Prone position increases the risk of pancreatic fistula after laparoscopic radical gastrectomy combined with heated intraperitoneal chemotherapy: a case report

Abstract

Background: There has not been reported that prone position increases the risk of postoperative pancreatic fistula. We present a case of prone position leading to hyperthermia and pancreatic fistula in a patient with acute respiratory distress syndrome(ARDS) after laparoscopic radical gastrectomy(LRG) combined with heated intraperitoneal chemotherapy(HIPEC).Case presentation: A 68-year-old male developed moderate ARDS after LRG combined with HIPEC. Since low tidal volume and high positive end expiratory pressure(PEEP) ventilation could not improve oxygenation, prone ventilation was selected to improve heterogeneous lung injury. However, chills and fever appeared after the position change. Abdominal computed tomography (CT) showed that the mesenteric fat space in the middle abdomen was fuzzy, local exudation was increased, and the boundary of pancreas was not clear. The increase of amylase in peritoneal drainage fluid was 10 times higher than that in serum amylase. After communicating with the general surgeon, we learned that during the operation, the surgeon had opened the pancreatic capsule to clean the local lymph nodes. It was considered that prone position lead to the sharp increase of abdominal pressure, especially the change of peripancreatic pressure. The visceral organs of the abdominal cavity squeezed each other, the pancreatic tissue was compressed, the pancreatic juice extravasation occurred, and even aggravated the pancreatic fistula. In the follow-up treatment process, the patient were given continuous abdominal drainage and avoided prone position as far as possible. Since then, the patient's temperature tended to be stable. On the 10th day after the operation, the patient successfully withdrew from the ventilator and transferred to the general ward for further specialized treatment.Conclusion: Our case adds further concerns in ARDS patients after LRG combined with HIPEC, including the monitoring of postoperative pancreatic fistula and how to perform prone ventilation more safely.