LAUSR

A 32-year-old woman underwent an open surgery to resect cystic tumor at pancreatic neck with pancreaticogastrostomy. Thirty-nine days later, she complained of severe epigastric pain, abdominal distension and vomiting immediately after celiac pancreatic duct drainage tube was removed. Obvious thickening of gastric wall was shown by enhanced CT (Fig. 1a,b). Esophagogastroduodenoscopy revealed diffuse red mucosa, congested and swollen protuberant gastric folds in the whole gastric body and antrum (Fig. 1c). A fissure like gap at small curvature of gastric antrum near pylorus was suspicious of pancreatogastric anastomosis (Fig. 1d). Radial and linear endoscopic ultrasonography (EUS) showed a significantly thickened gastric wall of 13–22 mm around middle and lower segments of gastric body and antrum (Fig. 1e). Hypoechoic changes occurred through mucosal layer to muscularis propria. Main pancreatic duct was tortuous and dilated to 5–8 mm in pancreatic tail and body (Fig. 1f,g). It became extremely distorted and narrowed into 1–2 mm when extending to anastomosis (Fig. 1h). Corroded gastric wall due to pancreatic fistula after pancreaticogastrostomy was highly suspected. To avoid gastric perforation, endoscopic treatment was performed. Repeated attempts of retrograde intubation through original pancreatogastric anastomosis by duodenoscopy failed. EUS-guided pancreatic duct (EUS-PD) rendezvous drainage failed again because guidewire could not pass through anastomosis in an antegrade fashion. Then EUS-guided transmural drainage by a 5Fr × 6 cm plastic stent was performed (Fig. 2a–c). After procedure, patient recovered soon without abdominal pain or complications. CT in 7 days showed markedly reduced thickening of gastric wall (Fig. 2d). During 1 year followup, patient showed no symptom and normal CT image (Fig. 2e, f). After stent was removed, a mature pancreatogastric fistula by EUS-PD was established and original pancreatogastric anastomosis by surgery was closed (Fig. 2g,h). And the patient still showed no symptom. Postoperative pancreatic fistula (POPF) is a severe complication after pancreatic surgery with incidences of 11.2–21.4%. This is the first case that more leaking pancreatic juice infiltrates through gastric subserosa to corrode the whole gastric wall than exudation into the abdominal cavity after pancreaticogastrostomy. And transluminal EUS-PD proved the effectiveness and safety through long time follow-up to safe gastric wall.