A Case of Rendezvous Dilation under Laparotomy for Pancreaticojejunostomy Stricture after Pancreaticoduodenectomy

Abstract

Introduction: Pancreatico-enterostomy stenosis is a late postoperative complication following pancreaticoduodenectomy. We report a case in which a surgical "rendezvous" procedure was performed to address the stenosis.

Case presentation: A 20-year-old woman underwent laparoscopic pancreaticoduodenectomy for a solid pseudopapillary neoplasm in the pancreatic head. During the follow-up, she presented with recurrent abdominal pain, elevated pancreatic enzymes, and dilation of the main pancreatic duct, suggestive of a remnant pancreatitis secondary to pancreaticojejunostomy stenosis. Endoscopic evaluation using double-balloon endoscopy failed to locate the anastomosis. Endoscopic ultrasound enabled puncture and cannulation of the main pancreatic duct, though the anastomotic site remained obstructed. An endoscopic nasal pancreatic drainage tube was placed within the main pancreatic duct. Subsequently, open surgery was performed to dilate the anastomosis and insert a drainage tube. A gastrotomy was created, revealing a fistula between the stomach and pancreas, and a guidewire was introduced from the fistula to the anastomosis. The guidewire was inserted through the fistula and guided to the jejunum through the anastomosis by incising the jejunum on the opposite side of the pancreaticojejunostomy. A stent was deployed across the anastomosis, and a transgastric pancreatic duct drainage was made. The patient subsequently underwent endoscopic dilation and is currently asymptomatic.

Conclusions: Symptomatic anastomotic stenosis necessitates treatment, with an endoscopic approach generally preferred as the first-line option. When endoscopic visualization of the anastomosis proves challenging, an ultrasound endoscope can be utilized to puncture the main pancreatic duct from the stomach and establish a connection to the jejunum (the "rendezvous" method). If endoscopic interventions are unsuccessful, surgical intervention is warranted. Surgical management often involves anastomotic resection and reanastomosis. In this case, a less invasive surgical "rendezvous" approach was successfully employed, which may offer a valuable surgical alternative for managing pancreatico-enterostomy stenosis after pancreaticoduodenectomy.

Keywords: anastomotic stenosis; case report; pancreaticoduodenectomy; pancreaticojejunostomy; rendezvous.