Laparoscopy Assisted Transjejunal

Division of GI and Hepatology and
2
Department of Surgery, Mayo Clinic. Rochester, MN, USA
ABSTRACT
Context Pancreaticopleural fistula is a rare complication estimated to occur in 0.5% of the patients with pancreatitis and even
extremely rare in surgically altered anatomy (e.g. Roux-en-Y anastomosis) patients. The conventional ERCP is difficult to treat
pancreaticopleural fistula in a patient with complex upper GI anatomy because of long anatomical route. Case report We represent a
case of a 47-year-old female with remote subtotal gastrectomy with Roux-en-Y gastrojejunostomy admitted with recurrent left
pleural effusion due to pancreaticopleural fistula. After failed ERCP through the anatomical route, pancreaticopleural fistula was
treated successfully with laparoscopy-assisted transjejunal ERCP. Conclusion Laparoscopy-assisted ERCP is a useful modality in
patients with surgically altered anatomy.
INTRODUCTION
ERCP is challenging in patients with surgically altered
anatomy [1, 2], this is because of the distance needed
to be traversed, looping, and lack of side-viewing
capability. Although a percutaneous approach allows
access to the biliary tract it is generally not useful for
accessing the pancreatic ductal system. We describe
laparoscopy-assisted transjejunal ERCP to allow
successful treatment of a pancreaticopleural fistula.
CASE REPORT
A 47-year-old female with a history of chronic
alcoholic pancreatitis and remote subtotal gastrectomy
with Roux-en-Y gastrojejunostomy was referred to for
management of a pancreaticopleural fistula. The patient
presented with worsening dyspnea. Thoracentesis of a
large left pleural effusion was done showing a
markedly elevated amylase (138.000 IU/L). MRI
revealed a pancreatic pseudocyst with a
pancreaticopleural fistula (Figure 1). The patient
required daily therapeutic thoracentesis because of a
shortness of breath.
Initial ERCP was attempted using a standard pediatric
colonoscope (PCF-Q180AL, Olympus Corporation,
Center Valley, PA, USA). The jejunojejunostomy was
reached. Subsequently, the major papilla was
identified. Unfortunately, because an en face view of
the major papilla could not be achieved
pancreatography was unsuccessful. The following day
the patient underwent laparoscopic assisted ERCP.
In the operating room under general endotracheal
anesthesia, a total of three trocars were placed. A
Hasson trocar was placed in the infraumbilical position
with moderate difficulty due to adhesions but there
were no complications or bowel injury.
An additional two ports were placed in the right side; a
10/12-mm port in the subcostal position and a 5-mm
port approximately 8 cm inferior to this. Since it was
difficult to determine which limb was the afferent limb,
Received November 18th, 2009 - Accepted December 3rd, 2009
Key words Anastomosis, Roux-en-Y; Cholangiopancreatography,
Endoscopic Retrograde; Hydrothorax; Pancreatic Fistula /therapy
Correspondence Todd H Baron
Division of GI and Hepatology, Mayo Clinic, 200 First Street, SW,
Charlton 8A, Rochester, MN 55905, USA
Phone: +1-507.266.6931; Fax: +1507.266.3939
E-mail: baron.todd@mayo.edu
Document URL http://www.joplink.net/prev/201001/18.html
Figure 1. MRI showing a leak from the main pancreatic duct (narrow
arrow) into fluid tracking superiorly toward the left pleural space
(wide arrow).

Page 2
JOP. J Pancreas (Online) 2010 Jan 8; 11(1):69-71.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 11, No. 1 - January 2010. [ISSN 1590-8577]
70
a pediatric colonoscope was inserted transorally while
observing intra-abdominally. The biliopancreatic limb
was then identified. Following this, the bowel was
easily drawn up to the abdominal wall through the right
subcostal laparoscopic port. A longitudinal enterotomy
was performed and tacked to the skin in the right
subcostal area using four 3-0 silk sutures. A
therapeutic-channel video duodenoscope (TJF-160VF,
Olympus Corporation, Center Valley, PA, USA) was
introduced into the enterotomy and advanced to the
level of the major papilla, which was only
approximately 20 cm from the enterotomy. Using
portable C-arm fluoroscopy the pancreatic duct was
easily cannulated and pancreatography was performed.
The main duct was without obvious stricture.
Extravasation of contrast was seen at the mid
pancreatic duct (Figure 2). A hydrophilic guidewire
was advanced beyond the leak to the tail of the
pancreas. A 7-French, 12-cm pancreatic duct stent was
placed across the leak (Figure 3). A pancreatic
sphincterotomy was performed using a needle knife
over the pancreatic duct stent. The bowel was then
freed from the skin and the enterotomy was closed.
Post-operatively, the patient did not require additional
thoracentesis and discharged home 5 days later. She
continued to improve and a follow-up chest X-ray one
month later showed near complete resolution of the
pleural effusion. The pancreatic stent was removed
using the pediatric colonoscope in the ERCP suite with
moderate sedation. A pancreatogram was not
performed, again because the papilla could not be seen
en face. Then patient continues to do well 2 months
later.
DISCUSSION
To our knowledge this is the first case report of
laparoscopic assisted transjejunal ERCP.
In patients with complex upper GI tract anatomy per
oral ERCP is challenging because of the long-length
anatomy, endoscopic stability and lack of side-viewing
endoscopes.
Intraoperative ERCP is usually performed in patients
with Roux-en-Y gastric bypass in which the papilla is
usually not accessible endoscopically [3]. The excluded
stomach is accessed to allow anterograde endoscope
passage to the papilla. In our case the only
intraoperative option was a transjejunal approach.
Intraoperative transjejunal ERCP using an open
approach with a small incision was first reported by
Mergener et al. [4]. In that case successful biliary
intervention was performed in a patient with a Roux-
en-Y hepaticojejunostomy. It is important to note that
in this case the papilla could be reached in order to
retrieve the stent without need for a second
laparoscopic procedure. If this was not the case,
another option would have been to place a
nasopancreatic tube at the time of laparoscopically-
assisted ERCP. The nasopancreatic tube could have
been withdrawn non-endoscopically when the leak was
confirmed to be closed by contrast injection through
the tube. This case confirms the feasibility of
laparoscopic transjejunal ERCP and is useful in
selected cases when pancreatic intervention is required.
Since these procedures require expertise in
laparoscopic surgery and ERCP, they are likely to be
useful for a limited number of patients and probably
best performed in a tertiary center.
Conflict of interest The authors have no potential
conflicts of interest
References
1. Feitoza AB, Baron TH. Endoscopy and ERCP in the setting of
previous upper GI tract surgery. Part II: postsurgical anatomy with
alteration of the pancreaticobiliary tree. Gastrointest Endosc 2002;
55:75-9. [PMID 11756919]
2. Feitoza AB, Baron TH. Endoscopy and ERCP in the setting of
previous upper GI tract surgery. Part I: reconstruction without
Figure 2. Radiographic image showing endoscope in position passed
retrograde. A pancreatic leak is identified and is identical to the MRI.
Figure 3. Radiographic image following placement of a 7Fr
transpapillary stent across the pancreatic leak.

Page 3
JOP. J Pancreas (Online) 2010 Jan 8; 11(1):69-71.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 11, No. 1 - January 2010. [ISSN 1590-8577]
71
alteration of pancreaticobiliary anatomy. Gastrointest Endosc 2001;
54:743-9. [PMID 11726851]
3. Dapri G, Himpens J, Buset M, Vasilikostas G, Ntounda R,
Cadière GB. Laparoscopic transgastric access to the common bile
duct after Roux-en-Y gastric bypass. Surg Endosc 2009; 23:1646-8.
[PMID 19343441]
4. Mergener K, Kozarek RA, Traverso LW. Intraoperative
transjejunal ERCP: case reports. Gastrointest Endosc 2003; 58:461-3.
[PMID 14528232

There are no products listed under this category.