Keywords
postoperative pancreatic fistula
Whipple procedure
high-flow nasal oxygen
How to Cite
Abstract
Background: Postoperative pancreatic fistula (POPF) remains one of the most serious complications following pancreaticoduodenectomy and may lead to sepsis, respiratory failure, and acute respiratory distress syndrome (ARDS). Respiratory management in these patients is particularly challenging because positive-pressure ventilation may increase the risk of gastrointestinal anastomotic disruption and worsen postoperative outcomes.
Case Presentation: This report describes a case of moderate acute respiratory distress syndrome (ARDS) due to postoperative pancreatic fistula (POPF) in a 68-year-old female following a Whipple procedure for pancreatic head adenocarcinoma. The patient developed progressively worsening hypoxemia, respiratory distress, tachypnea, and hemodynamic instability. Computed tomography revealed bilateral pulmonary infiltrates consistent with ARDS, gastric distention, and intra-abdominal inflammatory changes (due to the presence of POPF). Markedly elevated amylase and lipase levels from drains confirmed the diagnosis of POPF.
Results: Because of the recent gastrointestinal reconstruction and the potential for anastomotic compromise, both continuous positive airway pressure and non-invasive ventilation were not used for this patient. Conservative care included high-flow nasal oxygen (HFNO), broad-spectrum IV antibiotics, gastric decompression, nutritional support, and multidisciplinary care in the intensive care unit. The patient demonstrated continued improvement in respiratory and clinical status without the need for reintubation and or invasive mechanical ventilation. HFNO was progressively weaned; enteral nutrition was reinitiated successfully; and the patient was discharged from the hospital in a clinically stable condition.
Conclusions: This case illustrates that HFNO has the potential to be an effective method of providing respiratory support for ARDS due to POPF after a Whipple procedure, particularly in the patient population at risk of postoperative anastomotic complications from positive-pressure ventilation.
References
Bassi C, Marchegiani G. Updates on pancreatic fistula after pancreaticoduodenectomy. Lancet Gastroenterol Hepatol. 2021;6(6):482–494.
Pulvirenti A, Marchegiani G, Pea A, et al. Clinical implications of postoperative pancreatic fistula. Br J Surg.2020;107(7):784–793.
Matthay MA, Zemans RL, Zimmerman GA, et al. acute respiratory distress syndrome. Nat Rev Dis Primers.2021;7:18.
Futier E, Jaber S. Non-invasive ventilation after abdominal surgery. Curr Opin Crit Care. 2020;26(4):367–374.
Oczkowski S, Ergan B, Bos L, et al. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J. 2022;59(4):2101574.
Ranieri VM, Rubenfeld GD, Thompson BT, et al. Berlin definition of ARDS: updated perspectives. Intensive Care Med. 2021;47:1440–1443.
Frat JP, Ricard JD, Marjanovic N, et al. High-flow oxygen therapy in acute hypoxemic respiratory failure. N Engl J Med. 2021;384:1309–1319.
Papazian L, Aubron C, Brochard L, et al. Formal guidelines: management of ARDS. Ann Intensive Care.2020;10:69.
Gianotti L, Sandini M, Biffi R, et al. Nutritional support after pancreatic surgery. Nutrients. 2021;13(6):1976.