A short summary of the Whipple Surgery, Pancreaticoduodenectomy, the complications, and 140 day Hospital stay that followed. Most of the information is a direct copy from my Hospital discharge report (spelling mistakes have not been corrected). I have added some other information, those notes are in italics. Warning medically graphic picture links included. A more complete summary, with pictures maybe seen here : https://fap-whipple-report.blogspot.com/2025/01/a-summary-of-key-events-for-whipple_10.html
I had the Whipple Surgery in Nov 2023, it seemed to go well, 4 hrs of less in the OR. Normal as it could be the 1st few days, mild pain, walking as often as I could.
Nov
24, 2023 Nurses note “ Abdomen +++ distended and firm.” “ Patient now
complaining of 10/10 pain and laying in bed in fetal position holding
abdomen.” “ Pending CT,
form completed, IV access available.”
Nov 26,2023 Nurses note “ CT abdomen pelvis ordered on Friday. Still not done on Sunday. Action:
I spoke to CT tech on Sunday at about 1030 . She said they are aware
and when I said that CT ordered Friday and patient is having increased
pain and abdomen distended And the physicians are concerned about an
anastomotic leak. She then said they would call for him next which they
did.”
Discarge report:
The post-operative course was complicated. CT scan November 26, 2023 revealed a GJ leak( I think this should say PJ leak). CT reports says this: ”Gastrojejunostomy appears intact with no gas or localized fluid collection seen at this anastomosis site.” Two IR abdominal drains were inserted at this time. TPN was started. The PJ leak resulted in infected RUQ and pelvic collections with extension to the extraabdominal soft tissues persisting through the laparotomy incision. The abdominal collections (RUQ and pelvic) were followed with serial imaging.
CT imaging on December 15, 2023 conformed an ongoing anastamotic leak. The patient developed a HJ leak, following the PJ leak. An additional percutaneous drain was inserted on December 18, 2023. Diet was slowly increased and TPN was weaned. The drainage from the midline incision and the abdominal drains decreased.
Dec 23, 2023 CT CHEST PULMONARY ANGIOGRAM- Chest CT Scan. Reports: “
0.7 cm subpleural pulmonary nodule in the LEFT lower lobe. This is
probably a lymph node.”
CT scan on January 1, 2024 showed a stable RUQ collection, decreased pelvic collection and no evidence to suggest an active enterocutaneous fistula or bowel leak. He was discharged home January 5, 2024.
Jan 5, 2024 Discharged from Hospital. Fistula pictures 20240105_103422.jpg 20240105_103803.jpg
Staying with friends, while out of the hospital, I was seen by a team of Home Care nurses. Struggled with eating, cramping, bloating, pain and still having fluid, or paste leaking from 2 small openings ( fistula) in the incision. 20240112_095135.jpg Jan 13_110239.jpg 20240113_110240.jpg 20240113_111244.jpg
Jan 18, 2024 saw surgeons assistant, drain removed, and prescribed Creon (pancrelipase) a pancreatic enzymes, to help with digestion issues.
I can’t help wondering if the Creon did cause more damage to internal tissue when it got into the fistula? Not sure if there needs to be a stronger warning on the medication. Things were starting to improve before I started to take the Creon. Jan 19, 2024 Home Care note: “ Wound opening significantly smaller and slightly hyper granulated.” 20240119_111836.jpg
Jan 26, 2024 notice strange stringy material hanging out of what was now only one opening in the incision. 20240126_123144.jpg
Jan
27, 2024 a new larger opening in the incision, with fleshy looking
material hanging out of both openings ( an new opening had now formed) 20240127_232745.jpg . Went to the Emergency Dept.
Scott was re-admitted to the Hospital on January 29, 2024. CT abdomen/pelvis (January 28, 2024): At the superior aspect of previous midline laparotomy site, there is a skin defect with increased size of a subincisional collection which now contains fluid and scattered foci of gas throughout. EMR Report-9.png
Jan 28, 2024 Nurse Notes: “ Writer assessed patient and found dressing, including abd pads, completely soaked with bile to the point of dripping.Writer removed the dressing and found a puddle of bile with mucous underneath. Cleaned with moist towels. Incision had large attached lump of slough. Writer cleaned around it several times. Skin surrounding was excoriated and painful. After a few wipes, hte slough piece lifted on the right then completely, to reveal a crater-like hole approximately the size of a golf ball and about 2cm deep.” 20240129_020315.jpg EMR Report-273 copy.png 20240129_040238.jpg
February 2, 2024 - IR failed PTC insertion due to undilated ducts and unfavorable anatomy. Pt was made NPO, TPN was started and Octreotide was added.
Feb 4, 2024 - CT showed new portal vein thrombus throughout the horizontal and ascending branch left portal veinextending into segment II and III portal veins. Theraputic tinza was started for same.
Feb 9, 2024 - Red rubber catheter inserted into the fistula. Plan for sinogram.
Feb 11, 2024 - RF Sinogram showed a small amount of contrast is seen opacifying the biliary tree.
Feb
15 PICC line ordered then cancelled. After discussion with Resident Dr
and NP PICC was re-ordered and started TNP feeding. No notes of this
were made other than my private notes on my phone. “ PICC line oredered,
then canceled at last minute, and asked to start eating. Didn't make
sense to me so asked to stay on original plan un till stent attempt in 7
days. Out put to Wound manager is down, I thought that was the goal of
the IV Perolimel feeding? Now will be on TPN feeding, better nutrition
to help healing.”
Feb 22, 2204 - PTC drain successfully placed. After placement of the PTC drain, the midline output started to decrease and the right upper abdominal cramping and pain improved.
March 7, 2024 - Clear fluids re-introduced. Tolerated well. March 13, 2024 - Diet advanced to include Ensure and full fluids.
Mar 14, 2024 Full Fluids started I noted: “ 5pm, paste looks like chocolate insure,” had a chocolate insure earlier, took pictures and showed team. 20240314_165722.jpg 20240314_170813.jpg 20240314_170822.jpg
March 15, 2024 - Fistula output increasing. Thick creamy drainage noted. A red rubber catheter was placed into the fistula and a RF sinogram was ordered which showed:
1. Gastrocutaneous fistula. Approximately 50 cc water-soluble contrast was injected into the fistula via this catheter and immediately opacifies the stomach through opening in the oversewn distal end of stomach. Confirmation that the opacified structure is stomach evidenced by emptying via the gastrojejunostomy and opacification of proximal small bowel along the left lateral aspect of the abdomen.
March 18, 2024 - Successful PTC exchange with cholangiogram was performed through a sheath with nohepaticojejunostomy leak identified. There was excellent opacification of the biliary ducts, with contrast seen flowing freely into the duodenum. PTC clamped. Fistula output decreasing with TPN and Octreotide.
Apr 2, 2024 I noted “ Clean gauze, no out put since 9 am the day before. Just some dryed blood around fistula. “ The day the fistula seem to close over. 20240402_063211.jpg
April 4, 2024 - NJ placed and enteral feeds started. Midline output almost nil.
April 9-17, 2024 - Enteral feeds appropriately increased according to patient's tolerance. TPN weaned and stopped. CT A/P (April 17, 2024) - Internal/external biliary drain with interval resolution of the previously seen right upper quadrant and abdominal wall fluid collection, known to represent a bile leak. No new collection. Now chronic thrombosis of the left portal venous system with decrease in caliber. No new findings
April 18-25, 2024 - Enteral feeds changed from 24 hour to cycled over 16 hours. Referred to HENT and teaching completed for DC home.
Jun 24, 2024 Scab fell off fistula. 20240624_070243.jpg 20240624_210049.jpg
July 4, 2024 Hospital visit - General Surgery Clinic. NJ Feeding tube removed.
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