Endoscopic Options for Complications after Pancreatic Surgery

Abstract

Background: The shift in surgery is taking place in two directions. On the one hand, it is shifting from open surgery to minimally invasive surgery which will ultimately morph into robot-assisted surgery. On the other hand, the therapeutic possibilities of flexible endoscopy have developed enormously in recent years. Various procedures, such as the debridement of pancreatic necrosis, the resection of early neoplasms, the treatment of achalasia, or the resection of numerous submucosal tumors, have passed into the hands of the interventional endoscopist. Endoscopic procedures have also become established in the management of complications of major intestinal procedures. Despite the fact that endoscopic therapy requires time to heal, for example, in VAC therapy, it being less invasive reduces patient morbidity.

Summary: The most common complications in modern pancreatic surgery are pancreatogenic fistulas and fluid collections, as well as insufficiencies of pancreatointestinal or biliodigestive anastomoses. Such complications can be treated endoscopically using methods such as stent placement in the pancreatic or bile duct, endosonographically guided drainage of fluid collections, and even VAC therapy.

Key messages: Endoscopic intervention is the first procedure of choice offered in the treatment of complications in pancreatic surgery. It primarily reduces morbidity in the recovery phase of patients.

Keywords: Endoscopic retrograde cholangiopancreatography; Endoscopic therapy; Pancreatic surgery; Postsurgical complications; Surgical endoscopy.

Fig. 1.

Fistula after left pancreas resection with fluid retention on ultrasound.

Fig. 2.

a ERP. Probing of the pancreas after left resection up to the pistil opening. b Transpancreatic plastic stent up to the collection.

Fig. 3.

a Endosonographic transgastric puncture of an infected fluid retention after left resection. b Endosonographic transgastric placement of a lumen-apposing metal stents (lams). c Nasocystic irrigation probe through the metal stent.

Fig. 4.

a Insufficient biliodigestive anastomosis. b Two stent insertion in the bile-ducts using a slim colonoscope.

Fig. 5.

a Bleeding from pancreatogastrostomy. b Hemostasis using hemostatic clip.