The Department of Hepatobiliary and Pancreatic Surgery of Changzhou Second Hospital recently successfully treated a patient with acute severe necrotizing pancreatitis complicated by pancreaticoduodenal surgery.
Last year, 50-year-old Mr. Rong went to Changzhou Second Hospital for treatment due to vague pain and discomfort in the upper abdomen accompanied by yellowing of the whole body. Zhu Chunfu, director of the Department of Hepatobiliary and Pancreatic Surgery of Changzhou Second Hospital, preliminarily diagnosed it as an ampullary mass after a detailed examination, and judged that it was likely to be an ampullary malignant tumor. However, Mr. Rong has suffered from hypertension, hyperlipidemia, hyperuricemia and hypercholesterolemia for many years, and his weight is heavy with a high BMI of 2698, and at the same time, I want to do minimally invasive surgery, which is difficult.
Finally, after rigorous preoperative evaluation and preparation, Zhu Chunfu's team performed minimally invasive pancreaticoduodenal ** surgery for Mr. Rong. The operation was very smooth, it took 5 hours, there was almost no bleeding during the operation, and the postoperative pathology confirmed that it was a malignant tumor in the lower bile duct. On the second day after surgery, Mr. Rong was able to get out of bed on his own.
However, from the second day after surgery, Mr. Rong had persistent fever with a maximum temperature of 39, and although the blood amylase continued to decrease, there was no obvious abnormality in multiple follow-up color ultrasound and abdominal CT, and the drainage fluid and bacterial culture of the catheter were also negative.
On the 9th day after the operation, Mr. Rong's condition did not improve, he continued to have fever, his blood picture continued to rise, and the ascites effusion increased significantly after CT examination. After the bedside B-ultrasound guided puncture, more dark brown fluid was drained, and Zhu Chunfu's team judged that it was likely to be a digestive fistula. In view of the severity and urgency of Mr. Rong's condition, the team decided to perform an emergency laparoscopic examination for Mr. Rong.
Intraoperative exploration revealed that a large amount of dark brown fluid had accumulated in Mr. Rong's abdominal cavity, and the residual pancreas was acutely necrosis-like. Zhu Chunfu decisively performed open irrigation and drainage surgery for Mr. Rong to remove part of the necrotic tissue, and placed multiple drainage tubes and double cannula around the pancreas to facilitate subsequent irrigation and drainage. The operation was successfully completed and Mr. Rong was transferred to the ICU for continued monitoring**.
Since the second day of Mr. Rong's admission to the ICU, Zhu Chunfu's team began to carry out continuous irrigation and manual irrigation of the double cannula, and a large amount of necrotic tissue was flushed out every day. Mr. Rong's condition gradually improved, and a follow-up abdominal CT examination showed that pancreatitis was improving and the effusion was decreasing.
On the 19th day after surgery, Mr. Rong suddenly bleed heavily from the bilateral drainage bag and abdominal wound, bleeding nearly 400 ml within 1 hour. The situation was critical, and the team actively rehydrated and transfused Mr. Rong while pushing him into the DSA to intervene to stop the bleeding.
DSA imaging showed a pseudoaneurysm hemorrhage in Mr. Rong's common hepatic artery. If the common hepatic artery is embolized to stop bleeding, it will seriously affect the blood flow to the liver. Zhu Chunfu said, "Generally speaking, the left hepatic artery and the right hepatic artery both originate from the original hepatic artery and are relatively small. However, after imaging, we found that Mr. Rong's left hepatic artery was not only very thick, but also originated from the proximal end of the common hepatic artery. Therefore, we boldly performed embolization of the common hepatic artery for Mr. Rong. The surgery went smoothly and there was no effect on the liver function after the postoperative examination. ”
After more than 10 days in the intensive care unit**, Mr. Rong was successfully transferred to the general ward of the Department of Hepatobiliary Surgery. Although Mr. Rong's pancreatitis symptoms improved significantly, and the residual pancreas gradually returned to normal on follow-up CT examination, the infected effusion under the left spleen was not completely cleared.
Zhu Chunfu had an idea, and used a choledoscope to flush the sinus tract of the left double cannula, and under the direct vision of the choledoscope, he used a stone removal basket and foreign body forceps to remove the necrotic tissue. After six or seven rounds of cholangioscopic irrigation, Mr. Rong's residual abdominal infection was finally overcome. Under the meticulous efforts of Zhu Chunfu's team, ICU and interventional department, Mr. Rong's condition has gradually improved, and he has been successfully discharged from the hospital.