Case Description :
A 55-year-old gentleman diagnosed with a carcinoma of pancreas head with obstructive jaundice, presented to us in extreme distress of pain and not able to eat. He was an operable case but due to high bilirubin and low albumin, he was recommended preoperative ERCP with biliary stenting. He was unfortunate to develop post-stenting pancreatitis. He was recommended conservative management and nutritional optimisation. When he was recommended for surgery after 3 weeks, he developed one more attack of pancreatitis. He had multiple episodes of pancreatitis and by now the patient had lost hope of recovery as surgery was a very high risk.
Consultation & Diagnosis
Tumor Board
Individualized Care
Modular Care
What We Did :
We discussed this in our joint clinic and it was a tough decision for me and my team
,as we were aware of 70 percent mortality in severe pancreatitis patients planned for Whipple surgery. We had to decide as nothing was helping him. We optimised him nutritionally and planned for surgery with high operative risk. During Surgery, we saw that it was an extremely challenging case as the pancreas had undergone necrosis. The only thing running through my mind was, if I backed out, what were the consequences, and I realised that this was the only chance to take out the tumour.
I continued and finally, I was able to perform the surgery with our excellent team. It took 12 hours to complete it. He required a prolonged ICU stay and aggressive physiotherapy rehabilitation as the patient was not motivated. After 20 days of good rehabilitation, he recovered.
Action Plan
- Optimised patient nutritionally
- Managed pancreatic necrosis & Whipple surgery
- Arduous surgery performed
- Aggressive physiotherapy and rehab
Final Results :
Postoperatively, he had a grade B leak which was managed conservatively. He is doing well now and his final histopathology report came out as Neuroendocrine tumour (a good variety of tumour), which was the icing on the cake. Neuroendocrine tumors are a rare variety but very good biology. Retrospectively thinking, if I would have backed out because of the difficulty, he would have been devoid of the curative surgery.
Note: Whipple surgery in patients with severe pancreatitis is a very big challenge. A personalised approach helps you to make the right decisions. According to the literature, we should not operate on such patients for 8-12 weeks. The most important thing is that every patient is different and has a different mindset which needs to be considered while making the decision.
