Citation Nr: 21077091 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 15-23 162A DATE: December 28, 2021 REMANDED Entitlement to service connection for residuals from a Whipple procedure is remanded. REASONS FOR REMAND The Veteran served on active duty as a commissioned officer in the U.S. Marine Corps from September 1971 to September 1974, from September 1994 to March 1995, from January 1996 to June 1996, from May 1998 to September 1998, from April 1999 to August 1999, from January 2001 to April 2001 and from March 2006 to June 2011 including service in Iraq and Afghanistan. The Board most recently remanded this issue in April 2021 to the RO for additional development. Unfortunately, additional development is necessary prior to adjudication. Entitlement to service connection for pancreatitis with residuals from a Whipple procedure The Veteran is seeking service connection for pancreatitis and residuals from a Whipple procedure, to include irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), pancreatitis, and neuropathy. The Veteran underwent a Whipple procedure in October 2010 for suspected malignancy, but none was found. The Veteran was placed in the supine position for 8 hours and 50 minutes during the procedure. The Veteran reported that shortly after the surgery, he experienced chronic fatigue and numbness in his feet. He contends that he did not experience either symptom prior to the surgery. The Veteran also contends that he has acute pancreatitis which is caused from stent fragmentation and a duct blockage related to the 2010 Whipple procedure. Service treatment records (STRs) are associated with the claims file. The Veteran reported "infrequent" diarrhea in December 2010. In March 2011, he stated that he was getting tired and winded easily, he denied abdominal pain or GU symptoms. He denied any neurological symptoms in April 2011. He reported that his energy level was increasing, and his stools were regular. He was determined to be fit for duty and was told he did not need any additional follow-up appointments for the Whipple surgery. On his June 2011 Report of Medical History form, the Veteran reported neuropathy in his feet. His corresponding separation examination determined that his neurologic system was normal. The Veteran attended a VA examination in October 2011. He did not report and numbness or tingling and none was noted. He did not report any symptoms associated with IBS or CFS and none were noted. Pancreatitis was not noted. During January 2012 VA treatment, the Veteran reported only sleeping six hours nightly, and waking to urinate. He stated that he did not feel well rested upon waking. He told the treating physician that he had struggled with "sleep maintenance insomnia for over a decade." In May 2012, the RO granted service connection for degenerative arthritis of the lumbar spine and for right and left plantar fasciitis. During October 2012 VA treatment, the Veteran denied any gastrointestinal concerns or weakness or numbness in his legs. He again denied weakness or numbness during December 2012 VA treatment, as well as abdominal pain, diarrhea, constipation, or bowel changes. In October 2013, the RO granted service connection for radiculopathy of the right lower extremity. October 2014 VA treatment records reflect that the Veteran had been diagnosed with acute pancreatitis, but following his Whipple surgery, his pain resolved. During a March 2015 VA examination, a VA examiner stated that the Veteran's peripheral neuropathy of the hands and feet were likely related to the Whipple surgery because the Veteran reported symptoms arising shortly after the procedure. An addendum opinion was obtained later in March 2015. The VA examiner stated that the previous opinion did not include sufficient rationale. She stated that it was less likely than not that any peripheral neuropathy was secondary to the Whipple procedure because "the medical community at large recognizes that there is no objective clinical evidence supporting a peripheral neuropathy of the hands is incurred in or caused by a Whipple procedure." During the Veteran's October 2018 Board hearing, one of the Veteran's sisters, who identified herself as a registered nurse currently employed in practice management, testified that that the circumstances with the surgery and his positioning, the length that he was in the recumbent position, along with his prior history with his back disorders led to or were contributing to the Veteran's current symptoms. In October 2018, the Veteran also submitted a statement from his other sister, also identified as a registered nurse, which explained that the placement of the epidural during the Whipple procedure may have caused residual neurological problems, resulting in polyneuropathy. The statement also reported that the Veteran continued to have GI or biliary pancreatic health problems. The Veteran attended a VA examination in November 2020. Following an examination and review of the claims file, the examiner determined that it was less likely than not that the Veteran had residuals from an in-service Whipple procedure. The examiner explained that the Veteran was walking without assistance the day after his surgery and no complications were noted. She emphasized that the medical records reflect that the Veteran's symptoms did not present until four months following his surgery. Furthermore, she explained that there was no evidence in the pertinent medical literature that being placed in the supine position during a surgical procedure for whatever length of time causes a peripheral neuropathy. While she considered the Veteran's sisters' statements, the examiner stated that there was no contemporaneous evidence documenting that the sisters conducted a detailed orthopedic or neurologic examination of the Veteran before or after his surgery. She noted that the Veteran's "physicians [had] stated that his persistent use of antifungals, despite being told not to, both topical and oral (clotrimazole and lamisil) might be the cause of the peripheral neuropathy." The examiner also clarified the position that the Veteran was in during his surgery, explaining that he was in the supine position, and not the recumbent or flat or lithotomy position as referenced by the Veteran's sister. The examiner very strongly objected to the statements made by the Veteran's sisters. She explained that the statements are either blatantly wrong or "deliberately duplicitous." Further explaining her conclusion, the examiner stated that: It is not biologically plausible for epidural catheter placement in thoracic spine, and epidural PCA for a few days post-op to cause symptoms: 1. that start 4 months later with foot drop 2. that occur in bilateral upper and lower limbs 3. that worsen with time, rather than improve with increasing time from the administration of the analgesia 4. that occur in the central nervous system such as the mental confusion and fatigue the Veteran has been experiencing 5. that have nothing to do with Veteran's positioning. The Veteran submitted correspondence in March 2021, objecting to the findings of the November 2020 VA examination. He explained that the examiner's findings were based on inaccurate factual premises. Namely, the Veteran asserted that symptoms could have developed earlier to his surgery, but he was heavily medicated and would not have noticed. He also asserted that contrary to the VA examination report, he was unable to walk unassisted for several weeks following the procedure. The Veteran also stated that following the Whipple procedure, but prior to his separation, he was unable to complete military fitness standards due to exhaustion. The Veteran also pointed out that some symptoms manifested shortly following his surgery and during active duty, like his peripheral neuropathy. He also objected to the November 2020 VA examiner's findings regarding his use of antifungals, instead reporting minimal use years prior to the Whipple procedure. Addendum opinions were obtained in July 2021 and September 2021. Initially, the VA examiner stated that a, "Whipple procedure (pancreaticoduodenectomy) is a complex operation to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct. The Whipple procedure is used to treat tumors and other disorders of the pancreas, intestine and bile duct and often causes major changes to the digestive system. This can translate into some serious long-term effects, including abdominal discomfort, weight loss, digestive problems, and chronic fatigue." However, in her addendum opinion in September 2021, the examiner determined that it was less likely than not that the Whipple procedure caused any residuals. She explained that the Veteran experienced severe pain and fatigue before and after the procedure, as evidenced by the January 2012 medical records. The examiner also reinforced the findings of the November 2020 VA examiner. She stated that a review of the November 2020 examination did not indicate any deficiencies on the part of the examiner, and the purpose of the examination was to document objective findings because subjective data can be manipulated or exaggerated. The VA examiner also determined that the Veteran's neuropathy was less likely than not related to the Whipple procedure. She stated that a review of the Veteran's medical records did not indicate any link between his neuropathy and the Whipple procedure. She explained that the Veterans had a long history of skeletal pain including in his back and feet, and a June 2016 medical note stated that his history of neuropathy was possibly from his back. The September 2021 VA examiner also addressed the Veteran's objections to the November 2020 VA examiner's findings regarding his use of antifungals, instead reporting minimal use years prior to the Whipple procedure. Regarding the long use of antifungals, the September 2021 VA examiner stated that the November 2020 examiner was correct. The Veteran had a long history of antifungal use, which can cause neuropathy. She pointed to the April 2015 treatment record when he was seen for polyneuropathy, and the doctor who saw him advised him to talk to his podiatrist regarding his "long history of antifungal use" as they can cause neuropathy. The examiner concluded that: Based on records reviewed to include the [V]eteran's lay statement, the 2020 evaluation, and my medical expertise. This is to further clarify that there [was] evidence of these reported residuals right after the Whipple procedure as these are known complications. However, a gap of 10 years post-surgery and with the recent examination performed [in November 2020], with no current diagnosis for pancreatitis, irritable bowel, chronic fatigue and a diagnosis of neuropathy NOS, it is less likely than not that these current complaints are continuous residuals of the 2010 Whipple procedure. Furthermore, these reported residuals [do] not show any chronicity from the date of surgery through the 2020 examination. Unfortunately, the September 2021 VA opinion did not comment on the entire March 2021 statement provided by the Veteran. She did not discuss the Veteran's contention that his neuropathy could have gone undetected for several months following his Whipple surgery because he was on heavy medications or that he was unable to walk unassisted for several weeks following the Whipple procedure. Accordingly, an addendum opinion is warranted. Additionally, the Veterans medical records are unclear on whether he has a diagnosis of pancreatitis. The records both list pancreatitis as an active problem, and as a condition that resolved following the Whipple procedure. Clarification is necessary on remand. The matter is REMANDED for the following action: Obtain an addendum opinion by appropriate specialist physician to determine the nature and etiology of any pancreatitis with neurological residuals from a Whipple procedure. A specialist is requested because of the medical complexity of the case. Only schedule the Veteran for another examination if deemed necessary. The scope of the claim includes the digestive system and neurological deficits associated with an extended surgical procedure. The physician must opine whether any residuals from a Whipple procedure, to include pancreatitis, irritable bowel, chronic fatigue, and neuropathy (separate from the already service connected lumbar spine, bilateral plantar fasciitis, and right lower radiculopathy) are at least as likely as not caused by an in-service injury or disease, including the October 2010 Whipple procedure. The examiner is asked to clarify whether the Veteran has pancreatitis. If a diagnosis cannot be provided but the Veteran's conditions manifest in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion. Though a review of the entire claims file is requested, the examiner is asked to specifically comment on the statements provided by the Veteran in the March 2021 correspondence. It is imperative that the examiner address the Veteran's contentions that his neuropathy could have gone undetected for several months following his Whipple surgery because he was on heavy medications. The Board also calls attention to the file of service treatment records prior to and after the October 2010 surgery. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Fitzgerald, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.