A Case of Focal Liver Necrosis Following Whipple’s Procedure - Presentation, Workup, and Management

Sep 30, 2026

Liver necrosis, liver abscess, and mesenteric ischemia are uncommon but serious complications after Whipple’s procedure. The case describes a 53-year-old woman who developed focal left-lobe liver necrosis and early transient liver failure 48 hours postoperatively, with hepatic arterial flow not visualized on duplex ultrasound. Mesenteric angiography showed abrupt hepatic arterial cut-off at the common hepatic origin, but distal perfusion was maintained by a left gastric to left hepatic collateral pathway. Initial liver failure management led to recovery, followed by later purulent wound drainage; CT confirmed necrosis with abscess tracking into the skin. Laparotomy with washout and drainage, plus follow-up imaging, resulted in gradual resolution.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages8

Reading Time20 min

AccessFree to download

Introduction

Case Presentation

Preoperative presentation

We present this unique case with segmental liver necrosis following Whipple’s procedure, discuss the diagnostic and management challenges, and emphasize the role of collateral circulation.

Management of ischemic liver complications

How to cite this article

Review began 10/17/2025 Review ended 12/04/2025 Published 12/08/2025 © Copyright 2025 Rathnayake et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98722 Open Access Case Report A Case of Focal Liver Necrosis Following Whipple’s Procedure: Presentation, Workup, and Management Isuri S. Rathnayake 1, Kangaiyanan Sivarajah 2, Mahanama Gunasekara 2, Sasindu S. De Silva 2 1. Surgery, Lady Ridgeway Hospital for Children, Colombo, LKA 2. Surgery, National Hospital of Sri Lanka, Colombo, LKA Corresponding author: Isuri S. Rathnayake, [isuri.saumya@gmail.com](isuri.saumya@gmail.com) Abstract Liver necrosis, liver abscess, and mesenteric ischemia are uncommon but serious complications of Whipple’s procedure. Hepatic arterial tree assessment before surgery and meticulous surgical technique may prevent liver injury. We present a case of focal liver necrosis of the left lobe following Whipple’s procedure due to hepatic arterial cut off, with minimal clinical effects due to an aberrant arterial connection of the left gastric artery to the left hepatic artery. A 53-year-old female underwent Whipple’s procedure for a neuroendocrine tumor of the head of the pancreas. Forty-eight hours later, liver enzyme levels were high, and direct bilirubin levels were elevated. The duplex ultrasound scan showed a normal portal venous flow. Hepatic arterial flow was not visualized. She was managed with a liver failure regimen and recovered within a week. The patient was re-admitted with a purulent discharge from the surgical incision on postoperative day 30, which tested negative for amylase and microbial growth. CT of the abdomen showed a necrotic segment of the left lobe of the liver with an abscess tracking into the skin. However, the liver biochemistry was normal. Mesenteric angiography showed an abrupt cut-off of the hepatic artery at the common hepatic artery origin. However, right and left hepatic artery flow was intact distally to the bifurcation, due to a communicating collateral artery from the left gastric artery to the left hepatic artery. She underwent a laparotomy. Necrotic material was washed out, and a drain was inserted. Outpatient care with monthly ultrasound scans was performed. Drain output gradually reduced. The patient resumed her daily activities and preoperative body weight. A follow-up CT at eight months showed minimal hepatic collection. Subsequently, the drain was removed. Hepatic arterial flow disruption can present as transient liver failure, focal liver necrosis, and abscess formation. Liver necrosis and abscess can be managed by initial medical treatment and percutaneous surgical drainage. Collateral arterial pathways to the hepatic artery may minimize the extent of liver injury. Categories: General Surgery Keywords: aberrant gastric artery, elevated liver enzymes, liver abscess, liver necrosis, mesenteric angiogram, whipple’s procedure Introduction Despite technological advances and developments, pancreateco-duodenectomy (Whipple’s procedure) is still considered a challenging surgery due to its operative morbidity and mortality. Hospital mortality was approximately 25% during the early 1960s, which decreased to nearly 5% by the late 1990s [1] . Morbidity ranges from 30% to 60%, which includes pancreatic fistulae, anastomotic leaks, bile leaks, delayed gastric emptying, wound-related complications, pulmonary complications, and ischemic complications [2,3] . Ischemic complications following Whipple’s are rare but can be devastating, and include mainly hepatic, bile duct, or bowel ischemia. Main reasons are intraoperative injury to the main blood vessels or aberrant vessels, pre-existing arterial diseases, or postoperative embolism. Liver ischemia and/or focal necrosis after

FAQs

What complication developed after Whipple’s procedure in this case?

The patient developed focal liver necrosis of the left lobe, with transient liver failure and later an abscess that tracked into the skin.

How was the cause of the hepatic injury determined?

Duplex ultrasound did not visualize hepatic arterial flow, while mesenteric angiography showed an abrupt cut-off at the common hepatic origin with intact distal flow via a collateral artery from the left gastric artery.

What treatment led to recovery and resolution?

She was first managed with a liver failure regimen, then later underwent laparotomy with washout and drain placement, followed by outpatient monthly ultrasound monitoring until the drain was removed.

Sep 30, 2026

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