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Wed Jun 27 14:51:36 BST 2007

Excellent management.
To answer your questions:
1.Octreotide: we don't use it=no evidence it impacts recovery 
2.Feeding: if he is tolerating it you are doing well. We would try to
place a NCJ but if the bowel didn't look good, we would try to pass a
dobhoff post pyloric intra-op; but if trans-gastric is working, great..
3.ERCP was not indicated in your case-it was obvious you had to resect.
It may have a role in equivocal cases where injury or duct disruption is
initially not clear. We don't do it "to improve drainage"
4.You are fortunate that the colonic anastamosis has held in the face of
the pancreatic fistula... 
5. Be patient.... the fistula should heal with good drainage.
Good job!
Jeffry L. Kashuk, M.D, FACS
Surgery, Trauma, Surgical Critical Care
Denver Health Medical Center
777 Bannock St, MC 0206
Denver, CO 80204
Ph 303-436-6558
Fax 303-436-6572

-----Original Message-----
From: caesar ursic [mailto:cmursic at gmail.com] 
Sent: Tuesday,June 26,2007 10:19 PM
To: Trauma &amp, Critical Care mailing list
Subject: Tales of the Pancreas

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=ShowDet
ailView&TermToSearch=8480272&ordinalpos=5&itool=EntrezSystem2.PEntrez.Pu
bmed.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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