Welcome to morning session

Dept of Surgery
Unit-2
Particulars of the patient:
Name: Mrs. Shorifa Akhter
Age : 40 years
Sex : Female
Religion : Islam
Occupation: Housewife
Address : Lalmatia, Mohammadpur,Dhaka
Phone No: 01706432968
Date of admission: 1 November 2022
Presenting features :
1. Repeated episodes of pain in the upper abdomen
for last 1 year. Which initially started as sudden
colicky in nature. But subsequently became
constant with variable intensities.
2. When the severity increases in intensity it often
persists for hours or days which prevents her
from daily works and sleeping.
Presenting features (contd..)
3. The pain aggravates by fatty meal. Relieved by
sitting or leaning forward. Sometimes radiates to
back
4. Nausea and vomiting for same duration.
History of past illness:
History of repeated hospitalization due to chronic
pancreatitis. Never suffered from jaundice. No
history of blood transfusion
Personal history:
•Menstrual history-
Age of menarche :14yreas
Cycle:Regular
Period:4 days
Flow: Average
LMP:18.10.2022

•Obstetrical history :-
para:1(C/S)+0
Age of last child: 12 years
Family history:
All family members are apparently healthy

Drug history:
History of analgesics abuse
General Examination:
Appearance - I'll looking Dehydration- absent
Body built - average Oedema - absent
Cooperation - cooperative Clubbing- absent
Decubitas- lying Thyroid gland- not enlarged
Anaemia - absent Lymph nodes - not palpable
Jaundice- Present, mild JVP- not raised
Cyanosis- absent
Clubbing- absent
Local Examination :
Abdomen:
Inspection:
•Shape of the abdomen:scaphoid
•Position of the umbilicus:centrally placed
•Movements of the abdomen:thoraco-abdominal
•No visible peristalsis
•No engorged vein
•Scarmark: absent
Palpation:
•Temperature:Not raised
•Tenderness:No superficial tenderness but deep tenderness in
epigastric region
•No organomegaly or mass found
Local Examination (contd.)
Percussion- Tympanitic
Shifting dullness- absent
Auscultation
Normal bowel sound-present
Digital Rectal Examination- Not done
PV Examination - Not done
Systemic Examination
Other systemic examinations reveals no obvious
abnormality.
Provisional Diagnosis:

Chronic Pancreatiis
Differential diagnosis:
Chronic PUD
Chronic cholecystitusy/Cholangitis
Investigations : (on 4/11/22)
COMPLETE BLOOD COUNT
•WBC: 7.14x 10^9 /L
▪Neutrophil: 56%
▪Lymphocyte: 35%
▪Eosinophil: 6%
▪Monocyte: 3%
▪Basophil: 0%
•Hb%: 12g/dL
•RBC: 4.09x 10^12 /L
•Platelet: 350x 10^9 /L
•ESR: 20mm in1sthour
CLINICAL BIOCHEMISTRY (on 4/11/22)
•RBS: 6.12mmol/L
•Creatinine: 0.54mg/dL
•Serum Electrolytes
▪Na+: 138mmol/L
▪K+: 3.19mmol/L
▪Cl-: 104mmol/L
▪HCO3 : 25mmol/L
Investigations (contd.) • • • (4/11/22)
• Total protein : 71.7 gm/L
Albumin: 49.5 gm/L
Calcium : 9.36 mg/dL
Magnesium: 1.79 mg/dL
Lipase: 11.6 U/L
HBsAg (screening) : negative
TSH : 1.78 uIU/mL
Investigations (contd.)

XRAY CHEST (P/A VIEW)

IMPRESSION: Findings
are of a normal XRay Chest
Investigations (contd).

XRAY WHOLE ABDOMEN

IMPRESSION:
Radio-opaque shadow resembling
morphological anatomy of MPD &
it’s secondary branches.

Diagnosis: multiple pancreatic

calculi
USG of HBS and Spleen:
Liver: Normal in size and uniform in tissue character. No focal or
diffuse lesion is seen.
Gall bladder:Gallbladder is normal in size & shape. The wall is not
thickened. Sludge noted within the gallbladder.
Biliary tree : Not dilated.
Pancreas: appears normal in size. Pancreatic duct is dilated (8 mm).
Multiple echogenic structures are noted in the dilated duct at the head
of pancreas.
Spleen: normal in size and tissue character.
USG of KUB and Pelvic organs:
Kidneys: Normal in size, shape and position with well differentiated
cortex and medulla. The pelvi-calyceal systems are not dilated. At
present - there is no evidence of calculus or any focal lesions.
Urinary bladder: Urinary bladder is well filled. The wall is not
thickened. No intrinsic lesion is seen.
Uterus: Normal in size and anteverted in position.Myometrium is
homogeneous.Endometrial thickness is normal. Cervix is elongated.
Adnexae: Both adnexal regions are normal.
Impression
Sludge within the gallbladder.
Dilated pancreatic duct with calculi.
Clinical diagnosis:
Pancreatic duct
calculi
Next plan:
• Counsel the patient about the diagnosis and
treatment and its outcomes.
Operation note
•Date & time: 9/11/22 @ 11:30AM
Indication: Pancreatic duct calculi
•Operation done: Pancreaticolithotomy with
pancreaticoJejunostomy with Roux-en-Y
jejunojejunostomy.
•Anaesthesia:G/A by Dr. Ani
•Surgeons:
Prof. Dr. Md. Rezaur Rahman Talukdar
Dr. Ziaur Rahman
Dr. Shusmita
Dr. Faiyaz ; Dr. Mohua
Operation Findings:
1 There were extensive adhesions in the upper
abdomen.Between the stomach, liver, greater
omentum, gall bladder etc. The posterior wall of the
stomach was also adherent with the posterior
abdominal wall, closing the lesser sac.
2. The pancreas was swollen, mostly hard and
nodular with big calculi within the grossly dilated
pancreatic duct.
3. The pancreatic duct also contained some dirty
turbid fluid mixed with lots of granular particles.

4. Most of the stones were located in the body and

head regions.
Procedures:
After dividing the gastro-colic segment of the greater omentum
the lesser sac was exposed. And the Pancreas was identified.
Stones within the main pancreatic duct were located by
needling. The MPD was opened longitudinally along the body
and head portion. And the calculi were removed.
The duct was thoroughly flushed with normal saline. And a side
to side pancreatico jejunostomy (type- Eder-Puestow) with
Roux-en-Y jejuno jejunostomy was done.A drain tube was left in
situ beside the pancreaticojejunostomy. And the abdomen was
closed in layers.
The pancreas is exposed and
the main pancreatic duct is
opened from the head to the
tail of the pancreas. The
opened pancreatic duct is
then connected to a loop of
jejunum. The proximal end of
jejunum which is situated
30cm below the dudeno-
jejunal junction was
connected with another end
of jejunum
Per-operative
photos:

Identification of
the duct by
syringing
Per-operative
photos:
Opening of the main
pancreatic duct
Stone in the
main
pancreatic
duct (MPD)
Multiple stones collected
from the pancreatic duct
Formation of window in
greater omentum
Pancreatico
jejunostomy
Roux-en-y
Pancreatico
jejuno
jejunostomy
Per Operative x ray
 Post Operative management:
•NPO for 5 days.Then gradually switch over to
oral feeding.
•Inf. 5%DNS (1L)+ Inf. Hartsol (1.5L)
I/V @ 25d/min
•Inj. Ceftizone (2gm)
1vial I/V and 12 hourly
•Inj. Filmet (500mg)
1bottle I/V 8 hourly
•Inj. Pethidine (75mg)
I/M when patient comes around
•Inj. Emistat (8mg)
1amp. I/V along with pethidine
•Inj. Maxpro (40mg)
I/V 12 hourly
•Inj. Napa (100ml)
1 bottle I/V @10 d/min 8 hourly
THANK YOU
DISCUSSION