Tales of the Pancreas

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I apologize for the length of the expository preamble to this case.

Three weeks ago I admitted a 37 year old motorcyclists who crashed into a
stationary vehicle.  Obvious injuries included rib fractures and pulmonary
contusion requiring aggressive ventilatory support.  His abdominal CT scan
was, initially, pretty normal.  Over the ensuing 48-72 hours, however, he
became increasingly febrile, tachycardic and began complaining of abdominal
pain.  His WBC increased to 20,000.  I performed a laparotomy expecting to
find a missed hollow viscus injury.  I was not disappointed.  He had a
devascularizing contusion of the splenic flexure of the colon (not yet
perforated, no fecal spillage), and what appeared to be an inflamed tail and
distal body of the pancreas, although the gland itself appeared intact ,i.e.
wasn't transected, which is what the initial CT scan showed as well.

Performed a segmental colonic resection with primary end-to-end anastomosis
and drained the pancreas with two large sump drains.  He didn't really get
better.  Two days later I re-explored, finding the tail of pancreas
significantly worse.  It was frankly necrotic with the usual surrounding fat
saponification, etc.  So he got a distal pancreatectomy and splenectomy.  I
found what appeared to be the main pancreatic duct at the margin of gland
transection and ligated it with 3-0 PDS suture ligature.  The previous
colonic repair was fine and was located well away from all the inflammation
in the left upper quadrant.

Now, three weeks later, he is draining about 200-300 ml of pancreatic juice
(amylase level > 10,000 U/L) via the drains I left near (but not on) the
pancreatic stump.  Clinically he's doing better, with resolving sepsis
syndrome .  I had initially placed him empirically on imipenem, (invoking
the ghost of Pederzoli<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8480272&ordinalpos=5&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum>)
when I diagnosed his traumatic pancreatitis at the first laparotomy, and
have since added vancomycin to cover an enterococcus that grew from the
resected pacreatic tail specimen.  Serum amylase mildly elevated at around
150 U/L (highest it ever got was around 300)  Bilirubin and liver enzymes
are normal.

Questions for Team Trauma:

1. Any role for octreotide now?  Should i have started octreotide early on,
when I first suspected the pancreatitis/pancreatic injury?
2. Any role for ERCP now?  How about initially?  He was pretty sick back
then (high PEEPS, etc) so moving him for the procedure was a scary
proposition at the time.  GI guys wouldn't do it in the ICU.
3. I'm now feeding him intragastrically, and he's tolerating it fine at this
point (started with TPN and slowly switched him to continuous enteral
feedings).  This is NOT post-pyloric feeding.  I didn't give him a
jejunostomy at the second laparotomy because the small bowel looked like it
shouldn't be messed with (it was edematous and engorged).  Are the feedings
aggravating the pancreatic fistula?  Should he still be on total bowel rest
and TPN rather than enteral feedings?

thank you for reading this far and even considering a response

CM Ursic, MD
Santa Fe
USA
-- 
'Twas brillig, and the slithy toves
Did gyre and gimble in the wabe:
All mimsy were the borogoves,
And the mome raths outgrabe.

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