Name
Syed Basha
Age
Diagnosis
Procedure
Exploratory laparotomy/ Lavage/
Necrosectomy with pus drainage/
Intraperitoneal bleed/ Necrotizing
Retrograde tube duodenostomy with
pancreatitis inv transerse mesocolon/
serosal patch closure of duodenal
20/M Duodenal blowout/ Biliary EC fistula
blowout/ Right hemicolectomy with
s/p patch closure of traumatic D2-D3
end
ileostomy/
Pyloric
exclusion/
GJ/
injury/ FJ
Jejunal resection & anastomosis/
Redo FJ
◦ RTA/ BTA on 26/1/21. Underwent emergency laparotomy by
general surgery team, peripheral GH
◦ Patch closure of D2-D3 perforation & FJ
◦ Developed wound dehiscence with biliary enterocutaneous fistula.
Referred to MMC & admitted under general surgery
◦ Received referral on 23/2/21. Transferred to our care
◦ FJ feeding, TPN & wound care -> Further evaluation & optimisation
◦ Developed melena & blood tinging in ECF & DT on 28/2/21. Patient
was resuscitated. CT Angiogram abdomen was taken on 1/3/21,
showed no active bleed but e/o transection in neck of pancreas
◦ Patient planned for emergency laparotomy.
Investigations
◦ CBC - 12.6/ 12000/ 3.1
◦ RFT – 22/ 1.0/ 138/ 4.5
◦ LFT - 0.7/ 0.2/ 72/ 44/ 107/ 5.1/ 3.5
◦ INR - 0.9
CT abdominal angiogram
◦ e/o herniation of bowel loops in the anterior midline to
laparotomy wound
◦ e/o possible transection of head of pancreas noted, body & tail
appear normal
◦ Collection with air pockets in the area of head of pancreas
extending into interbowel spaces & tracking into right paracolic
areas & to the midline
◦ Normal angiogram. No e/o aneurysm/ contrast extravasation
Findings
◦ Dehisced wound of previous surgery filled by granulation
tissue overlying bowel & omentum
◦ Dense adhesions – plastered intraperitoneal contents
◦ Head of pancreas necrosed with abscess collection ~
5x5cm
◦ Unhealthy proximal transverse mesocolon adjacent to
pancreatic necrosis. Bleeding from involved areas
◦ Duodenal blowout
◦ Multiple serosal tears in the jejunum
Surgery (6/3/21)
Exploratory laparotomy/ Lavage
Necrosectomy with pus drainage
Retrograde tube duodenostomy
with serosal patch closure of
duodenal blowout
Right hemicolectomy with end
ileostomy
Pyloric exclusion/ GJ
Jejunal resection & anastomosis/
Redo FJ
◦ POD-5 - biliopurulent discharge from laparotomy wound ~
500ml/day. Managed with vacuum suction dressings & culture
guided antibiotics . Gradually decreased & wound granulated
◦ Tube duodenostomy - bilious output of 1 to 1.5 L/day. Bile
refeeding done
◦ Lesser sac DT initially output of 400-500ml/day, gradually
reduced
◦ Patient received TPN in immediate postop period. Started on FJ
feeds on POD-8
◦ Oral liquids started on POD-18, soft diet on POD-22
◦ Developed SAIO on POD-27. Contrast study through tube
duodenostomy showed no leak. Managed conservatively
◦ Discharged 1 month postop with right DT (lesser sac) draining
<50ml/day bilious output & tube duodenostomy (1 to 1.5L/day)
◦
◦
◦
◦
Biopsy
Pancreas - coagulative necrosis with areas of haemorrhage
Small bowel mucosa - lymphocytic infiltration
Appendix - chronic appendicitis