Recurrent neurogenic shock as a rare postoperative complication associated with pancreaticoduodenectomy with mesopancreas excision in elderly patient: a case report.

Background: Surgical resection of locally advanced or borderline pancreatic ductal adenocarcinoma is a recognized procedure with curative intent performed in specialized oncology centers. Postoperative dysautonomia such as gastroparesis, mild hypotension, and diarrhea are common in elderly patients undergoing pancreaticoduodenectomy. A distinctive feature of our case, is the severing of an important sympathetic chain by the surgical procedure, leading to recurrent severe neurogenic shock. Locally advanced borderline tumor extension, aggressive maximal local tumor resection, and advanced age of the patient were the combined factors that explained the observed postoperative complication.

Case description: An 80-year-old woman underwent an elective R0 pancreaticoduodenectomy with total mesopancreas excision, distal gastrectomy and portal vein resection without relevant intraoperative and immediate postoperative complication. Pathology confirmed a 5.0 cm × 3.2 cm × 1.9 cm ductal adenocarcinoma in the head of the pancreas. After discharge, the patient returned to the emergency room complaining of nonspecific malaise, lipothymia, and cold sweating that was exacerbated by bowel movement attempts. During hospitalization, the patient experienced two additional severe hypotensive episodes with identical clinical presentation that required resuscitative measures in the intensive care unit (ICU). Because the third hypotensive episode developed without an obvious causal factor, apart from evacuation attempts, the hypothesis of neurogenic shock due to secondary splanchnic dysautonomia caused by extensive resection of the celiac plexus nerve structures after duodenopancreatectomy was considered.

Conclusions: This discussion is important, as it enables the care team to recognize this differential diagnosis and provide the best care for the patient. The patient was treated with sympathomimetics, fludrocortisone, and mechanisms to increase venous return when clinical improvement promptly occurred, allowing discharge from the hospital. Despite the challenging prognosis of the disease, we were able to provide the patient with moments at home with their family.