duct to mucosa) anastomosis protected by a free floating 6 Fr Nelaton stent in the Wirsung duct. Twenty-three months after surgery the patient accessed Emergency Department for severe abdominal pain associated to temperature, high white blood cell count and an significant increase in C reactive protein. Method Abdominal CT scan shown the presence of a tubular stent in the mesogastrium/lower right quadrant. No evident free intra-abdominal air was detected. The patient was submitted to explorative laparotomy. After debridement for localized peritonitis the Nelaton trans anastomotic stent was found in the abdomen. There was no evidence of bowel perforation, but intestinal loops covered with fibrin and suspect for impending perforation were resected. Conclusion There is a lack of evidence about the true rate of post-operative complications related to pancreatic stenting. We believe that in patients presenting with abdominal pain or peritonitis that previously underwent PD with stent-guided pancreaticojejunal anastomosis, the hypothesis of stent migration should at least be taken into consideration.

Image: Decubitus sign of the stent.


Intestinal Perforation; Stents

Full Text:



Martin JA, Haber GB Ampullary adenoma: clinical manifestations, diagnosis, and treatment. Gastrointest Endosc Clin N Am 2003; 13:649-669. [PMID: 14986792]

Shinkawa H, Takemura S, Kiyota S, Uenishi T, Kaneda K, Sakae M et al. Long-term outcome of surgical treatment for ampullary carcinoma. Hepatogastroenterology 2012; 59:1010-1012. [PMID: 22580650]

Askew J, Connor S. Review of the investigation and surgical management of resectable ampullary adenocarcinoma. HPB (Oxford) 2013. [PMID: 23458317]

La Torre M, Ramacciato G, Nigri G, Balducci G, Cavallini M, Rossi M et al. Post-operative morbidity and mortality in pancreatic surgery. The role of surgical Apgar score. Pancreatology 2013; 13:175-179. [PMID: 23561976]

Dominguez-Comesaña E, Gonzalez-Rodriguez FJ, Ulla-Rocha JL, Lede-Fernandez A, et al. Morbidity and mortality in pancreatic resection. Cir Esp 2013; 91:651-658. [PMID: 21421096]

Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002; 346:1128–1137. [PMID: 11948273]

Al-Taan OS1, Stephenson JA, Briggs C, Pollard C, Metcalfe MS, Dennison AR et al. Laparoscopic pancreatic surgery: a review of present results and future prospects. HPB (Oxford) 2010; 12:239-243. Review [PMID: 20590893]

Roulin D, Cerantola Y, Demartines N, Schäfer M. et al. Systematic review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg 2011; 15:1055-1062 [PMID: 21267670]

Hackert T, Werner J, Büchler MW. Postoperative pancreatic fistula. Surgeon 2011; 9:211-217. [PMID: 16003309]

Shrikhande SV, D'Souza MA. Pancreatic fistula after pancreatectomy: evolving definitions, preventive strategies and modern management. World J Gastroenterol 2008; 14:5789-5796. [PMID: 18855976]

Molinari E1, Bassi C, Salvia R, Butturini G, Crippa S, Talamini G, et al. Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients. Ann Surg 2007; 246: 281-287. [PMID: 17667507]

Price LH1, Brandabur JJ, Kozarek RA, Gluck M, Traverso WL, Irani S. Good stents gone bad: endoscopic treatment of proximally migrated pancreatic duct stents. Gastrointest Endosc 2009; 70:174-179. [PMID: 19559842]

Choe YM, Lee KY, Oh CA, Lee JB, Choi SK, Hur YS et al. Risk factors of pancreatic leakage after pancreaticoduodenectomy World J Gastroenterol 2005; 11:2456-2461. [PMID: 15832417]

Shrikhande SV, Qureshi SS, Rajneesh N, Shukla PJ. Pancreatic anastomoses after pancreaticoduodenectomy: Do we need further studies? World J Surg 2005; 29:1642-1649. Review [PMID: 7524375]

Zhou Y1, Zhou Q, Li Z, Chen R. Internal pancreatic duct stent does not decrease pancreatic fistula rate after pancreatic resection: a meta-analysis. Am J Surg 2013; 205:718-725 Review. [PMID: 23433889]

Imaizumi T1, Harada N, Hatori T, Fukuda A, Takasaki K. Stenting is unnecessary in duct-to-mucosa pancreaticojejunostomy even in the normal pancreas. Pancreatology 2002; 2:116–121. [PMID: 12123091]

Biehl T, Traverso LW. Is stenting necessary for a successful pancreatic anastomosis? Am J Surg 1992; 163:530–532. [PMID: 1575313]

Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg 2006; 244:10–15. [PMID: 16794383]

Abu Hilal M1, Malik HZ, Hamilton-Burke W, Verbeke C, Menon KV. Modified Cattell’s pancreaticojejunostomy, buttressing for soft pancreases and an isolated biliopancreatic loop are safety measurements that improve outcome after pancreaticoduodenectomy: a pilot study. HPB (Oxford) 2009; 11:154–160. [PMID: 19590641]

Katsaragakis S1, Larentzakis A, Panousopoulos SG, Toutouzas KG, Theodorou D, Stergiopoulos S et al. A new pancreaticojejunostomy technique: A battle against postoperative pancreatic fistula. World J Gastroenterol 2013; 19:4351–4355. [PMID: 23885146]

Takano S, Ito Y, Watanabe Y, Yokoyama T, Kubota N, Iwai S. Pancreaticojejunostomy versus pancreaticogastrostomy in reconstruction following pancreaticoduodenectomy. Br J Surg 2000; 87:423–427. [PMID: 10759736]

Bassi C1, Butturini G, Molinari E, Mascetta G, Salvia R, Falconi M et al. Pancreatic fistula rate after pancreatic resection. The importance of definitions. Dig Surg 2004; 21:54–59. [PMID: 10931023]

Hamanaka Y, Suzuki T. Total pancreatic duct drainage for leak proof pancreatojejunostomy. Surgery 1994; 115:22-26. [PMID: 8284756]

Roder JD, Stein HJ, Böttcher KA, Busch R, Heidecke CD, Siewert JR. Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy: a prospective study. Ann Surg 1999; 229:41-48. [PMID: 9923798]

Layec S1, D'Halluin PN, Pagenault M, Sulpice L, Meunier B, Bretagne JF. Removal of transanastomotic pancreatic stent tubes after pancreaticoduodenectomy: a new role for double-balloon enteroscopy. Gastrointest Endosc 2010; 72:449-451. [PMID: 20541191]

Topazian M, Baron TH, Fidler JL, Chari S. Endoscopic retrieval of a migrated pancreatic stent from the retroperitoneum. Gastrointest Endosc 2008; 67:728-729. [PMID: 18243190]

Rezvani M1, O'Moore PV, Pezzi CM. Late pancreaticojejunostomy stent migration and hepatic abscess after Whipple procedure. J Surg Education 2007; 64:220-222. [PMID: 17706575]

Ammori BJ, White CM. Proximal migration of transanastomotic pancreatic stent following pancreaticoduodenectomy and pancreaticojejunostomy. Int J Pancreatology 1999; 25:211-215. [PMID: 10453422]

Biffl WL, Moore EE. Pancreaticojejunal stent migration resulting in ‘‘bezoar ileus.’’ Am J Surg 2000; 180:115-116. [PMID: 11044524]

Mok KT1, Wang BW, Liu SI. Management of pancreatic remnant with strategies according to the size of pancreatic duct after pancreaticoduodenectomy. Br J Surg 1999; 86:1018-1019. [PMID: 10460636]

Yoshimi F1, Ono H, Asato Y, Ohta T, Koizumi S, Amemiya R et al. Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy in patients undergoing pancreat-oduodenectomy to promote earlier discharge form hospital. Surg Today 1996; 26:665-667. [PMID: 8855507]



Article Metrics

Metrics Loading ...

Metrics powered by PLOS ALM


  • There are currently no refbacks.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

ISSN 1590-8577 | JOP is published by CAB - Center for Libraries at "Federico II" University of Naples using Open Journal System