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Cho A, Katagiri S, Ota M, Onizawa S, Higuchi R, Sugishita T, Niwa Y, Ishita T, Mouri T, Kato A, Iwata M. No-touch isolation technique in emergency pancreaticoduodenectomy for neoplastic hemorrhage: Two case reports and review of literature. World J Gastrointest Surg 2024; 16:1910-1917. [PMID: 38983346 PMCID: PMC11230025 DOI: 10.4240/wjgs.v16.i6.1910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/08/2024] [Accepted: 04/30/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Emergency pancreaticoduodenectomy (EPD) is a rare event for complex periampullary etiology. Increased intraoperative blood loss is correlated with poor postoperative outcomes. CASE SUMMARY Two patients underwent EPD using a no-touch isolation technique, in which all arteries supplying the pancreatic head region were ligated and divided before manipulation of the pancreatic head and duodenum. The operative times were 220 and 239 min, and the blood loss was 70 and 270 g, respectively. The patients were discharged on the 14th and 10th postoperative day, respectively. Thirty-two patients underwent EPD for the treatment of neoplastic bleeding. The mean operative time was 361.6 min, and the mean blood loss was 747.3 g. The complication rate was 37.5%. The in-hospital mortality rate was 9.38%. CONCLUSION The no-touch isolation technique is feasible, safe, and effective for reducing intraoperative blood loss in EPD.
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Affiliation(s)
- Akihiro Cho
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Satoshi Katagiri
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Masao Ota
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Shunsuke Onizawa
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Ryota Higuchi
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Toshiya Sugishita
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Yukiko Niwa
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Takeshi Ishita
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Toshihiko Mouri
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Akita Kato
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
| | - Moe Iwata
- Division of Gastroenterological Surgery, Tokyo Women’s Medical University, Yachiyo Medical Center, Chiba 276-8524, Japan
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Dumitrascu T. Pancreaticoduodenectomies with Concurrent Colectomies: Indications, Technical Issues, Complications, and Oncological Outcomes. J Clin Med 2023; 12:7682. [PMID: 38137749 PMCID: PMC10744251 DOI: 10.3390/jcm12247682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Multi-visceral resections for colon and pancreatic cancer (PDAC) are feasible, safe, and justified for early and late outcomes. However, the use of pancreaticoduodenectomy (PD) with concurrent colectomies is highly debatable in terms of morbidity and oncological benefits. Based on current literature data, this review assesses the early and long-term outcomes of PD with colectomies. The association represents a challenging but feasible option for a few patients with PDAC or locally advanced right colon cancer when negative resection margins are anticipated because long-term survival can be achieved. Concurrent colectomies during PD should be cautiously approached because they may significantly increase complication rates, including severe ones. Thus, patients should be fit enough to overcome potential severe complications. Patients with PD and colectomies can be classified as borderline resectable, considering the high risk of developing postoperative complications. Carefully selecting patients suitable for PD with concurrent colectomies is paramount to mitigate the potentially severe complications of the two surgical procedures and maximize the oncological benefits. These procedures should be performed at high-volume centers with extensive experience in pancreatectomies and colectomies, and each patient situation should be assessed using a multimodal approach, including high-quality imaging and neoadjuvant therapies, in a multidisciplinary team discussion.
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Affiliation(s)
- Traian Dumitrascu
- Division of Surgical Oncology, Department of General Surgery, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Watanabe G, Satou S, Tsuru M, Momiyama M, Nakajima K, Nagao A, Satodate H, Muramoto T, Ohata K, Noie T. Pancreas-sparing partial duodenectomy as an alternative to emergency pancreaticoduodenectomy for a major duodenal perforation: a case report. Clin J Gastroenterol 2023; 16:761-766. [PMID: 37389799 DOI: 10.1007/s12328-023-01823-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/13/2023] [Indexed: 07/01/2023]
Abstract
A 71-year-old woman underwent endoscopic submucosal dissection for early duodenal cancer at the second portion of the duodenum and developed acute peritonitis due to delayed duodenal perforation. Emergency laparotomy was performed. A huge perforation formed at the descending duodenum without ampulla involvement. Pancreas-sparing partial duodenectomy (PPD) with gastrojejunostomy was performed (250 min operative time) with 50 mL of intraoperative blood loss. She required intensive care for 3 days and was discharged on postoperative day 21 with no severe complications. Emergency treatment for a major duodenal injury or perforation remains challenging because of high morbidity and mortality. An appropriate treatment should be considered according to the nature of the defect. Although PPD is an acceptable procedure for patients with a duodenal neoplasm, its use in emergency surgery is rarely reported. PPD is more reliable than primary repair or anastomosis using a jejunal wall, and less invasive than pancreaticoduodenectomy, for emergency treatment. We performed PPD in this patient because the duodenal perforation was too large to reconstruct and did not involve the ampulla. PPD can be a safe and feasible alternative surgical procedure to pancreaticoduodenectomy for a major duodenal perforation, especially in patients with a duodenal perforation that does not involve the ampulla.
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Affiliation(s)
- Genki Watanabe
- Department of Surgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Shouichi Satou
- Department of Surgery, NTT Medical Center Tokyo, Tokyo, Japan.
| | - Mao Tsuru
- Department of Surgery, NTT Medical Center Tokyo, Tokyo, Japan
| | | | | | - Atsuki Nagao
- Department of Surgery, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Takashi Muramoto
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Ken Ohata
- Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan
| | - Tamaki Noie
- Department of Surgery, NTT Medical Center Tokyo, Tokyo, Japan
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4
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Fickenscher M, Vorontsov O, Müller T, Radeleff B, Graeb C. Pancreaticobiliary Diseases with Severe Complications as a Rare Indication for Emergency Pancreaticoduodenectomy: A Single-Center Experience and Review of the Literature. J Clin Med 2023; 12:5760. [PMID: 37685827 PMCID: PMC10488344 DOI: 10.3390/jcm12175760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023] Open
Abstract
The pancreaticobiliary system is a complex and vulnerable anatomic region. Small changes can lead to severe complications. Pancreaticobiliary disorders leading to severe complications include malignancies, pancreatitis, duodenal ulcer, duodenal diverticula, vascular malformations, and iatrogenic or traumatic injuries. Different therapeutic strategies, such as conservative, interventional (e.g., embolization, stent graft applications, or biliary interventions), or surgical therapy, are available in early disease stages. Therapeutic options in patients with severe complications such as duodenal perforation, acute bleeding, or sepsis are limited. If less invasive procedures are exhausted, an emergency pancreaticoduodenectomy (EPD) can be the only option left. The aim of this study was to analyze a single-center experience of EPD performed for benign non-trauma indications and to review the literature concerning EPD. Between January 2015 and January 2022, 11 patients received EPD due to benign non-trauma indications at our institution. Data were analyzed regarding sex, age, indication, operative parameters, length of hospital stay, postoperative morbidity, and mortality. Furthermore, we performed a literature survey using the PubMed database and reviewed reported cases of EPD. Eleven EPD cases due to benign non-trauma indications were analyzed. Indications included peptic duodenal ulcer with penetration into the hepatopancreatic duct and the pancreas, duodenal ulcer with acute uncontrollable bleeding, and penetration into the pancreas, and a massive perforated duodenal diverticulum with peritonitis and sepsis. The mean operative time was 369 min, and the median length of hospital stay was 35.8 days. Postoperative complications occurred in 4 out of 11 patients (36.4%). Total 90-day postoperative mortality was 9.1% (1 patient). We reviewed 17 studies and 22 case reports revealing 269 cases of EPD. Only 20 cases of EPD performed for benign non-trauma indications are reported in the literature. EPD performed for benign non-trauma indications remains a rare event, with only 31 reported cases. The data analysis of all available cases from the literature revealed an increased postoperative mortality rate of 25.8%. If less invasive approaches are exhausted, EPD is still a life-saving procedure with acceptable results. Performed by surgeons with a high level of experience in hepatobiliary and pancreatic surgery, mortality rates below 10% can be achieved.
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Affiliation(s)
- Maximilian Fickenscher
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
| | - Oleg Vorontsov
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
| | - Thomas Müller
- Department of Gastroenterology, Sana Hospital Hof, 95032 Hof, Germany
| | - Boris Radeleff
- Department of Diagnostic and Interventional Radiology, Sana Hospital Hof, 95032 Hof, Germany
| | - Christian Graeb
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
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Popa C, Schlanger D, Chirică M, Zaharie F, Al Hajjar N. Emergency pancreaticoduodenectomy for non-traumatic indications—a systematic review. Langenbecks Arch Surg 2022; 407:3169-3192. [DOI: 10.1007/s00423-022-02702-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/04/2022] [Indexed: 11/25/2022]
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Abdullah M, Babieker K, Almohammed Saleh AA. Successful Conservative Management of Traumatic Pancreatic Duct Injury: A Case Report. Cureus 2022; 14:e27749. [PMID: 36106245 PMCID: PMC9447472 DOI: 10.7759/cureus.27749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/05/2022] Open
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7
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Schlanger D, Popa C, Ciocan A, Șofron C, Al Hajjar N. Emergency Pancreatoduodenectomy: A Non-Trauma Center Case Series. J Clin Med 2022; 11:jcm11102891. [PMID: 35629017 PMCID: PMC9143146 DOI: 10.3390/jcm11102891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/14/2022] [Accepted: 05/17/2022] [Indexed: 11/21/2022] Open
Abstract
(1) Background: Emergency pancreatoduodenectomy (EPD) is a rare procedure, especially in non-trauma centers. Pancreatoduodenectomy is a challenging intervention, that has even higher risks in emergency settings. However, EPD can be a life-saving procedure in selected cases. (2) Methods: Our study is a single-center prospective consecutive case series, on patients that underwent emergency pancreatoduodenectomies in our surgical department between January 2014 to May 2021. (3) Results: In the 7-year period, 4 cases were operated in emergency settings, out of the 615 patients who underwent PD (0.65%). All patients were male, with ages between 44 and 65. Uncontrollable bleeding was the indication for surgery in 3 cases, while a complex postoperative complication was the reason for surgery in one other case. In three cases, a classical Whipple procedure was performed, and only one case had a pylorus-preserving pancreatoduodenectomy. The in-hospital mortality rate was 25% and the morbidity rate was 50%; the two patients that registered complications also needed reinterventions. The patients who were discharged had a good long-term survival. (4) Conclusion: EPD is a challenging procedure, rare encountered in non-traumatic cases, that can be a life-saving intervention in well-selected cases, offering good long-term survival.
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Affiliation(s)
- Diana Schlanger
- Surgery Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Street Emil Isac no 13, 400023 Cluj-Napoca, Romania; (D.S.); (A.C.); (C.Ș.); (N.A.H.)
- Surgery Department, Regional Institute of Gastroenterology and Hepatology Prof. Dr. O. Fodor, Street Croitorilor no 19–21, 400162 Cluj-Napoca, Romania
| | - Călin Popa
- Surgery Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Street Emil Isac no 13, 400023 Cluj-Napoca, Romania; (D.S.); (A.C.); (C.Ș.); (N.A.H.)
- Surgery Department, Regional Institute of Gastroenterology and Hepatology Prof. Dr. O. Fodor, Street Croitorilor no 19–21, 400162 Cluj-Napoca, Romania
- Correspondence: ; Tel.: +40-074-357-8432
| | - Andra Ciocan
- Surgery Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Street Emil Isac no 13, 400023 Cluj-Napoca, Romania; (D.S.); (A.C.); (C.Ș.); (N.A.H.)
- Surgery Department, Regional Institute of Gastroenterology and Hepatology Prof. Dr. O. Fodor, Street Croitorilor no 19–21, 400162 Cluj-Napoca, Romania
| | - Cornelia Șofron
- Surgery Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Street Emil Isac no 13, 400023 Cluj-Napoca, Romania; (D.S.); (A.C.); (C.Ș.); (N.A.H.)
- Surgery Department, Regional Institute of Gastroenterology and Hepatology Prof. Dr. O. Fodor, Street Croitorilor no 19–21, 400162 Cluj-Napoca, Romania
| | - Nadim Al Hajjar
- Surgery Department, “Iuliu Haţieganu” University of Medicine and Pharmacy, Street Emil Isac no 13, 400023 Cluj-Napoca, Romania; (D.S.); (A.C.); (C.Ș.); (N.A.H.)
- Surgery Department, Regional Institute of Gastroenterology and Hepatology Prof. Dr. O. Fodor, Street Croitorilor no 19–21, 400162 Cluj-Napoca, Romania
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8
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Hariprasad CP, Gupta R, Kumar A. Domestic violence and assault leading to isolated grade III pancreatic injury managed conservatively; A rare case report. Int J Surg Case Rep 2020; 75:476-478. [PMID: 33076199 PMCID: PMC7527624 DOI: 10.1016/j.ijscr.2020.09.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 12/05/2022] Open
Abstract
The haemodynamically stable grade III pancreatic injury may be managed conservatively. Assault with punching leading to isolated grade III pancreatic injury in an adult is extremely rare to occur. The decision of operation is mainly based on the clinical conditions of patients.
Introduction Isolated complete pancreatic transection following blunt trauma abdomen is associated with very high mortality. Conservative management in such a scenario is a rare experience. Majority of the patients with American Association for Surgery of Trauma (AAST) grade III or IV pancreatic injury are treated with surgical options and have poor outcomes. As per the available literature we are reporting a rare case of isolated AAST grade III pancreatic injury managed conservatively in adult. Case presentation A 37-year-old female presented with complaints of severe epigastric pain with the alleged history of domestic violence. CECT of the patient suggested isolated pancreatic injury with complete transection of pancreas. Considering the clinical and hemodynamic status of the patient a trial of conservative management was started. Serial assessment of biochemical and clinical parameters depicted improvement in the clinical status of the patient. She was doing well at 6 months of follow up. Discussion Operative procedures in patients with high grade pancreatic injury are associated with high risk of mortality and morbidity. Emergency surgeries can be avoided in patient with stable clinical and haemodynamic status. In selected cases decision on the basis of radiology may lead to unnecessary surgeries, whereas conservative approach may have better outcomes. Conclusion Tailored approach in cases of high-grade pancreatic injury will augment the decision taking between operative and non-operative management. Clinical and haemodynamic status should play a pivotal role and radiology should be used as an adjunct for deciding the management.
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Affiliation(s)
| | - Rohit Gupta
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India.
| | - Anil Kumar
- Department of Trauma & Emergency (Gen Surgery), All India Institute of Medical Sciences, Patna, India.
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9
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Driedger MR, Puig CA, Thiels CA, Bergquist JR, Ubl DS, Habermann EB, Grotz TE, Smoot RL, Nagorney DM, Cleary SP, Kendrick ML, Truty MJ. Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients. BMC Surg 2020; 20:169. [PMID: 32718311 PMCID: PMC7385869 DOI: 10.1186/s12893-020-00822-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/10/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown. METHODS ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP - distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types. RESULTS Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%). CONCLUSION Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.
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Affiliation(s)
- Michael R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Carlos A Puig
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Cornelius A Thiels
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - John R Bergquist
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Daniel S Ubl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Health Care Research and Policy, Mayo Clinic, Rochester, MN, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David M Nagorney
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sean P Cleary
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark J Truty
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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10
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Duggan W, Hannan E, Brosnan C, O'Sullivan S, Conlon K. Conservative management of complete traumatic pancreatic body transection; A case report. Int J Surg Case Rep 2020; 71:222-224. [PMID: 32480329 PMCID: PMC7262372 DOI: 10.1016/j.ijscr.2020.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 11/15/2022] Open
Abstract
Pancreatic trauma is associated with considerable morbidity and mortality. Traditionally, cases that involved injury to the pancreatic duct were almost always managed operatively. Much of the morbidity and mortality associated is related to operative complications. This case highlights that where possible, in instances where there is no bile leak or active haemorrhage, a conservative management approach may be safe and effective.
Introduction Isolated pancreatic body transection secondary to blunt abdominal trauma is a very rare injury associated with poor outcomes. Almost all previously reported cases were managed by emergency distal pancreatectomy, which is associated with high morbidity and mortality. To our knowledge, this is the first reported case of complete transection of the pancreas at the body that was successfully treated by conservative management in an adult patient. Presentation of case A 19-year-old male was found to have complete transection of the pancreatic body on computed tomography (CT) following blunt force abdominal trauma. Given that he was haemodynamically stable without evidence of haemorrhage or bile leakage on imaging, a trial of conservative management was initiated. He remained well through his admission, gradually improving clinically and biochemically with stable appearances on serial imaging. He remains asymptomatic as of six months since discharge from the hospital and continues to be monitored in the outpatient setting. Discussion Management of pancreatic trauma with ductal injury has typically been with emergency distal pancreatectomy, which is associated with high morbidity and mortality. The decision to operate should not be purely based on radiological findings, and should take into account clinical status, haemodynamic stability, coexisting injuries and evidence of active haemorrhage or bile leak. Conclusion In select cases, it is reasonable to trial conservative management in isolated traumatic pancreatic body fracture by means of close clinical observation and serial imaging. This may allow the patient to avoid a high-risk emergency distal pancreatectomy.
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Affiliation(s)
- W Duggan
- St Vincent's University Hospital, 196 Merrion Road, Elm Park, Dublin, Ireland.
| | - E Hannan
- St Vincent's University Hospital, 196 Merrion Road, Elm Park, Dublin, Ireland
| | - C Brosnan
- St Vincent's University Hospital, 196 Merrion Road, Elm Park, Dublin, Ireland
| | - S O'Sullivan
- St Vincent's University Hospital, 196 Merrion Road, Elm Park, Dublin, Ireland
| | - K Conlon
- St Vincent's University Hospital, 196 Merrion Road, Elm Park, Dublin, Ireland
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11
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Bass GA, Gillis AE, Cao Y, Mohseni S. Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease. BJS Open 2020; 4:622-629. [PMID: 32418332 PMCID: PMC7397364 DOI: 10.1002/bjs5.50294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/25/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Complicated acute biliary calculous disease poses clinical challenges. The European Society of Trauma and Emergency Surgery (ESTES) snapshot audit of complicated biliary calculous disease aims to make novel comparisons between self-reported institutional adherence to the Tokyo guidelines (TG18) and 'real-world' contemporary practice across Europe. METHODS A preplanned analysis of a prospective observational multicentre audit that captured patients undergoing emergency admission for complicated biliary calculous disease (complicated cholecystitis, biliary pancreatitis, or choledocholithiasis with or without cholangitis) between 1 and 31 October 2018 was performed. An anonymized survey was administered to participating sites. RESULTS Following an open call for participation, 25 centres from nine countries enrolled 338 patients. All centres completed the anonymized survey. Fifteen centres (60 per cent) self-reported that a minority of patients were treated surgically on index admission, favouring interval cholecystectomy. This was replicated in the snapshot audit, in which 152 of 338 patients (45·0 per cent) underwent index admission cholecystectomy, 17 (5·0 per cent) had interval cholecystectomy, and the remaining 169 (50·0 per cent) had not undergone surgery by the end of the 60-day follow-up. Centres that employed a dedicated acute care surgery model of care were more likely to perform index admission cholecystectomy compared with a traditional general surgery 'on call' service (57 versus 38 per cent respectively; odds ratio 2·14 (95 per cent c.i. 1·37 to 3·35), P < 0·001). Six centres (24 per cent) self-reported routinely performing blood cultures in acute cholecystitis; patient-level audit data revealed that blood cultures were done in 47 of 154 patients (30·5 per cent). No centre self-reported omitting antibiotics in the management of acute cholecystitis, and 144 of 154 (93·5 per cent) of patients in the snapshot audit received antibiotics during their index admission. CONCLUSION Awareness of TG18 recommendations was high, but self-reported adherence and objective snapshot audit data showed low compliance with TG18 in patients with complicated acute biliary calculous disease.
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Affiliation(s)
- G A Bass
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.,Surgery, Örebro University School of Medical Sciences, Örebro, Sweden
| | - A E Gillis
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Y Cao
- Departments of Clinical Epidemiology and Biostatistics, Örebro, Sweden
| | - S Mohseni
- Surgery, Örebro University School of Medical Sciences, Örebro, Sweden
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12
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Gabriel V, Grigorian A, Nahmias J, Pejcinovska M, Smith M, Sun B, Won E, Bernal N, Barrios C, Schubl SD. Risk Factors for Post-Operative Sepsis and Septic Shock in Patients Undergoing Emergency Surgery. Surg Infect (Larchmt) 2019; 20:367-372. [PMID: 30950768 DOI: 10.1089/sur.2018.186] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Sepsis after emergency surgery is associated with a higher mortality rate than elective surgery, and total hospital costs increase by 2.3 times. This study aimed to identify risk factors for post-operative sepsis or septic shock in patients undergoing emergency surgery. Methods: A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program (NSQIP) by identifying patients undergoing emergency surgery between 2012 and 2015 and comparing those who developed post-operative sepsis or septic shock (S/SS) with those who did not. Patients with pre-operative sepsis or septic shock were excluded. Multiple logistic regression was used to identify risk factors for the development of S/SS in patients undergoing non-elective surgery. Results: Of 122,281 patients who met the inclusion criteria, 2,399 (2%) developed S/SS. Risk factors for S/SS were American Society of Anesthesiologists Physical Status (ASA PS) class 2 or higher (odds ratio [OR] 2.57; 95% confidence interval [CI] 2.19-3.02; p < 0.0001), totally dependent (OR 2.00, 95% CI 1.38-2.83; p = 0.00021) or partially dependent (OR 1.62, 95% CI 1.35-2.00; p < 0.0001) functional status, and male gender (OR 1.31; 95% CI 1.18-1.45; p < 0.0001). Compared with colorectal procedures, patients undergoing pancreatic (OR 2.33, CI 1.40-3.87; p = 0.00108) and small intestine (OR 1.27; CI 1.12-1.44; p = 0.00015) surgery were more likely to develop S/SS. Patients undergoing biliary surgery (OR 0.38; CI 0.30-0.48; p < 0.0001) were less likely to develop S/SS. Conclusions: Risk factors for the development of sepsis or septic shock are ASA PS class 2 or higher, partially or totally dependent functional status, and male gender. Emergency pancreatic or small intestinal procedures may confer a higher risk. Greater vigilance and early post-operative screening may be of benefit in patients with these risk factors.
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Affiliation(s)
- Viktor Gabriel
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Areg Grigorian
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Jeffry Nahmias
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Marija Pejcinovska
- 2 Department of Statistics UC Irvine Center for Statistical Consulting, University of California, Irvine, Orange, California
| | - Megan Smith
- 2 Department of Statistics UC Irvine Center for Statistical Consulting, University of California, Irvine, Orange, California
| | - Beatrice Sun
- 3 School of Medicine, University of California, Irvine, Orange, California
| | - Eugene Won
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Nicole Bernal
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
| | - Cristobal Barrios
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
| | - Sebastian D Schubl
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
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Menahem B, Lim C, Lahat E, Salloum C, Osseis M, Lacaze L, Compagnon P, Pascal G, Azoulay D. Conservative and surgical management of pancreatic trauma in adult patients. Hepatobiliary Surg Nutr 2016; 5:470-477. [PMID: 28124001 DOI: 10.21037/hbsn.2016.07.01] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The management of pancreatic trauma is complex. The aim of this study was to report our experience in the management of pancreatic trauma. METHODS All patients hospitalized between 2005 and 2013 for pancreatic trauma were included. Traumatic injuries of the pancreas were classified according to the American Association for Surgery of Trauma (AAST) in five grades. Mortality and morbidity were analyzed. RESULTS A total of 30 patients were analyzed (mean age: 38±17 years). Nineteen (63%) patients had a blunt trauma and 12 (40%) had pancreatic injury ≥ grade 3. Fifteen patients underwent exploratory laparotomy and the other 15 patients had nonoperative management (NOM). Four (13%) patients had a partial pancreatectomy [distal pancreatectomy (n=3) and pancreaticoduodenectomy (n=1)]. Overall, in hospital mortality was 20% (n=6). Postoperative mortality was 27% (n=4/15). Mortality of NOM group was 13% (n=2/15) in both cases death was due to severe head injury. Among the patients who underwent NOM, three patients had injury ≥ grade 3, one patient had a stent placement in the pancreatic duct and two patients underwent endoscopic drainage of a pancreatic pseudocyst. CONCLUSIONS Operative management of pancreatic trauma leads to a higher mortality. This must not be necessarily related to the pancreas injury alone but also to the associated injuries including liver, spleen and vascular trauma which may cause impaired outcome more than pancreas injury.
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Affiliation(s)
- Benjamin Menahem
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France
| | - Chetana Lim
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France;; INSERM, U965, Paris, France
| | - Eylon Lahat
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France
| | - Michael Osseis
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France
| | - Laurence Lacaze
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France
| | - Philippe Compagnon
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France;; INSERM, U955, Créteil, France
| | - Gerard Pascal
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary, Pancreatic Surgery and Liver transplantation, Henri Mondor Hospital, Créteil, France;; INSERM, U955, Créteil, France
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