Endoscopic clipping of gastrojejunostomy leakage following Whipple procedure: A case report

Abstract

BACKGROUND

Currently, perioperative complications of classic Whipple surgery occur at a rate of approximately 40%. Common complications include delayed gastric emptying, pancreatic fistula, and bile leakage, whereas gastrojejunostomy (GJ) leakage is rare.

CASE SUMMARY

This case report will assess the management of a GJ leak in a 71-year-old male patient following the Whipple procedure. After surgery, the patient was transferred to the clinic after four days of intensive care, where vacuum therapy was used to handle a developing subcutaneous collection. The patient, who had bile in the drains and incision during follow-up, underwent endoscopic examination on the 21^st day after the operation. An opening of approximately 4 mm was observed in the GJ anastomosis during endoscopy. Five titanium clips were used to close the openings. The drainage of bile decreased to less than 50 mL on the first day after the procedure, and the patient's oral intake was opened.

CONCLUSION

Current literature reports a GJ leakage rate of 0. 54% following Whipple surgery, with clinical findings lasting on average between 4-34 days. Surgery was the main form of therapy for this case, with a success rate of 84%, and percutaneous drainage was also utilized as a treatment option. This case report is the first to document endoscopic treatment of GJ leaks following the classic Whipple procedure.

Key Words: Pancreas cancer; Whipple procedure; Gastrojejunostomy; Leakage; Endoscopic management; Case report

Core Tip: Gastrojejunostomy leakage post-Whipple procedure, although rare, presents significant management challenges. This case highlights the successful endoscopic application of titanium clips to close leakage in a 71-year-old patient, marking a novel approach for treating such complications. Typically managed through surgery or percutaneous drainage with an 84% success rate, this report introduces endoscopy as a viable and less invasive option. Early intervention and adoption of such innovative techniques could potentially enhance recovery outcomes, emphasizing the importance of considering endoscopic treatment in similar clinical scenarios.

INTRODUCTION

Whipple surgery pancreaticoduodenectomy (PD) is a major procedure used for both benign and malignant tumors in the periampullary region. It has a 5% mortality rate and up to 40% morbidity rate, even with advanced surgical methods and intensive care[1,2].

Whipple surgery can be performed using two techniques: Gastrojejunostomy (GJ) (classic PD) or duodenojejunostomy (DJ) and pylorus-preserving PD (PPPD)[3]. Anastomotic leakage occurs in approximately 10%-20% of pancreaticojejunostomy (PJ) cases and 3% of hepaticojejunostomy cases[4]. Anastomotic leakage of the GJ or DJ after PD is uncommon but can be severe and challenging to manage. The rate ranges from 0.54% to 1% in literature for GJ or DJ[5,6].

The rarity and complexity of GJ leakage after Whipple surgery necessitate enhanced clinical understanding. This report introduces an endoscopic solution for such a complication in a 71-year-old male, a novel approach in clinical practice. Through this case and literature review, we aimed to broaden the knowledge on management strategies and the potential of endoscopic repair in similar cases.

CASE PRESENTATION

Chief complaints

Approximately 500 mL of bile was drained from the incision site and drains of a patient who underwent an open Whipple operation for a pancreatic head tumor, starting on the postoperative seventh day.

History of present illness

The patient, whose American Society of Anesthesiologists physical status classification score was 3 and body mass index: 30.8, was taken to the open, classical Whipple operation. The operation time was 300 minutes, and the estimated blood loss was 150 mL. During the operation, the two erythrocyte suspensions and fresh frozen plasma were replaced. Postoperatively, the patient was transferred to the intensive care unit as intubated. Bleeding from the gastroenterostomy line was detected in the endoscopy performed after active hemorrhagic content was seen in the nasogastric tube on the first postoperative day. Bleeding was controlled using endoscopic adrenaline injection. The patient was extubated on the 2^nd postoperative day and transferred to the clinic on the 4^th postoperative day.

Vacuum closure treatment was applied to the patient, who was discharged from the incision site on the 7^th postoperative day, as extralumination and collection were not observed on oral contrast-enhanced computed tomography (CT) (Figure 1).

Figure 1 Computed tomography evaluation when subcutaneous collection was observed. The marked area shows the collection.

On the 21^st postoperative day, the discharge was distinctly bilious, with a flow rate of 500 mL. A control endoscopy decision was made because the pancreatic stent was placed outside the parenchyma and there was significant fluid collection around the gastroenterostomy line on control CT (Figure 2). During examination, an opening of approximately 4 mm was observed in the gastroenterostomy line. The opening was closed using five titanium clips (Figure 3). At this point, we hypothesized that adrenaline injections might interfere with anastomotic blood supply, leading to fistula formation.

Figure 2 Control computed tomography imaging. The image shows a displaced pancreatic stent.

Figure 3 Endoscopic clipping. Gastroenterostomy opening closure.

History of past illness

Approximately one month ago the patient presented with mechanical icterus (total bilirubin level 7 mg/dL) and underwent endoscopic ultrasonography, CT, and magnetic resonance cholangiopancreatography (Figure 4). The intrahepatic bile ducts were normal, and the common bile duct measured 12 mm in diameter. An approximately 23 mm lesion was detected in the uncinate process of the pancreatic head. The major vascular structures were also preserved. A plastic stent was placed in the common bile duct to lower the bilirubin levels. Five days after the procedure, the patient underwent Whipple operation using the classical technique. The patient was extubated on the 2^nd postoperative day and taken to the clinic on the 4^th day.

Figure 4 Preoperative imaging. A: Preoperative magnetic resonance cholangiopancreatography examination. The marked area indicates the absence of contrast in the distal common bile duct; B: Preoperative upper abdominal magnetic resonance imaging examination. The marked area shows the pancreatic mass.

Personal and family history

The patient denied a family history of malignant tumors. The patient had a history of undergoing cholecystectomy and inguinal hernia repair.

Physical examination

On physical examination, the vital signs were as follows: Body temperature, 37.1 ℃; blood pressure, 123/77 mmHg; heart rate, 103 beats per min; respiratory rate, 21 breaths per min. During the abdominal examination, the incision remained intact, but there was an opening in the umbilicus for the vacuum-assisted dressing to get inside (Figure 5). There was a total of over 500 mL of bile from the drains and incision. No obvious signs of peritoneal irritation were noted. Patients can be mobilized and perform breathing exercises.

Figure 5 Physical examination findings. A: Opening in the incision; B: Vacuum assisted closure therapy.

Laboratory examinations

When endoscopic intervention was performed, white blood cell was 9.34 × 10³ cells/uL, hemoglobin was 11.1 g/dL, and total bilirubin was 1.45 mg/dL. Liver and renal function tests were normal. There was no acidosis in arterial blood gas examination, respiratory parameters were normal.

Imaging examinations

Gastroscopy was performed for diagnostic purposes because of the presence of collection and minimal air density in the gastroenterostomy line, as shown in the CT scan. 4 mm fistula openings in the gastroenterostomy stapler line were closed using five titanium clips during the examination.

Further diagnostic

Following the identification of excessive biliary drainage and suspected fistula, further diagnostic steps were initiated. Radiological and endoscopic examinations were conducted on the 21^st postoperative day, which confirmed a fistula along the staple line. Gastroscopy revealed a 4 mm fistula within the gastroenterostomy line. Subsequent imaging, including a CT scan, highlighted the minimal air density near the site, indicating the presence of a fistula. This comprehensive diagnostic approach facilitated targeted intervention and guided successful closure of the fistula using titanium clips during endoscopy.

FINAL DIAGNOSIS

The final diagnosis for the patient was a post-Whipple GJ fistula. This diagnosis was established after the detection of biliary fluid leakage from the surgical site and confirmation of a fistula along the gastroenterostomy staple line through endoscopic examination.

TREATMENT

On the initial day after the procedure, the patient's bile drainage decreased to less than 50 mL. No bile-like fluid was observed in the vacuum dressing applied through the incision. On the third day post-procedure, the patient resumed oral intake, and drains were removed.

OUTCOME AND FOLLOW-UP

The fistula was successfully managed using endoscopic treatment. The patient resumed oral intake the day after the procedure. The patient was in good general condition, with stable vital signs.

DISCUSSION

Labori et al[5] reported gastroenterostomy leakage rates of 0.74% following Whipple operation. Furthermore, PJ leakage was detected in 50% of the cases. Eighty-four percent of the cases were managed surgically, with a mortality rate of 15%. In the context of gastroenterostomy leaks, which are uncommon according to the literature, we did not observe a leak in the PJ and decided to perform endoscopic management.

Studies have highlighted that low preoperative hemoglobin levels and a history of radiotherapy are significant risk factors for gastroenterostomy leaks following the Whipple operation[7]. Preoperative blood urea nitrogen/creatinine ratio and perioperative blood transfusion were associated with gastroenterostomy leaks[6]. The preoperative hemoglobin level and renal function in our patient were within the normal ranges. Two units of erythrocyte suspension was transfused during surgery.

The emergence of symptoms after GJ varies between 4 and 34 days according to the literature. In terms of surgical technique, no statistical difference has been observed in the literature between GJ/DJ leaks in classic PD and PPPD[3]. Likewise, according to the literature, there is no statistically significant difference in the leakage rate in gastroenterostomies performed with a stapler or handsewn[8]. We think that the findings in our patient emerged on the 7th postoperative day. We performed anastomosis using a stapler.

In 84% of the cases, laparotomy was performed to manage gastroenterostomy leaks following Whipple. Percutaneous drains inserted by interventional radiologists have also been used as management techniques. Regarding endoscopic management, only one esophagectomy case involved the use of a stent as an advanced endoscopic technique[5,7,8]. There is only one report available on endoscopic treatment. An endoscopic stent was used to manage a post-Whipple DJ leak in a patient who had undergone esophagectomy[9]. In this context, we believe we are the first to report a case of managing a GJ leak following the Whipple procedure using the endoscopic clip method.

The endoscopic treatment of GJ leaks has also been documented in cases of bariatric surgery and gastrectomy for gastric cancer. The defect diameter for endoscopic treatment should be less than 2 cm, and the separation should be less than 70% of the lumen[10]. Options such as fibrin material spraying[11], endoscopic suturing[11], stenting[12], and endoscopic vacuum-assisted closure[13] are technically available. The efficacy of these techniques varies, and decisions should be based on clinical findings and experience.

This case report has several limitations. Firstly, it is based on a single patient, which limits the generalizability of the findings. The clinical outcomes observed may not be representative of a broader patient population undergoing similar procedures. Secondly, as a retrospective analysis, the study is subject to inherent biases and limitations related to data collection and analysis. The specific clinical environment and conditions under which the observations were made may also affect the results. Furthermore, the long-term efficacy and safety of the endoscopic clipping technique used in this case require further investigation through prospective studies involving a larger cohort of patients. Additionally, this case report does not include a comparative analysis with other treatment options, which makes it difficult to fully assess the advantages and disadvantages of the endoscopic approach. More extensive and comparative research is needed to better understand the potential benefits and limitations of this technique in the management of GJ leaks after Whipple procedure.

CONCLUSION

In this extraordinary case, we describe the first reported instance of managing a GJ leak following Whipple surgery via endoscopic clipping. This novel approach shows the potential of less invasive endoscopic techniques than traditional surgical interventions for such complications. Our experience emphasizes the importance of considering endoscopic methods in the management of post-Whipple anastomotic leaks, potentially offering a safer and more efficient alternative to conventional surgical repair. This case contributes significantly to the existing literature by suggesting a paradigm shift in the treatment strategy for GJ leaks after the Whipple procedure.