Post-gastrectomy acute pancreatitis in a patient with gastric carcinoma and pancreas divisum

Abstract

Gastrectomy is commonly performed for both benign and malignant lesions. Although the incidence of post-gastrectomy acute pancreatitis (PGAP) is low compared to other well-recognized post-operative complications, it has been reported to be associated with a high mortality rate. In this article, we describe a 70-year-old man with asymptomatic pancreatic divisum who underwent palliative subtotal gastrectomy for an advanced gastric cancer with liver metastasis. His post-operative course was complicated by acute pancreatitis and intra-abdominal sepsis. The patient eventually succumbed to multiple organ failure despite surgical debridement and drainage, together with aggressive antibiotic therapy and nutritional support. For patients with pancreas divisum or dominant duct of Santorini who fail to follow the normal post-operative course after gastrectomy, clinicians should be alert to the possibility of PGAP as one of the potential diagnoses. Early detection and aggressive treatment of PGAP might improve the prognosis.

Figure 1

The esophagogastroduodenoscopy (EGD) showed an ulcerated, annular lesion over the gastric antrum.

Figure 2

Preoperative abdominal CT images in coronary and transverse sections. The white solid arrows indicate diffuse wall thickening at the gastric antrum. The white dotted arrow indicates a contracted gallbladder with eccentric wall thickening. The black solid arrows point to the apparent deformity of the duodenal bulb with adhesion to the head of the pancreas. There is no evidence of intra-abdominal metastasis in this study.

Figure 3

Abdominal CT 8 d after the first operation demonstrates massive fluid accumulation in the peripancreatic area and the lesser sac. The homogenous fluid extends to the retroperitoneal space. The status of the duodenal stump (black arrow) cannot be clearly assessed. The pancreas is well enhanced and enlarged, and the head shows an uneven and infiltrative margin (white arrow).

Figure 4

Follow-up abdominal CT after the second operation. Severe fat stranding is seen. An edematous duodenal stump is observed without a clear fat plane surrounding it. This is highly suspicious of a stump leak (black arrow). The loculated fluid with heterogeneous changes indicates the possibility of an abscess formation (white arrow).

Figure 5

The preoperative CT scan. The dominant dorsal duct (duct of Santorini) drains into the minor papilla (white arrow). The CBD is seen in the section (black arrow) but the ventral duct (duct of Wirsung) can not be traced. These features are consistent with pancreas divisum.