Post-Surgery Fever in Pancreatic Cancer: Causes and Concerns

Recurrent fever after surgery for ampullary cancer?

Hello Dr.
Chen, my mother is 75 years old.
She was diagnosed with ampullary cancer at the end of May and underwent laparoscopic pancreaticoduodenectomy on June 9, during which the tumor was removed.
The pathology report indicated that the cancer had spread to one lymph node, and she was diagnosed with stage II.
However, since the surgery (as of July 1), she has been experiencing recurrent fevers.
We have conducted tests on the drainage fluid, blood tests, urinalysis, X-rays, and CT scans.
At one point, a liver abscess was discovered, and a drainage tube was placed, which helped reduce the fever for a couple of days.
However, the fever returned, and it was later determined to be due to a fungal infection, leading to a change in antibiotics.
Yesterday (June 30), all of her drainage tubes were removed, but she has started to have fevers again, reaching around 38 degrees Celsius, and we are repeatedly conducting blood tests and urinalysis, as well as X-rays.
About 10 days post-surgery, she began to experience vomiting, and her eating has been poor in recent days, with nausea fluctuating.
I would like to ask the doctor if it is normal to have persistent fevers after surgery.
I am very concerned that we have not been able to identify the source of the infection.
Is there any condition that could be causing these issues? Thank you for your help.

Miss Lin, 40~49 year old female. Ask Date: 2022/07/01

Dr. Chen Ronghong reply Surgery

Hello, Ms.
Lin.
After pancreatic surgery, fever is most commonly associated with anastomotic leakage, as well as pneumonia, urinary tract infections, and bloodstream infections.
I believe your mother's doctor has considered these possibilities, especially since you mentioned that many tests have been conducted.
Some potential overlooked causes may include drug fever from prolonged antibiotic use, or if diarrhea is present, consider Clostridium difficile infection.
Additionally, there could be skin wound infections (especially if there are pressure ulcers due to prolonged immobility), and in the context of the pandemic, COVID-19 infection should also be considered.
These are just some thoughts; unexplained fever is a specialty of infectious disease specialists, and for prolonged fever, it is common to discuss potential causes with them.
Wishing your mother a speedy recovery.

Reply Date: 2022/07/01

More Info

Post-surgery fever in patients who have undergone pancreatic surgery, such as a Whipple procedure (pancreaticoduodenectomy), can be a complex issue. In your mother's case, the persistent fever following her surgery for pancreatic cancer raises several important considerations.

Common Causes of Post-Surgery Fever:
1. Infection: The most common cause of fever after surgery is infection. This can include surgical site infections, pneumonia, urinary tract infections, or intra-abdominal infections such as abscesses. Given that your mother had a liver abscess, it is crucial to monitor for any signs of infection in other areas as well.

2. Non-infectious Causes: Fever can also arise from non-infectious causes such as drug fever (a reaction to medications), inflammatory responses to surgery, or even thromboembolic events like deep vein thrombosis or pulmonary embolism.

3. Leakage: In surgeries involving the pancreas, one of the significant concerns is the possibility of an anastomotic leak (leakage at the surgical connection site). This can lead to peritonitis and fever. Monitoring for signs of leakage is critical, especially if there are changes in abdominal pain or gastrointestinal symptoms.

4. Fungal Infections: As noted in your mother's case, the presence of a fungal infection can complicate recovery. Fungal infections can occur, especially in immunocompromised patients or those on broad-spectrum antibiotics.

5. Other Complications: Other potential complications include pancreatitis, which can occur post-operatively, or complications related to the drainage tubes that were placed.

Management and Next Steps:
1. Continued Monitoring: It is essential to continue monitoring her vital signs, laboratory results, and any imaging studies. If fever persists, further investigation may be warranted to identify the source.

2. Infectious Disease Consultation: Given the complexity of her case, involving an infectious disease specialist may be beneficial. They can help evaluate the need for specific cultures or tests to identify any underlying infections.

3. Nutritional Support: The vomiting and poor intake are concerning. Nutritional support may be necessary, either through enteral feeding (via a tube) or parenteral nutrition (IV nutrition), to ensure she receives adequate calories and nutrients during recovery.

4. Pain Management: Managing her pain effectively is crucial, as pain can also contribute to stress and fever. Discussing her pain management plan with her healthcare team may help improve her overall comfort.

5. Psychosocial Support: The emotional toll of dealing with cancer and post-surgical complications can be significant. Providing emotional support and possibly involving a social worker or counselor can be beneficial for both your mother and your family.

In summary, while some degree of fever can be expected after major surgery, persistent or recurrent fever warrants thorough investigation to rule out serious complications. It is essential to maintain open communication with her healthcare team to address any concerns and ensure that she receives the best possible care. Your vigilance in monitoring her symptoms and advocating for her needs is crucial during this challenging time.

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