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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 123-125

Intraperitoneal drain tip migration into the liver parenchyma following pancreaticoduodenectomy: A case report and review of literature


1 Department of Surgery, General Surgery Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos, Nigeria
2 Department of Surgery, General Surgery Unit, Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Radiology, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Submission26-Aug-2020
Date of Acceptance21-Oct-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Dr. Thomas Olagboyega Olajide
Department of Surgery, General Surgery Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_64_20

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  Abstract 


Intraperitoneal drains are widely used in surgery for therapeutic or diagnostic purposes. The placement of drains following pancreaticoduodenectomy may decrease postoperative complications. Commonly reported complications of intraperitoneal drains include pressure necrosis with bleeding, viscus perforation, fistula formation, and mechanical bowel obstruction. We report a rare complication of drain tip migration and erosion into the liver parenchyma.

Keywords: Drain migration, liver erosion, Whipple's procedure


How to cite this article:
Olajide TO, Makanjuola A, Adeuja DA, Atoyebi OA. Intraperitoneal drain tip migration into the liver parenchyma following pancreaticoduodenectomy: A case report and review of literature. J Clin Sci 2021;18:123-5

How to cite this URL:
Olajide TO, Makanjuola A, Adeuja DA, Atoyebi OA. Intraperitoneal drain tip migration into the liver parenchyma following pancreaticoduodenectomy: A case report and review of literature. J Clin Sci [serial online] 2021 [cited 2021 Sep 23];18:123-5. Available from: https://www.jcsjournal.org/text.asp?2021/18/2/123/314453




  Introduction Top


Intraperitoneal drains are widely used in surgical practice usually with the aim of preventing collection of intra-abdominal fluid and assist in diagnosing postoperative bleeding, pancreatic and biliary leakages, or anastomotic dehiscence.[1] They are also used in nonoperative treatment of a pancreatic fistula to create a controlled pancreaticocutaneous fistula and allow for spontaneous resolution.[1] Commonly reported complications of abdominal drains include pressure necrosis on adjacent tissues with bleeding, perforation and fistula formation, mechanical bowel obstruction, drain site infection, and hernias.[2] A rare case of intraperitoneal drain tip migration with erosion into the liver parenchyma following pancreaticoduodenectomy (PD) is reported and literature reviewed.


  Case Report Top


A 52-year-old man presented to the surgical outpatient clinic with a 3-month history of deepening jaundice and a 1-month history of generalized pruritus. There was associated passage of pale bulky stools, dark urine, and weight loss but no abdominal pain. On examination, he was deeply icteric with generalized skin scratch marks and abdominal tenderness with no palpable masses. A diagnosis of obstructive jaundice secondary to carcinoma of the head of the pancreas was made. The liver function test revealed elevated total bilirubin (71.7 µmol/L), conjugated bilirubin (71.2 µmol/L), alkaline phosphatase (506.7 µ/L), and gamma-glutamyltransferase (1044.1 µ/L). The serum CA19-9 level was 729.2 µ/mL.

Abdominal computed tomography (CT) scan with pancreatic protocol revealed an irregular hypodense lesion (18 mm × 12 mm) in the head of the pancreas that was abutting on but not infiltrating the portal vein. The superior mesenteric vessels and the inferior vena cava were free of the tumor. There were also subcentimeter peripancreatic and hepatic hilar lymph nodes. Dilatation of the pancreatic duct, common bile duct (10.4 mm), and intrahepatic ducts were also noted. There was no evidence of ascites or metastatic deposits in the liver [Figure 1].
Figure 1: Abdominopelvic CT image in axial view showing an ill-defined mass (big arrow) in the pancreatic head (anterior to IVC); the SMA and SMV are spared. Peripancreatic subcentimeter nodes (small arrows) are also noted. IVC = Inferior vena cava, SMA = Superior mesenteric artery, SMV = Superior mesenteric vein, CT = Computed tomography

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A standard Whipple's procedure (PD) was performed. Intraoperative findings revealed a 4 cm × 4 cm tumor within the head of the pancreas, peripancreatic lymph node at the origin of the portal vein, gross distension of the extrahepatic biliary tree, and absence of visible peritoneal and liver metastasis [Figure 2].
Figure 2: C loop of the duodenum and the head of the pancreas with the mass in situ before resection (arrow)

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At the end of the procedure, a tube drain (Redivac®) was inserted at the area of hepaticojejunostomy but used as a passive drain.

Histopathology of the specimen revealed well-differentiated adenocarcinoma extending from the pancreatic head into the duodenum. The surgical resection margins were free of tumor cells.

The initial postoperative recovery of the patient was satisfactory. The wound drain output progressively decreased to 200 ml of serous fluid on the 7th postoperative day.

However, on the 8th postoperative day, the abdominal wound drain output was 800 ml of bilious effluent and increased progressively to a maximum of 3200 ml on the 16th day.

Abdominal CT scan revealed pneumobilia and mild perihepatic collection. Magnetic resonance imaging [Figure 3] and magnetic resonance cholangiopancreatography [Figure 4] showed about 5 cm of the drainage catheter tip in segment 2 of the liver and intact hepaticojejunostomy with no anastomotic leakage. The contour and caliber of the intrahepatic and extrahepatic bile duct were preserved, with termination of the bile duct into the small bowel. There was no evidence of extraluminal signal intensity, indicating that the hepaticojejunostomy was intact with no leakage.
Figure 3: Postintervention T1-weighted magnetic resonance image in axial view demonstrating the drain (small arrow) with its tip in the left lobe of the liver (big arrow)

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Figure 4: Postintervention MRCP image in coronal view demonstrating anastomotic area between CBD (big arrow) and jejunal loops (small arrow). No extravasation is noted. CBD = Common bile duct, MRCP = Magnetic resonance cholangiopancreatography

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The peritoneal drain was adjusted by pulling it out by about 10 cm, and the drain output progressively decreased. On the 42nd postoperative day, the abdominal drain accidentally dislodged. Following the absence of clinical and sonographic evidence of intra-abdominal collections, he was discharged on the 48th postoperative day and referred to the oncology unit for adjuvant therapy.


  Discussion Top


PD is the common potentially curative surgery performed for cancer of the pancreatic head.[3] Postoperative morbidity remains high despite advancement in surgical techniques and perioperative management, with about one-third of patients still developing complications.[4] One of the most dreaded complications of PD is a pancreatic fistula with a frequency of between 9% and 13%.[5] Although there currently exists no global consensus in the literature on drainage following PD, timely detection and routine drainage of pancreatic and anastomotic fistulas, intraperitoneal hemorrhage, and fluid collections after PD are regarded as efficacious in reducing morbidity and mortality.[5],[6],[7] A recent national surgical quality improvement program analysis showed that drain placement with early removal defined as postoperative day 4 may decrease postoperative complications.[2] In the index patient, the drain was left for longer due to the persistently significant volume of effluent.

The timing of removal would depend on the reduction and eventual cessation of drainage of any effluent. While the use of drains is known to sometimes result in intra-abdominal infections, delay in return of bowel function, anastomotic leakage, activation of pancreatic enzymes, and fistulas (especially if suction drains are used), the migration of the drain into the liver parenchyma that was observed in this patient has not been previously reported following PD.

Our literature search revealed only one report on intra-abdominal drain erosion into the liver parenchyma.[8] In this postmortem report, it occurred following correct intraoperative placement of a Robinson drain after subtotal gastrectomy for carcinoma and resulted in fatal biliary peritonitis. The authors suggested that the patient's poor nutritional state may have played a role in this complication. In our index patient, the reason for the migration could not easily be ascertained as an appropriate length was inserted into the peritoneum and the drain was secured. Withdrawal may have resulted in an intraperitoneal length that was too short leading to dislodgment. The Redivac® drain is made from polyvinyl chloride, and some available brands are not very pliable. This may have contributed to its ability to erode into the liver.


  Conclusion Top


Drain erosion into the liver parenchyma is a very rare and previously unreported complication following PD. It should be considered in the event of persistently increasing bilious drainage following PD. A higher index of suspicion leading to early evaluation with appropriate imaging is recommended in this type of scenario as it would lessen the morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Čečka F, Loveček M, Jon B, Skalický P, Šubrt Z, Ferko A. DRAPA trial – Closed-suction drains versus closed gravity drains in pancreatic surgery: Study protocol for a randomized controlled trial. Trials 2015;16:207.  Back to cited text no. 1
    
2.
Addison P, Nauka PC, Fatakhova K, Amodu L, Kohn N, Rodriguez Rilo HL. Impact of drain placement and duration on outcomes after pancreaticoduodenectomy: A national surgical quality improvement program analysis. J Surg Res 2019;243:100-7.  Back to cited text no. 2
    
3.
Hartwig W, Werner J, Jäger D, Debus J, Büchler MW. Improvement of surgical results for pancreatic cancer. Lancet Oncol 2013;14:e476-85.  Back to cited text no. 3
    
4.
Vollmer CM Jr., Lewis RS, Hall BL, Allendorf JD, Beane JD, Behrman SW, et al. Establishing a quantitative benchmark for morbidity in pancreatoduodenectomy using ACS-NSQIP, the Accordion Severity Grading System, and the Postoperative Morbidity Index. Ann Surg 2015;261:527-36.  Back to cited text no. 4
    
5.
Wang Q, Jiang YJ, Li J, Yang F, Di Y, Yao L, et al. Is routine drainage necessary after pancreaticoduodenectomy? World J Gastroenterol 2014;20:8110-8.  Back to cited text no. 5
    
6.
Aumont O, Dupré A, Abjean A, Pereira B, Veziant J, Le Roy B, et al. Does intraoperative closed-suction drainage influence the rate of pancreatic fistula after pancreaticoduodenectomy? BMC Surg 2017;17:58.  Back to cited text no. 6
    
7.
Dou CW, Liu ZK, Jia YL, Zheng X, Tu KS, Yao YM, et al. Systematic review and meta-analysis of prophylactic abdominal drainage after pancreatic resection. World J Gastroenterol 2015;21:5719-34.  Back to cited text no. 7
    
8.
Biedrzycki OJ, Lauffer GL, Baithun SI. Fatal biliary peritonitis due to postinsertion migration of a Robinson drain tip, with erosion into the liver parenchyma. Am J Forensic Med Pathol 2007;28:230-1.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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