The unfortunate events of bowel ischaemia post-Whipple surgery

Abstract

Pancreaticoduodenectomy is an extensive procedure with multiple postoperative complications which include surgical site infections, bleeding, delayed gastric emptying, and anastomotic leakage. Among all, postoperative bowel ischaemia is the rarest complication that might be difficult to diagnose and ascertain the cause. If it is left untreated, it may lead to mortality.The aim is to describe the management of bowel ischaemia post-Whipple surgery.A 76-year-old female patient underwent a Whipple procedure for adenocarcinoma of the ampulla which was complicated by postoperative bowel ischemia. A series of investigations, namely endoscopy and imaging, revealed postoperative bowel ischemia beyond the gastro-jejunostomy anastomosis. The patient underwent a series of surgeries and was eventually discharged well. The final histology was consistent with pancreatic cancer and did not require adjuvant chemotherapy.Bowel ischemia in any major surgery occurs due to thrombosis. It is multifactorial including cancer patients, complex reconstruction and major surgery. Identification of thrombosis early in the postoperative follow-up is difficult due to non-specific symptoms, postoperative paralysis of the gastrointestinal tract and modified pain reaction after analgesia. Once diagnosed, the goal is for cessation of thrombosis and fibrinolytic destruction of the thrombus.Bowel ischemia post-Whipple procedure is rare yet dreaded and requires a high level of clinical suspicion. Once diagnosed, an aggressive approach is needed, including relaparotomy and relook surgery. This complication is salvageable with a controlled fistula and adequate nutrition support.