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Wed Jun 27 09:40:22 BST 2007

Caesar

See my comments between your questions!

-----Original Message-----
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?
TIM SAYS: NO - there is good evidence that it does not work - not in pancreatitis, nor in trauma!
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.
TIM SAYS: Only to do a sphinctoerotomy to improve drainage from the ampulla, in the hoe it decreases the fistula drainage; otherwse let the controlled fistula drain into a stoma-bag (cut the drains short or remove them - there should be a tract by now!) and give it a tincture of time: 6 - 8 weeks is quite aceptable!
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?
TIM SAYS: No evidence in the recent studies that post-pyloric feeding has any difference to outcome / drainage rates than gastric feeding; 300ml/24 is a low-output fistula, it will slowly close, unless there is a cavity/pseudocyst: a sonar / repeat CT may be useful.

Regards
Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS  instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302

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