Triple Bypass: A case report
D. Vanitha
Nursing Superintendent, Kauvery Hospital, Tirunelveli
Abstract
Bypass surgery for cancer of the pancreatic head is usually done to palliate the obstructive symptoms in the biliary and/or digestive system. However, it is uncommon for patients to require pancreatic duct drainage for recurrent obstructive pancreatitis. 
Background
A 53 years old male came with complaints of Jaundice (yellowish discoloration of sclera and urine) for 20 days. No history of abdominal pain, melena and hematemesis. MRCP done on 31.03.2024 showed likely hemangioma and possible distal Cholangiocarcinoma with upstream dilatation of CBD and bilobar moderate intrahepatic biliary radicals (IHBR). Hence came here for further evaluation and management. Not known case of DM/HTN/CAD/CKD. Known case of Anemia on treatment.
Examination
- Patient Conscious, oriented, Afebrile.
- PR – 82/min
- BP – 130/80 mmHg
- CVS – S1 S2 (+)
- RS – Bilateral air entry (+)
- P/A – Soft
- CNS – NFND
Investigation
- Hb – 6.9 g/dl
- TLC – (3360)
- Amylase -116.2
- CEA – 5.64
- CA – 19-9 was low (9.20)
Pre-Operative CT Report
Course in the Hospital
He was planned for Side view scopy. He underwent Side view Scopy on 04.04.2024, which showed Large periampullary growth infiltrating into duodenum, biopsy taken and sent for HPE. He was started on IV fluids, IV antibiotics, PPI’s, vitamin supplements and other supportive measures.
Surgical Gastroenterologist opinion was obtained and advised for Whipple procedure. He was transfused with 1 unit of PRBC. No transfusion reaction noted. Post transfusion hemoglobin level was 9.2 g/dl.
HPE report collected on 08.04.2024, which shows detached glands and strips of duodenal mucosa with high Grade dysplasia, no evidence of malignancy in the material, studied.
Patient was planned for Whipple procedure. In view of low haemoglobin,2 units PRBC was transfused in alternate days. 2D echo done reports enclosed. Cardiology & Anesthesia fitncss obtained for procedure and advised followed. On 12/04/24, Under GA, after informed consent,patient underwent triple by-pass procedure (GastroJejunostomy, cholecystojejunostomy, jejunojejunostomy) Along with perioperative endoscopy done, biopsy was taken from lesion, Drain tube kept, wound closed in layers. Postoperatively hemodynamics stable. Incentive spirometry was advised. Patient was started on IV fluids as per need, IV antibiotics, PPIS, NSAIDs, opioids and other supportive medications.
FNAC Biopsy from lesion of 3rd part duodenum reported Smear Positive for malignancy. Repeat CBC showed Hb-8.2 gm%. Hence 2 units PRBC was transfused.
Endoscopic biopsy from duodenal growth reported Adenocarcinoma grade II. Patient vitals monitored closely. Patient Had intermittent hiccups c/o from postop day 4, treated with prokinetic drugs, antiemetic, muscle relaxants. Repeat blood tests found Mild hypokalemia, D dimer- 2.11mg/L, procalcitonin- 0.50ng/ml, total bilirubin-3.95mg/dl. Doppler study of both lower limbs venous system reported No features of DVT. Patient started on prophylactic LMWH injection once daily. USG abdomen (20/4/24) showed No collection in peritoneal cavity, Hemangioma liver, GB sludge seen. CT scan Abdomen with oral contrast (22/04/24) showed postoperative stromal edema with wall thickening in gastrojejunostomy site, irregular wall thickening in 2nd part duodenum abutting IVC, Liver Hemangioma. X ray abdomen& X ray chest taken. Hypokalemia Correction given with potassium infusion.
Patient Started on Inj.Octreotide, Inj.albumin, Inj.Prokinetic, pulse steroids and other supportive medications. Mobilization exercises and incentive spirometry were given. In view persistent hiccups, patient was given chlorpromazine Medication. Surgical wound was healthy. No soakage. On 25.04.2024, Screening Endoscopy done. Steroids tapered slowly. RT aspiration reduced. CBC and Procalcitonin was done and found to be normal. RT removed. Inj. Octreotide was stopped. Patient gradually started on diet. Hiccups stopped. Patient was comfortable. Patient general condition improved. Medical oncologist opinion obtained. Patient planned for NACT and reassessment after three cycles of resectability and if intestinal type can plan CAPEOX.
Post-Operative CT Report
Medications
| Drug | Dose | Frequency |
|---|---|---|
| Tab. Lupiheme | 1-0-0 | |
| Tab. Folvite | 5mg | 0-0-1 |
| Tab. Ganaton | 50 mg | 1-0-1 |
| Tab. Pan | 40mg | 1-0-1 |
| Syp. Sucraz | 10 ml | BD |
| Syp. Zinkovit | 10ml | BD |
Nursing Management
- Perform assessments and administer treatments
- Manage treatment-related side effects
- Provide supportive care and education
- Coordinate interdisciplinary care
- Offer emotional support and counseling
- Advocate for patient needs
- Monitor patient responses and report changes
- Facilitate access to resources and support services
- Frequent monitoring of vital signs is an essential part of management as they offer the first sign of a worsening systemic condition. Monitoring (both initially at baseline and subsequently at periodic intervals) includes parameters such as pulse rate, blood pressure, respiratory rate, fluid intake and urine output chart, blood glucose.
- Completing all necessary documentation including patient notes and discharge
Diet: Soft Solid Diet
Outcome of the patient
General condition good, Vitals stable, Nil complaints. Chest – Clear, Wound healthy
D. Vanitha
Nursing Superintendent