Topical Area: Medical Nutrition
PN is a mainstay for ECF after pancreatoduodenectomy. LC has been studied for cutaneous wound healing. Oct lacks consistent evidence in ECF but may be beneficial with soft pancreatic texture or small ducts, as in pediatric patients. Prior experience suggests that intravenous Oct is superior for ECF than intermittent forms. This case demonstrates the value of isonitrogenous PN, LC and Oct infusion in ECF management.
A 59-year-old male with familial adenomatous polyposis underwent pancreaticoduodenectomy. He returned to the OR after 4 weeks for abscess drainage, cholecystojejunostomy with transhepatic stent, and small bowel resection. The patient returned from rehabilitation 6 months later with persistent fistula output from recurrent ECF. We started on PN and subcutaneous Oct (100 mg TID). The PN amino acid content was guided based on nitrogen balance data. Carnitine levels were very low and LC (1,000 mg) was added to the PN.
The patient continued to have high volume fistula output and returned to the OR for closure of an anterior ECF, which was followed by development of a right-sided and left-sided ECFs. Continuous infusion of Oct was initiated at 250 mcg/d and gradually ramped-up by 250 mcg/d increments to 1500 mcg/d. ECF fluid output decreased with each step. Complete closure of ECFs was seen after 4 weeks. Oct drip was ramped downward by 250 mcg increments/d and discontinued. The patient advanced his diet and PN was discontinued. He was discharged to rehabilitation without re-emergence of ECF.
This case demonstrates the value of combination isonitrogenous PN, LC and continuous Oct for ECF. Nitrogen balance based amino acid intake ensured PN nutritional adequacy. Car was similarly based on actual patient data rather than empiric therapy. A continuous Oct ramping protocol enabled judgement of the beneficial effect and determine the need for further dosage increases. Continuous infusion was superior to the previous intermittent Oct. It is possible that the continuous infusion induced more significant suppression of gastrointestinal secretions than subcutaneous Oct administration, thereby improving its efficacy.
Combination therapy with PN, Car continuous Oct could be an effective approach for ECF management for patients who have failed surgery and standard medical therapy.
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