Emergency pancreaticoduodenectomy: When is it needed? A dual non-trauma centre experience and literature review

Pancreaticobiliary Diseases with Severe Complications as a Rare Indication for Emergency Pancreaticoduodenectomy: A Single-Center Experience and Review of the Literature

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.

Emergency Pancreatoduodenectomy: A Non-Trauma Center Case Series

(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.

Two distinct episodes of life-threatening hemobilia due to a lesion of common bile duct and delayed intrapancreatic arteriobiliary fistula managed by emergency pancreatoduodenal resection

Hemobilia is an extremely rare cause of upper gastrointestinal bleeding. It often has intermittent manifestation, which may lead to significant diagnostic delay. In 65% of the cases, the causes are iatrogenic, in 7% the cause is malignancy, in 5% - gallstones, in 8% it is inflammation (cholecystitis, parasites, reflux cholangitis), vascular abnormality is the cause in 7% (most commonly pseudoaneurysm of the hepatic artery), and pancreatic pseudocyst causes hemobilia in 1%. In almost all cases, the bleeding originates from intrahepatic or extrahepatic bile ducts, and rarely from the pancreas.

PUBMED search with keywords “hemobilia” and “arteriobiliary fistula” found a total of 44 papers. No case with intrapancreatic arterio-biliary fistula was found. To the best of our knowledge, we present a unique case of delayed life-threatening hemobilia caused by intrapancreatic arterio-biliary fistula. It was diagnosed at the fourth admission and managed successfully by emergency Traverso-Longmire pancreatoduodenal resection. We briefly discuss the keys to a timely diagnosis and the cornerstones of the treatment.

The timely diagnosis of hemobilia depends on a high index of suspicion and careful interpretation of the symptoms. Hemodynamic stability has a crucial role in the decision-making process. Angioembolization is the cornerstone of the treatment, whereas surgery is reserved only for cases with an unstable hemodynamic or unsuccessful embolization. Surgical approach depends on the bleeding site. Although an emergency pancreatic head resection is a procedure of last resort, it can be life-saving in cases with intractable bleeding due to intrapancreatic arteriobiliary fistula.

Analysis of Later Stage Morbidity and Mortality after Pancreatic Surgery Because of Abdominal Trauma

Background: Pancreatic trauma surgery is a complicated surgical procedure for severe pancreatic injuries, accompanied by a high incidence of complications and mortality. This study was designed to explore the long-term prognosis of pancreatic surgery because of abdominal trauma. Patients and Methods: The clinical data of 103 patients who were admitted to Jinling Hospital between August 2012 and August 2019 who had pancreatic trauma surgery were analyzed retrospectively. Results: All admissions involved pancreatic trauma surgery performed at an outside hospital network, which later transferred patients to our institution because of post-operative later-stage complications. Eight patients received American Association for the Surgery of Trauma (AAST) grade 1 or 2 pancreatic injuries and 95 received AAST grade 3, 4, or 5 pancreatic injuries. The primary surgical management of pancreatic injuries included drainage of the pancreatic injury (n = 28), repair of the pancreas (n = 35), partial pancreatectomy (n = 15), pancreaticojejunostomy (n = 6), and pancreaticoduodenectomy (n = 19). The most common mechanism of trauma was motor vehicle collision (n = 72), crush injury (n = 26), and stab wound (n = 5). Of 103 patients suffered varying degrees of gastrointestinal fistulae and intra-abdominal infections, there were 66 cases of pancreatic fistulae (64.1%), 49 cases of enteric fistulae (47.6%), 26 cases of colonic fistulae (25.2%), 14 cases of gastric or gastrointestinal anastomotic fistulae (13.6%), and 13 cases of biliary fistulae (12.6%). Ninety-five patients survived and eight patients died after therapy; the mean length of intensive care unit stay was 33 days. The number of patients who underwent emergency pancreaticoduodenectomy (EPD), the incidence of blood transfusion, the number of fistulae per patient, and the duration of mechanical ventilation and bacteremia in the mortality group were substantially higher than in the survival group (p < 0.05 each). The patients who underwent EPD had more grade 5 pancreatic injuries, more blood transfusions, higher peak total bilirubin, greater numbers of fistulae and open abdomen, and longer duration of mechanical ventilation and mortality than other patients (p < 0.05 each). Conclusions: The grade of pancreatic injury was associated with mortality and post-operative complications. The post-operative mortality and occurrence of complications of EPD because of abdominal trauma were significant; use of damage control surgery could potentially reduce the morbidity and mortality related to this procedure.

Emergency Pancreatoduodenectomy for Ampullary Cancer Post-Iatrogenic Duodenal Perforation: No Option but to Strike

Endoscopic retrograde cholangiography related duodenal perforation is an infrequent complication and associated with significant morbidity. The management of such perforations, especially in the setting of malignancy, is not standardized given the paucity of literature. We encountered a patient who was diagnosed with periampullary carcinoma and had a perforation in the duodenum during endoscopy. Emergency pancreatoduodenectomy (EPD) was performed considering it to be a resectable disease with minimal contamination. He had a prolonged hospital course due to surgical site infection and hepaticojejunostomy leak, however, which was managed successfully. At one year follow up, he is healthy with no evidence of recurrence. We conclude that EPD can be attempted for selected iatrogenic duodenal perforations with co-existent resectable malignancy in a stable patient. It may help to avoid the morbidity of a second surgery in the setting of a distorted anatomy and simultaneously preventing the probable upstaging of disease due to peritoneal seedling.

Emergency Radical Gastrectomy with Pancreatico-duodenectomy for a Recent Onset Perforation of Locally Advanced Gastric Cancer with Pancreatic Head Involvement-Exceptional but a Definite Option

Gastric cancer perforations are rare events with management options ranging from lavage and perforation closure, to resection. Usual aim is to perform a damage control procedure, and very few patients are suitable for a curative resection. We report the first case of emergency gastrectomy with pancreatico-duodenectomy performed in emergency for a perforated stomach cancer with pancreatic head invasion. The patient was a 32-year-old gentleman who presented with a perforated antro-pyloric cancer with infiltration of pancreatic head. Emergency radical gastrectomy with en-bloc pancreatico-duodenectomy was performed with due considerations to the patient and disease factors. He had an uneventful postoperative recovery and remains disease free at 18 months of follow-up after having received adjuvant chemotherapy. Curative resections should be selectively offered in advanced (T4b) gastric cancers in patients without multiple adverse factors. In an emergency situation with perforation peritonitis, if the magnitude of resection is deemed unlikely to add to significant morbidity of the surgery, taking multiple factors into consideration, an R0 resection can offer a large survival benefit in such settings.

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review

BACKGROUND

Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice.

METHODS

From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review.

RESULTS

The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period.

CONCLUSION

The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.

The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis

Trauma pancreaticoduodenectomy (TP) remains a challenging operation with morbidity and mortality rates as high as 80% and 50%. Many trauma surgeons consider it surgical dogma to avoid performing a TP during the index operation for patients with severe pancreatic or duodenal injuries. However, there is no modern analysis evaluating this belief. Therefore, we hypothesized no difference in risk of mortality between patients with severe pancreatic or duodenal injury undergoing a TP for penetrating trauma to propensity-matched controls undergoing laparotomy without TP. The Trauma Quality Improvement Program (2010–2016) was queried for adults with severe penetrating pancreatic or duodenal injuries undergoing laparotomy. A 1:2 propensity-matching including demographics/comorbidities, injury severity score, vitals on admission, Glasgow Coma Scale and concomitant injuries for laparotomy with or without TP was performed. Risk of mortality was reported using a univariable logistic regression model. Of 2182 patients with severe pancreatic or duodenal injuries undergoing laparotomy, 54 (2.5%) underwent TP and 2128 (97.5%) underwent laparotomy without TP. There were no differences in propensity-matching characteristics. Patients undergoing TP had a similar mortality rate (20.0% vs. 28.7%, p = 0.302) but a longer length of stay (LOS) (27.5 vs. 16.5 days, p = 0.017). The TP group had a similar associated risk of mortality (OR = 0.62, p = 0.302) but higher risk of major complications (OR 3.44, CI 1.35–17.47, p = 0.015). In appropriately selected penetrating trauma patients with severe pancreatic/duodenal injuries, TP is associated with a similar risk of mortality compared to laparotomy without TP. However, TP patients did have an increased associated risk of major complications and longer LOS.

Emergency Pancreaticoduodenectomy for Exsanguinating Ampullary Malignancy

How to cite this article: Subbarayan R, Anand S, Selvaraj S. Emergency Pancreaticoduodenectomy for Exsanguinating Ampullary Malignancy. Indian J Crit Care Med 2020;24(12):1279–1280.

Risk Factors for Post-Operative Sepsis and Septic Shock in Patients Undergoing Emergency Surgery

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.

Clinical update on management of pancreatic trauma

BACKGROUND

Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma.

METHODS

Systematic literature review until May 2018.

RESULTS

Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries.

CONCLUSION

Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.

Lethal Bleeding from a Duodenal Cancerous Ulcer Communicating with the Superior Mesenteric Artery in a Patient with Pancreatic Head Cancer

Pancreatic cancer often invades the duodenum and causes obstruction, but rarely causes massive duodenal bleeding. A 68-year-old male was admitted to our hospital because of vomiting. Enhanced abdominal CT showed a hypovascular tumor with air bubbles in the uncinate process of the pancreas. The tumor invaded the duodenum and metastasized to the liver and peritoneum. The main trunk of the superior mesenteric artery (SMA) was circumferentially involved. After admission, he had hematemesis and melena. Emergency gastroduodenoscopy revealed pulsating vessels in the third portion of the duodenum and he eventually experienced hemorrhagic shock. Severe bleeding occurred from his mouth and anus like a catastrophic flood. It was difficult to sustain blood pressure even with massive blood transfusion with pumping. After insertion of an intra-aortic balloon occlusion catheter, the massive bleeding was eventually stopped. Although we attempted interventional radiography, aortography revealed direct communication between the main SMA trunk and the duodenal lumen. The tumor was considered anatomically and oncologically unresectable. Thus, we did not perform further intervention. The patient died 2 h after angiography. Herein, we report the case of pancreatic head cancer causing lethal bleeding associated with tumor-involved SMA. Duodenal bleeding associated with pancreatic cancer invasion should be considered as an oncogenic emergency.

Management of Biliary Stricture Following Emergent Pancreaticoduodenectomy for Trauma: Report of Two Cases

Stricturing of the biliary-enteric anastomosis is a known complication of emergent pancreaticoduodenectomy (PD) performed for trauma. Percutaneous techniques have become the first-line option for the management of these strictures. In cases where percutaneous intervention fails, surgical revision of the biliary enteric anastomosis is necessary. We present two cases of young males with penetrating injuries to the pancreatic head managed with PD and subsequently developed post-operative biliary strictures. The biliary stricture was managed successfully with percutaneous intervention for one of the patients. The other patient required surgical revision of the biliary anastomosis. Pancreaticoduodenectomy is typically performed in patients with malignant or benign biliary obstruction with associated ductal dilatation. In the setting of trauma, the bile duct is typically non-dilated, creating greater susceptibility for anastomotic stricture. Although such strictures may be amenable to percutaneous cholangioplasty, strictures involving distal anastomoses may require operative revision. Thus, we suggest creating the more proximal hepaticojejunostomy during the initial operation, as this may benefit the success of percutaneous management should a stricture develop. Operative revision is the definitive management of post-PD biliary stricture.

Emergency Backwards Whipple for Bleeding: Formidable and Definitive Surgery

INTRODUCTION

During the past decades, the safety of pancreatoduodenectomy has improved, with low mortality and reduced morbidity, particularly in centers with extensive experience. Emergency pancreatoduodenectomy is an uncommon event, for treatment of pancreaticoduodenal trauma, bleeding, or perforation. We herein present a single center experience concerning nontrauma emergency pancreatoduodenectomy for pancreaticoduodenal bleeding.

METHODS

From January 2007 to December 2015, from a population of 134 PD (70 males and 64 females, mean age 62.2, range 34-82), 5 patients (3.7%; 2 males and 3 females, mean age 64, range 57-70) underwent one-stage emergency pancreatoduodenectomy for uncontrollable nontrauma pancreaticoduodenal bleeding in our tertiary center.

RESULTS

All the 5 patients underwent a backwards Whipple with a morbidity of 60% and a mortality of 20% (1/5). The other 4 patients were recovered and discharged with a median postoperative length of stay of 17 days (range 14-23).

CONCLUSION

Emergency pancreatoduodenectomy is a definitive life-saving procedure allowing for a rapid control of bleeding when other less invasive approaches (transcatheter arterial embolization or interventional endoscopy) are exhausted, unavailable, or unsafe. It should be particularly considered in neoplastic disease and tailored by surgeons with a high level of experience in pancreatic surgery.

The impact of preoperative etiology on emergent pancreaticoduodenectomy for non-traumatic patients

BACKGROUND

Emergent pancreaticoduodenectomy is a life-saving procedure in certain clinical scenarios when all the conservative treatment fails. The indications can be limited into perforation and bleeding. To clarify the impact of etiology on surgical outcomes of emergent pancreaticoduodenectomy for non-trauma, we analyzed our patients and performed a literature review.

METHODS

We reviewed 931 consecutive pancreaticoduodenectomies performed at our institute between January 2001 and July 2015. Patients with emergent pancreaticoduodenectomy for non-trauma etiologies were enrolled, whereas those who suffered from caustic injuries were excluded. The keywords "emergent/emergency" and "pancreaticoduodenectomy/pancreatoduodenectomy" were applied in a literature search. The universally available data for all the enrolled patients including etiology, surgical complications, outcomes, and hospital stays were analyzed. Univariate and multivariate logistic analysis for the contributing factors to surgical mortality were performed.

RESULTS

Six out of 931 (0.6%) registered pancreaticoduodenectomies matched our criteria of inclusion. The literature review obtained 4 series and 7 case reports, which when combined with our patients yielded a cohort of 31 emergent pancreaticoduodenectomies with 13 cases of perforation and 18 of bleeding. The rate of emergent pancreaticoduodenectomy for non-traumatic etiologies is similar between the present study and the other 3 series, ranging from 0.3 to 3%. The overall surgical complication rate was 83.9%. The rate of surgical mortality is significantly higher than in elective pancreaticoduodenectomy by propensity score matching with age and gender (19.4 versus 3.2%, P = 0.015). Univariate and multivariate logistic regression disclosed that etiology is the only preoperative risk factor for surgical mortality (perforation versus bleeding; odds ratio = 39.494, P = 0.031).

CONCLUSIONS

Emergent pancreaticoduodenectomy remains a rare operation. Surgical morbidity and mortality are higher than with elective pancreaticoduodenectomy among different reported series. By sorting the preoperative etiologies into two groups, perforation carries a higher risk of surgical mortality than bleeding.