1. Second to Fourth Hospital Day (1st to 3rd post-op day) maintained on NPO pre-operative antibiotic continued Vital Signs: BP=110-140/60-90, HR=76-112, RR=18-30, Temp=36.7-38.90C Drains: –Jackston Pratt drain – 100 cc/day, serosanguinous –Tube Jejunostomy – 50 cc, bilous (initial drain at 3rd day post-op or 4 th hospital day) –Pancreatic stent – 60 cc, clear (initial drain at 3rd day post-op or 4 th hospital day) –NGT – 500 cc, clear (initial drain at 3rd day post-op or 4 th hospital day)

2. Fifth to Seventh Hospital Day (4th to 6th post-op day) Jejunostomy feeding started –10 cc/hr (4th post-op day) –20 cc/hr (5th post-op day) –50 cc/hr (6th post-op day) vital signs: : BP=100-130/60-90, HR=70- 110, RR=26-34, Temp=36.0-38.80 C

3. Drains: –JP drain – 240 cc/day, serosanguinous –tube duodenostomy – 120 cc/day, bilous –pancreatic stent – 80 cc/day, clear –NGT – 110 cc/day, clear CBC, CXR, urinalysis were done Rx shifted to Piperacillin-Tazobactam 4.5 mg IV q8

4. CBCAdmission5 th HD Hemoglobin9883 MCH29.129 Hematocrit2825 MCV8587 MCHC33 RBC3.32.8 WBC16.915.3 Differential count Neutrophils Lymphocytes Monocytes Eosinophils Basophils Stabs 89 10 1 90 10 Platelet198355 RBC morphologySl. hypochromic, normocytic hypochromic, normocytic

5. UrinalysisAdmission5 th HD ColorYellowOrange TurbidityCloudyTurbid ReactionAcidic Specific Gravity1.0301.015 ProteinnegativeNegative SugarTraceNegative RBCPlentynone WBC8-12/hpf40-50/hpf CastsNone0-3/hpf BacteriaNoneAbundant Epithelial CellsNone Mucus threadsNonenone Amorphous uratesmoderate

6. Imaging StudiesImpression Plain Abdominal X- ray(Admission) Consider fecal stasis, however, if melena is present, CT scan is suggested. Chest X-ray (1 st HD) Pneumoperitoneum; clear lungs; atherosclerotic aorta Chest X-ray (5 th HD) Clear lungs, no evidence of pneumomediastinum, pneumothorax, hemomediastinum or hemothorax seen, atherosclerotic aorta, thoracic spondylosis, pneumoperitoneum is not evident in this study, taken in supine position.

7. Eighth to Tenth Hospital Day (7th to 9th post-op day) NGT accidentally removed and not reinserted Oral feeding with clear liquids started, then progressed to general liquids feeding jejunostomy maintained at 100 cc/hr vital signs: BP=90-140/60-90, HR=72-90, RR=22-36, Temp=36.5-38.10C Drains: –JP drain – 200 cc/day, serous –Tube duodenostomy – 250 cc/day, bilous –Pancreatic stent – 150 cc/day, clear

8. Eleventh to Thirteenth Hospital Day (10 to 12th post-op day) vital signs: BP=100-120/70-80, HR=76-92, RR=24-30, Temp=37-39.20 C drains: –JP drain – 300 cc/day, bile stained –tube duodenostomy – 300 cc/day, bilous –pancreatic stent – 170 cc/day, clear repeat CBC done

9. Imaging StudiesImpression Plain Abdominal X- ray(Admission) Consider fecal stasis, however, if melena is present, CT scan is suggested. Chest X-ray (1 st HD) Pneumoperitoneum; clear lungs; atherosclerotic aorta Chest X-ray (5 th HD) Clear lungs, no evidence of pneumomediastinum, pneumothorax, hemomediastinum or hemothorax seen, atherosclerotic aorta, thoracic spondylosis, pneumoperitoneum is not evident in this study, taken in supine position. Abdominal Ultrasound (13 th Hospital Day) Minimal fluid collection/ascites in right paraduodenal fossa; moderate ascites in right paracolic gutter and pelvic region; incidental finding of gallbladder sludge

10. Fourteenth Hospital Day (13th post-op day) Patient now afebrile Stable vital signs Drains: –JP drain – 200 cc/day, bile stained –Tube duodenostomy – 300 cc/day, bilous –Pancreatic stent – 200 cc/day, clear Patient noted to have slightly distended abdomen Ascites on abdominal ultrasound

11. Anastomotic leak entertained –managed conservatively via multiple intra-abdominal drains placed post-op –JP drain maintained on negative pressure –tube duodenostomy and pancreatic stent hooked to a suction machine –electrolyte imbalance corrected –volume replacement maintained –patient eventually discharged when minimal changes from the JP drain was obtained without bile staining