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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 3  |  Issue : 2  |  Page : 158-160

Early adhesive colonic obstruction post-radical gastrectomy – Do not forget the pancreas


Department of Surgical Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh, India

Date of Submission05-Aug-2020
Date of Decision03-Sep-2020
Date of Acceptance02-Feb-2021
Date of Web Publication04-Jun-2021

Correspondence Address:
Dr. Karthik Chandra Vallam
Flat 202, Door No. 8-3-13/3, Prasiddha Residency, Palace Layout, Peda Waltair, Visakhapatnam - 530 017, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_141_20

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How to cite this article:
Vallam KC, Alluri V, Voonna M. Early adhesive colonic obstruction post-radical gastrectomy – Do not forget the pancreas. J Med Evid 2022;3:158-60

How to cite this URL:
Vallam KC, Alluri V, Voonna M. Early adhesive colonic obstruction post-radical gastrectomy – Do not forget the pancreas. J Med Evid [serial online] 2022 [cited 2022 Oct 5];3:158-60. Available from: http://www.journaljme.org/text.asp?2022/3/2/158/355006




  Introduction Top


Radical gastrectomy with D2 lymphadenectomy is the standard surgical procedure for gastric cancer. The incidence of post-operative complications of this procedure ranges from 12.8 to 14%.[1] The most common early complications are anastomotic site bleeding, anastomotic leakage, duodenal stump dehiscence and pancreas-related complications. Herein, we describe a unique complication which has not been reported in the literature as per our literature search.


  Case Report Top


A 35-year-old patient presented with epigastric pain, dyspepsia for 2 months which gradually progressed to loss of appetite. On clinical examination, there were no other contributory findings, except for mild pallor. On upper gastrointestinal endoscopy, there was a large ulcero-proliferative growth involving the lesser curvature, mid-body of the stomach along the posterior wall and extending into the fundus of the stomach. Biopsy revealed moderately differentiated adenocarcinoma, intestinal variant. Contrast-enhanced computed tomography (CT) abdomen showed a large mid-stomach lesion with loss-of-fat planes with the pancreas and few enlarged perigastric and left gastric nodes [Figure 1]. There were no distant metastases (including omental/mesenteric/liver metastases). Diagnosis of locally advanced gastric cancer was made and neo-adjuvant chemotherapy was initiated with three cycles of epirubicin, oxaliplatin, capecitabine chemotherapeutic regimen. Response assessment CT scan showed a very mild reduction in the size of the tumour, and the tumour still appeared to be adherent to the body of the pancreas focally. A multi-disciplinary tumour board decision was taken to proceed with surgery in view of the limited response to chemotherapy.
Figure 1: Pre-operative computed tomographic scan showing the tumour being adherent to the pancreas

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The patient underwent an open, radical total gastrectomy and a D2 lymphadenectomy with a retrocolic Roux-en-Y oesophagojejunostomy (end-to-side stapled anastomosis). Feeding jejunostomy was done to initiate early feeding. A nasojejunal tube was placed across the anastomosis. Intra-operatively, the tumour was adherent to the pancreas and the tumour was shaved off the pancreas and left crus of the diaphragm. Post-operatively, on day 2, he developed epigastric pain and tachycardia which initially responded to analgesics. Patient was managed conservatively with bowel rest and analgesia. There was mild abdominal tenderness. Serum electrolyte levels were normal. However, the next day, abdominal distension and pain progressed. Tachycardia was persistent, and an erect abdominal X-ray showed dilated small bowel loops predominantly [Figure 2]. In view of failure of a conservative management protocol, we proceeded with exploratory laparotomy. Intra-operatively, there were massively dilated small bowel and proximal colon up to a point just beyond the hepatic flexure. However, there was evidence of saponification changes over the adjacent mesocolon with oedematous pancreas, suggestive of acute pancreatitis [Figure 3]. The colon was adherent to this area, and the distal colon was collapsed. The colon was separated from this acutely inflamed area. The proximal bowel was decompressed with a nasojejunal tube. Extensive wash was given. Two wide-bored drains were placed over the pancreatic region. Post-operatively, he received broad-spectrum antibiotics and octreotide. Serum amylase and lipase levels were 751 and 521 IU/L, respectively. He had an uneventful recovery and was discharged on the 8th day post-second surgery.
Figure 2: Abdominal X-ray showing dilated small bowel loops

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Figure 3: Saponification of the mesocolic fat suggestive of acute pancreatitis changes. Dilated small bowel and adjacent duodenal stump can be seen

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  Discussion Top


Acute intestinal obstruction post-gastrectomy is extremely rare, and here, we present a case of adhesive colonic obstruction post-gastrectomy which to our knowledge is the first of its kind in the literature. Here, the cause of the obstruction was probably acute pancreatitis arising due to micro-trauma at the time of dissection of the tumour off the pancreas. Although there was no structural injury to the pancreas intra-operatively, extensive handling of the pancreas would have triggered the onset of pancreatitis subsequently.

Post-gastrectomy pancreatic complications are infrequent and have an incidence of around 1% as per the meta-analysis by Guerra et al. Acute pancreatitis and pancreatic fistula have been described. Pancreas-related complications tended to occur more frequently in the minimally invasive (1.24%) than in the open (0.91%) group as per this analysis.[2]

White et al. published a case series of 733 patients who underwent biliary or gastric surgery. The incidence of post-operative acute pancreatitis was 9.5%. They suggested that a diagnosis of post-operative pancreatitis could be made if one or more of the following criteria were fulfilled: (1) a rise in serum amylase or serum lipase levels to five times normal or greater; (2) operative findings of fat necrosis, induration or calcification; (3) histologic evidence obtained at operation. In our patient, both the first two criteria are met.[3]

Nakanishi et al. have described three mechanisms of fluid leakage post-radical gastrectomy – (1) thermal injury to the pancreatic parenchymal surface, (2) blunt injury to the pancreas during retraction of the pancreas by the assistant surgeon and (3) direct injury to the pancreatic tail while mobilisation during total gastrectomy with splenectomy or distal pancreatico-splenectomy. Elevation of drain amylase in the immediate post-operative period is a predictor of post-operative pancreatic fistula and is an indication for retaining the drain longer.[4]

Another rare cause of post-gastrectomy pancreatitis is the obstruction of the afferent loop. Kinking of the afferent limb post-gastrectomy either acutely or chronically leads to raised back pressure, distension of the duodenum, dilatation of the pancreatic duct and pancreatic inflammation. Multiple case reports have described this syndrome.[5],[6]

Although there may not be a case for routine evaluation of drain fluid amylase in all gastrectomy patients, it may be prudent to evaluate these levels when extensive dissection has been performed adjacent to the pancreas and keep a low threshold of suspicion of pancreatitis or fistula. Early detection and intervention will lead to better outcomes in such patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wang S, Xu L, Wang Q, Li J, Bai B, Li Z, et al. Postoperative complications and prognosis after radical gastrectomy for gastric cancer: A systematic review and meta-analysis of observational studies. World J Surg Oncol 2019;17:52.  Back to cited text no. 1
    
2.
Guerra F, Giuliani G, Iacobone M, Bianchi PP, Coratti A. Pancreas-related complications following gastrectomy: Systematic review and meta-analysis of open versus minimally invasive surgery. Surg Endosc 2017;31:4346-56.  Back to cited text no. 2
    
3.
White MT, Morgan A, Hopton D. Postoperative pancreatitis. A study of seventy cases. Am J Surg 1970;120:132-7.  Back to cited text no. 3
    
4.
Nakanishi K, Kanda M, Sakamoto J, Kodera Y. Is the measurement of drain amylase content useful for predicting pancreas-related complications after gastrectomy with systematic lymphadenectomy? World J Gastroenterol 2020;26:1594-600.  Back to cited text no. 4
    
5.
Alawneh I. Afferent loop obstruction after gastrectomy simulating acute pancreatitis. Int Surg 1980;65:415-7.  Back to cited text no. 5
    
6.
Conter RL, Converse JO, McGarrity TJ, Koch KL. Afferent loop obstruction presenting as acute pancreatitis and pseudocyst: Case reports and review of the literature. Surgery 1990;108:22-7.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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