NPWT Management of Burst Abdomen in Pancreatic Juice Leak Following Distal Pancreatectomy Complicated by Tuberculosis

Authors:
Adianto Nugroho, Aditomo Widarso, Indah Jamtani, Rofi Y Saunat

Body of Abstract:
Introduction

Pancreatic fluid collection after distal pancreatectomy is common and can be managed conservatively. However, in some cases, it can lead to a devastating sequel, such as a burst abdomen.

Case Illustration

A 55-year-old male was consulted to the digestive surgery service with acute abdomen 24 hours after endoscopic drainage of pancreatic pseudocyst. The patient was diagnosed with cystadenoma of the pancreas tail, and the endoscopist internist successfully did endoscopic internal drainage of the cyst. However, one day after the procedure, the patient complained of severe abdominal pain accompanied by nausea, vomiting, and fever. His laboratory showed a marked leukocytosis, and a repeat abdominal CT scan showed a large amount of intraperitoneal air, which was a deliberate process of the endoscopic procedure. The decision to take the patient to surgery was made after 12 hours of conservative management failed. Upon exploration of the abdomen, we discovered pancreatic juice collection at the left paracolic gutter and pelvic floor. We performed a formal distal pancreatectomy, using a linear cutter, along with the spleen, and primary repair of the stomach. A large peritoneal drain was left at the peripancreatic space and another at the pelvic floor. The abdomen was cleansed with sterile saline and sutured closed. In the postoperative follow-up, pancreatic juice leakage through the peripancreatic drain was confirmed by amylase workup of the fluid. The pancreatic juice leaked through the abdominal incision as well, causing a burst abdomen by postoperative day 6. The patient had also developed an overwhelming post-splenectomy infection in the form of hospital-acquired pneumonia and was admitted to the ICU.
Meanwhile, pancreatic juice leakage was treated conservatively with optimal drainage through the peripancreatic drain, and a negative pressure wound therapy (NPWT) device was applied to treat the burst abdomen. The pathology examination of the specimen revealed a pancreatic pseudocyst with no signs of malignancy. We screened the patient for tuberculosis as another factor in his slow healing, and oral anti-tuberculosis (OAT) medicine was administered. Soon after the administration of OAT, the pancreatic juice drainage slowly reduced, and his abdominal wall defect showed progress. The patient recovered from OPSI, and his abdominal wall defect was healing well with VAC. He was discharged POD-30 for homecare with the VAC device still applied and was scheduled for abdominal wall closure within the next month.

Conclusion
Conservative management of pancreatic juice collection can be successful owing to detailed and comprehensive patient management. In endemic regions, tuberculosis should always be suspected in slow-recovering patients.