Endoscopic intracavitary pull-through vacuum treatment of an insufficient pancreaticogastrostomy.

A 73-year-old patient underwent pyloruspreserving pancreatic head resection due to a branch-duct type intraductal papillary mucinous neoplasm. At Day 7, repeat laparotomy was performed because of elevated amylase concentrations in the abdominal drains. During the procedure, signs of pancreatitis were observed but no pancreaticogastrostomy leak was seen. Drains provided continuous irrigation. At Day 9 gastric liquid was observed in the drains and 5 days later a computed tomography scan confirmed insufficiency of the pancreaticogastrostomy. As the patient was in a stable clinical condition, continuous irrigation was continued. On endoscopic placement of a jejunal feeding tube at Day 40, broad pancreaticogastrostomy insufficiency with an infected cavity was seen, with visible abdominal drainage (●" Fig.1). Endoscopic vacuum treatment was initiated. A gastric tube was connected to the abdominal drain at its external end, and the drain was then grasped endoscopically in the cavity and drawn out orally. An endosponge (Endo-SPONGE; B-Braun Melsungen AG, Melsungen, Germany) was minimized in size, connected to the gastric tube (●" Fig.2a), and drawn into the cavity under endoscopic view by pulling the gastric tube (●" Fig.2b). The vacuum pump applying a negative pressure of 30mmHg was then connected to the sponge and the sponge was changed twice (at 3-day intervals). The endosponge had a thread attached to enable it to be easily grasped for exchange later. At 8 days after initial sponge placement, a clean cavity with sponge-induced granulation tissue was observed (●" Fig.3). A rubber drain was introduced into the cavity as described above (●" Fig.4) in order to induce tissue granulation and promote cavity healing. The rubber drain was drawn back slowly over 17 days. At 26 days after beginning endoscopic treatment, the anastomotic leak and cavity were completely healed (●" Fig.5).