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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
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230
https://t.me/med1917
Fig. 41.3 Percutaneous
transhepatic cholangiography
(PTC) on the 18th
postoperative day
S.S. Gisbertz
PTC
Percutaneous drain
Illustration 41.1 Once diagnosed the leakage of the pancreaticojejunostomy, collection should
be drained percutaneously, along a PTC drain placed in front of the anastomosis for drainage
Leakage
Collection
Chapter 42
https://t.me/med1917
Case on Bile Leakage (and Portal Vein
Thrombosis) After Whipple Procedure
Miguel A. Cuesta
Keywords Bile leakage • Portal vein thrombosis • Whipple procedure • Pancreatic
head cancer
Diagnosis and Indication for Surgery
A 67-year-old female patient was referred because of a pancreatic head-uncinate
process tumor with obstructive jaundice and pain in her back. She had already lost
6 kg. Concerning her back pain, she could not explain clearly if this pain was different from the chronic pain she had felt for years. US and CT scan and ERCP revealed
a tumor locally invasive with no clear encasement of the superior mesenteric vein.
Preoperatively, biliary tract was drained by means of sphincterotomy and stent.
Biopsy showed adenocarcinoma and patient was scheduled for explorative
laparotomy.
Operation
During subcostal laparotomy, a Whipple resection was performed with a wedge
resection of the junction between the superior mesenteric and portal vein, because
of small ingrowth of the tumor. The vein was closed in horizontal direction without
necessity of a patch or mobilization.
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_42,
© Springer International Publishing Switzerland 2014
231
232
https://t.me/med1917
Fig. 42.1 CT scan, PTC
drainage and open wound
M.A. Cuesta
Postoperative Course: Identifi cation and Treatment
of the Complication
Postoperatively, she experienced several complications. First, deep wound infection
with biliary leakage through the wound, along the subhepatic drain, necessating
exploration and debridement under general anesthesia. Here, drains were left in the
subhepatic region and the wound was left open for adequate drainage. A PTC drainage was performed to drain conveniently the leakage of the hepaticojejunostomy
(Fig. 42.1 and Illustration 42.1 ). Patient remained low grade septic; after blood
cultures she was given broad spectrum antibiotics. Bleeding of the upper digestive
tract was suspected because of melena, being diagnosed by gastroscopy as having
an important hemorrhagic gastritis, and was treated by a stop of prophylactic heparin, correction of coagulation tests, and by proton inhibitors medication. Patient
was initially treated by TPN and afterwards by jejunal tube feeding. A new control
CT showed a portal vein thrombosis with hypoperfusion of the whole liver
(Fig. 42.2 ). Radiological thrombectomy was considered but due to the general con-
dition of patient, we decided to start carefully with anticoagulation by means of
subcutan heparin. Situation of the patient incrementally improved and after a period
of 2 months, she could be dismissed with a still open abdominal wound while having no more bile leakage.
Two years later patient appeared doing reasonably well with continuing back
pain yet stable weight. CT scans requested by the gastroenterologist showed different kinds of enlarged lymph nodes in the subhepatic area, but no signs of local
recurrence. The early diagnosed aneurysm in the infrarenal abdominal aorta has
grown up to 6 cm and vascular surgeon has recently treated this aneurysm successfully by means of endovascular aneurysm repair (EVAR).
42 Case on Bile Leakage (and Portal Vein Thrombosis) After Whipple Procedure
https://t.me/med1917
233
Leakage
Drainage
Portal vein thrombosis
Illustration 42.1 Leakage of the hepaticojejunostomy has been shown treated by PTC and
percutaneous drainage of the subhepatic collection. Moreover, the portal vein thrombosis with
impaired irrigation of liver was treated conservatively with success
PTC
Fig. 42.2 CT scan, portal
vein thrombosis and
subhepatic collection
Chapter 43
https://t.me/med1917
Case on Bleeding in the Small Remnant
of the Head of the Pancreas After Duodenum
Preserving Resection for Middle Pancreatic
Tumor
Suzanne S. Gisbertz and Rutger J. Lely
Keywords Pancreatic Cystadenoma • Laparoscopic TME • Rectum cancer •
Pancreatic resection • Whipple operation
Diagnosis and Indication for Surgery
A 68-year-old man presented with blood in feces and tenesmus and was diagnosed
with a mid-rectal cancer 8 cm from the anal verge. During screening for metastases,
a cystadenoma of the junction between pancreatic head and body of pancreas was
found on the CT scan (Fig. 43.1 ).
Operation
After radiotherapy, 5 × 5 Grays, he underwent 6 weeks later a laparoscopic TME
with LAR. The specimen was radical, T2N0M0 with a response Mandard type 2.
Protective ileostomy was closed 6 weeks after operation without complications.
Deliberation began when to operate the cystadenomatous pancreatic lesion.
Three months later, it was decided to operate the lesion by means of a median
upper laparotomy. After dissection of the pancreas, a central pancreatectomy was
performed, leaving a small strip of the head of the pancreas with the duodenum
S. S. Gisbertz , M.D. ()
Department of Surgery , Academic Medical Centre , Amsterdam , The Netherlands
e-mail: s.gisbertz@antoniusziekenhuis.nl
R. J. Lely, M.D.
Department of Radiology , VU Medical Center , Amsterdam , The Netherlands
e-mail: r.lelij@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_43,
© Springer International Publishing Switzerland 2014
235
236
https://t.me/med1917
Fig. 43.1 Preoperative CT
scan with tumor in the
pancreas
S.S. Gisbertz and R.J. Lely
a
b
Fig. 43.2 ( a ) Aspect of the
tumor during laparotomy.
( b ) Dissection of pancreas
43 Case on Bleeding in the Small Remnant of the Head of the Pancreas After Duodenum
https://t.me/med1917
Fig. 43.3 Angiography and
blush at the duodenum
being sutured. The start of the pancreas was anastomosed, end to side by means of
a Roux-en-Y anastomosis (Fig. 43.2a, b ). Pathology showed a serous cystadenoma
of 5 cm, radical resected.
Postoperative Course: Identifi cation and Treatment
of the Complication
237
Patient recovered well and went home. The day after the fi rst control at the outpatient
clinic, he was admitted to the emergency department because of hematemesis and
melena.
Evaluation by emergency gastroscopy and by CT angiography showed that the
bleeding was caused (blush) in the small rest of the head of the pancreas
(Figs. 43.3 and 43.4 )
An attempt to coil the bleeding site—the bleeding probably coming from
pancreaticoduodenal arteries—was considered impossible because the celiac trunk
was seriously stenosed/obstructed (Illustration 43.1 ). A second attempt to coil
the bleeding through the superior mesenteric artery was also considered impossible
because of the diffi cult angle to localize the bleeding point.
Due to hemodynamic instability, it was decided to perform a relaparotomy and
devascularize the head of the pancreas. Some arteries were found around the duodenum and were subsequently fi xed with stitches. Next day, bleeding recurred again
with hemodynamic instability in spite of coagulation correction and transfusions
and a relaparotomy was decided on. A clot of 7 cm was found near the second and
third part of duodenum and rest of pancreas with active bleeding present, and so we
decided to perform an acute Whipple resection. Anatomy was diffi cult to recognize,
especially the relation with the superior mesenteric vessels. Anastomosis with the
common hepatic duct and the stomach was completed.
238
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Fig. 43.4 Clots and bleeding
at the duodenum–pancreas rest
S.S. Gisbertz and R.J. Lely
Bleeding
Celiac trunk
occlusion
Blush
SM artery
Illustration 43.1 Bleeding of the remnant of the pancreas head. Angiography and coiling were
not possible because of occlusion of the celiac trunk
Whipple procedure
Patient was ventilated on the IC, yet was hemodynamically stable. After 2 days
he could be disconnected from mechanical ventilation. Pathology showed rest of
necrotizing pancreatitis with fat necrosis. He recovered and after 2 years is doing
very well.
Chapter 44
https://t.me/med1917
Case on Impaction of Enteral (Bezoars)
During Enteral Feeding After Whipple
Procedure
Miguel A. Cuesta
Keywords Whipple • Bezoar • Impacted • Jejunostomy • Pancreatic head cancer •
Enteral nutrition
Diagnosis and Indication for Surgery
An 80-year-old man, in good general condition, was referred to us for a Whipple
operation because of pancreatic head cancer. He had lost seven kg weight. On CT
scan and ERCP a double duct sign became visible. Due to very high bilirubin values
and itching, a stent was placed after sphincterotomy.
Operation
The Whipple resection occurred without problems, and the patient was fed
postoperatively by means of a jejunostomy tube placed during the operation.
Postoperative Course: Identifi cation and Treatment
of the Complication
In the fi rst postoperative days, 1.5 l high fi ber feeding was administered by
jejunostomy along with some oral feeding. On the seventh postoperative day, the
patient suddenly became septic, experiencing general abdominal pain and vomiting.
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_44,
© Springer International Publishing Switzerland 2014
239
240
https://t.me/med1917
Fig. 44.1 ( a , b ) CT scan
showing impaction of
intestinal contents, ischemia
of the wall, and leakage of
contrast in peritoneal cavity
M.A. Cuesta
a
b
A CT scan showed impaction of intestinal contents, ischemia in the intestinal wall,
and leakage of contrast in peritoneal cavity (Fig. 44.1a, b ). Decision was taken to
operate the patient immediately.
During relaparotomy, an impaction of the high fi ber feeding (bezoars) was found
in the small bowel in a length of 50 cm, middle jejunum with dilatation, and necrosis (Figs. 44.2 and 44.3 ). Proximal and distal jejunum and ileum were dilated but
considered well vascularized. The impacted necrotic bowel segment was resected
and primary anastomosis followed. Despite risk of leakages, the patient could be
weaned from the mechanical ventilation. After a slow recovery and rehabilitation,
he went home.
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