Thursday, May 12, 2016

What's the Surgery?

A middle aged patient presents with acute onset persistent severe epigastric abdominal pain. The pain radiates to the back and is relieved by sitting up or bending forward. It is accompanied by nausea, vomiting, and dyspnea. Exam shows diffuse tenderness, abdominal distension, and hypoactive bowel sounds. He is admitted to the hospital for supportive management.

Unfortunately, overnight, he develops fever, tachypnea, tachycardia, and hypotension. He is transferred to the critical care unit and started on norepinephrine and vasopressin for septic shock after adequate fluid resuscitation. A CT is shown below:


He has acute kidney injury and acute respiratory distress syndrome requiring intubation, but over the next few weeks, he is stabilized and eventually extubated. Four weeks after the initial presentation, he still has chronic low grade fever, nausea, lethargy, and inability to eat.

He then undergoes surgery even though the mortality rate is somewhere between 4-25% and complications include intra-abdominal fluid collections, bleeding, fistulas, incisional hernias, poor glucose control, and need for enzyme therapies.

Challenge: What was the operation?

Image shown under Fair Use.

2 comments:

RaH said...

It seems like this guy presents with acute pancreatitis... (biliary or alcoholic..) supportive managent includes fluid control and Calcium monitoring. probably a resektion of the necrotic part of the pancreas was needed.
there are basically 3 different types of surgeries... transgastral retroperitoneal necrotectomy / pancreatectomy, transabdominal laparoscopic or laparotomic

Craig Chen said...

you're right - great summary!
-
What’s the Surgery?

This is acute pancreatitis leading to symptomatic sterile pancreatic necrosis, and the surgery is a pancreatic debridement, also called necrosectomy. This is indicated for pancreatic or peripancreatic necrosis and progressive clinical sepsis. The ideal time for debridement is the late phase of pancreatitis, about four weeks after initial onset.

Source: UpToDate.