Endoscopic Management of an Acute Postsurgical Fluid Collection

CASE REPORT Endoscopic management of pancreatic and postoperative fluid collections is increasingly preferred over surgical or percutaneous approaches due to minimal invasiveness and high success rates. Traditionally delayed until collections mature (4–6 weeks), recent studies suggest that early endoscopic ultrasound (EUS)-guided drainage can be safe and effective.1–3 This case demonstrates successful endoscopic management of a 15-day-old postoperative fluid collections with concomitant biliopancreatic leak. A 71-year-old man with adenocarcinoma in D3 underwent resection and duodenojejunostomy. Surgery was challenging due to morbid obesity (body mass index 39) and tumor proximity to the ampulla, requiring cholecystectomy for biliary access and ampullary identification. Although afebrile, on postoperative day (POD) 12, the patient developed increasing bilious surgical-drain output with polymicrobial cultures, elevated serum bilirubin (8.1 mg/dL), and leukocytosis. Antibiotics were initiated, and Gastroenterology was consulted for consideration of endoscopic management with a working diagnosis of anastomotic leak, biliopancreatic leak, or biliary obstruction. Esophagogastroduodenoscopy and EUS on POD 14 confirmed common bile duct dilation and suture dehiscence at the blind stump of the duodenum (Video 1). An EUS-guided rendezvous approach on POD 15 revealed a bile leak from suture dehiscence with ampullary obstruction near the blind limb. After multidisciplinary discussions, an endoscopic approach was favored over radiologic interventions due to the absence of intrahepatic duct dilation on magnetic resonance cholangiopancreatography, and over surgical revision, as the only salvage therapy contemplated was a pancreaticoduodenectomy. Thus, an endoscopic approach was pursued to avoid potential major surgery. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Endoscopic management of an acute postsurgical fluid collection with concomitant biliopancreatic leak.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_qtgkkbvz"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Given that the ampulla could not be directly visualized endoscopically but appeared within the duodenal stump on cholangiogram, we opted against endoscopic closure of the dehiscence. Using an EUS-guided rendezvous approach on POD 15, we placed a biliary stent to divert bile into the cavity, relieving obstruction and facilitating future ampullary identification. In addition, multiple plastic stents were placed endoscopically via the duodenal stump dehiscence to promote drainage of retroperitoneal fluid directly into the duodenal lumen. At postoperative week 6, the patient developed a pseudocyst, managed via EUS-guided cystogastrostomy. In retrospect, this pseudocyst likely resulted from an early postoperative pancreatic leak, suggested by elevated amylase levels in the initial surgical-drain fluid analysis. This pancreatic leak also explains the isolated common bile duct dilation without pancreatic duct dilation observed on initial EUS. At 3 months postoperative, a repeat endoscopic retrograde cholangiopancreatograph was performed. The ampulla, located at the distal portion of the stump, was not visualized with a side-viewing scope and was only seen en face using a forward-viewing scope, making sphincterotomy technically challenging. Therefore, a metal stent was placed to maintain bile duct patency and to redirect the ampulla into the duodenal lumen. Subsequent endoscopic retrograde cholangiopancreatograph at 6 months postoperative confirmed closure of the dehiscence and successful intraluminal ampulla redirection. After stents removal, the patient remained asymptomatic, with imaging showing resolution of all collections. This case demonstrates successful endoscopic management of an acute (15-day-old), nonwalled-off postoperative collection with concomitant biliopancreatic leak, avoiding potential major surgery. DISCLOSURES Author contributions: MK Douedari: conception and design of the case report, collected patient data, drafted the manuscript, edited the video content, and narrated the voiceover. N. Chokshi: assisted in video editing and data collection. R. Tarakji: assisted in literature review and data collection. M. Berzosa: supervised the conception, design, and execution of the case report, and is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.