Transmural migration of an internal pancreaticojejunostomy stent causing delayed intra-abdominal sepsis: a case...

Internal pancreatic duct stents are commonly used during pancreaticojejunostomy (PJ) reconstruction following pancreaticoduodenectomy to facilitate drainage and potentially reduce postoperative pancreatic fistula (POPF). These stents are typically expected to migrate distally and pass without consequence. However, rare complications related to stent migration may occur and can present with atypical clinical and biochemical findings, creating diagnostic challenges.

A 63-year-old woman underwent pancreaticoduodenectomy for pancreatic adenocarcinoma with placement of an internal PJ stent. Her initial postoperative course was uneventful, with normal drain amylase levels. On postoperative day (POD) eight, she presented with fever, leukocytosis, and abdominal pain. Computed tomography (CT) demonstrated peripancreatic fluid and gas collections suspicious for POPF; however, drain amylase levels remained low, creating diagnostic uncertainty. Despite initial nonoperative management, the patient's clinical status deteriorated, prompting exploratory laparotomy. Intraoperatively, the PJ anastomosis was intact, but diffuse enteric contamination was present. Intraoperative ultrasound revealed transmural migration of the pancreatic duct stent through the jejunal wall into the mesentery, resulting in a concealed perforation with extraluminal leakage of enteric contents. The stent was retrieved via controlled enterotomy, the defect was repaired, and the abdomen was irrigated. The patient subsequently improved with resolution of sepsis and was discharged in stable condition.

Transmural migration of an internal PJ stent is a rare but serious complication that may present with intra-abdominal sepsis in the absence of elevated drain amylase levels. This case highlights an important diagnostic pitfall, as enteric contamination rather than pancreatic leakage may predominate. In patients with unexplained postoperative deterioration following pancreaticoduodenectomy, particularly when imaging is equivocal and biochemical markers are discordant, stent-related complications should be considered. Early recognition and prompt surgical intervention are critical for optimal outcomes.