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Uchida K, Hagawa N, Miyashita M, Maeda T, Kaga S, Noda T, Nishimura T, Yamamoto H, Mizobata Y. How to deploy a uniform and simplified acute-phase management strategy for traumatic pancreatic injury in any situation. Acute Med Surg 2020; 7:e502. [PMID: 32431843 PMCID: PMC7231571 DOI: 10.1002/ams2.502] [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: 12/30/2019] [Revised: 02/17/2020] [Accepted: 02/24/2020] [Indexed: 11/18/2022] Open
Abstract
Aim Management of traumatic pancreatic injury is challenging, and mortality and morbidity remain high. Because pancreatic injury is uncommon and strong recommendations for pancreatic injury management are lacking, management is primarily based on institutional practices. We propose our strategy of pancreatic injury management. Methods We retrospectively reviewed patients with pancreatic injury and evaluated our strategy and outcomes. Results From January 2013 to December 2019, 18 patients were included with traumatic pancreatic injury. The median Injury Severity Score was 22 (25–75% interquartile range, 17–34) and probability of survival was 0.87 (25–75% interquartile range, 0.78–0.93). Patients were grouped according to the American Association for the Surgery of Trauma injury grades: grade I, n = 3 (16.7%); II, n = 6 (33.3%); III, n = 7 (38.9%); and IV, n = 2 (11.1%). All patients underwent endoscopic pancreatic ductal evaluation within 1–2 days after admission. Abbreviated surgery because of hemodynamic instability and subsequent open abdominal management were undertaken in one patient with pancreas head injury and two patients with pancreas body/tail injury. Management was by laparotomy for closed suction drain insertion with main ductal endoscopic drainage in six patients, endoscopic ductal drainage only in six patients, and distal pancreatectomy with closed suction drainage and endoscopic drainage in five patients. One patient with grade I injury underwent observation only. Median length of closed suction drainage was 12 days and that of hospital stay was 36 days. The observed mortality during the study period was 0%. Late formation of pseudo‐pancreatic cyst was observed in two patients (11.1%). Conclusion Our uniform, simplified strategy offers good outcomes for any pancreatic injury site and any concomitant injuries, even in hemodynamically unstable patients.
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Affiliation(s)
- Kenichiro Uchida
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Naohiro Hagawa
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Masahiro Miyashita
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Toshiki Maeda
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Shinichiro Kaga
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Tomohiro Noda
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Hiromasa Yamamoto
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
| | - Yasumitsu Mizobata
- Department of Traumatology and Critical Care Medicine Osaka City University Graduate School of Medicine Osaka Japan
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Mori T, Ohira G, Kimura K, Yamazoe S, Amano R, Ohira M. A case of perforation of a pancreatic duct by a pancreatic stent during chemoradiotherapy for pancreatic head cancer: a case report. Surg Case Rep 2019; 5:10. [PMID: 30673900 PMCID: PMC6346691 DOI: 10.1186/s40792-019-0571-3] [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: 11/05/2018] [Accepted: 01/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pancreatic injuries are rare, and no treatment plan has yet been established for grade III injuries. In many cases, pancreatic stent placement has resulted in saving patients. However, some cases of perforation of a pancreatic duct during the placement of a stent have been described, and there are also a few cases of delayed perforation by a pancreatic stent. CASE PRESENTATION A 62-year-old man had obstructive jaundice and pancreatitis due to locally advanced pancreatic head cancer. Both biliary and pancreatic stent were placed by endoscopy, after which chemoradiotherapy was performed. Four months later, he visited our hospital with severe abdominal pain. We performed enhanced CT and diagnosed the patient as having a perforation of a pancreatic duct by a pancreatic stent; therefore, we performed an emergency operation. Since we deemed pancreatectomy risky, we inserted pancreatic tubes into both sides of the perforated site and performed percutaneous transgastric drainage. The postoperative course was uneventful. We thereafter cut the tubes and switched to internal drainage. CONCLUSION Many cases of pancreatic injuries have reported that pancreatic stent placement results in saving the patient, but there have been few cases in which a pancreatic stent causes perforation of a pancreatic duct. External drainage by pancreatic tubes is very effective in resolving perforation of a pancreatic duct.
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Affiliation(s)
- Takuya Mori
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585 Japan
| | - Go Ohira
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585 Japan
| | - Kenjiro Kimura
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585 Japan
| | - Sadaaki Yamazoe
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585 Japan
| | - Ryosuke Amano
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585 Japan
| | - Masaichi Ohira
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585 Japan
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Krige JE, Thomson SR. Pancreatoduodenectomy for trauma: applying novel reconstruction techniques. SURGICAL TECHNIQUES DEVELOPMENT 2016. [DOI: 10.4081/std.2016.6293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This single center study evaluated the technical modifications and outcome of reconstruction after pancreaticoduodenectomy for trauma. Prospectively recorded data including reconstructive techniques used in patients who underwent a pancreatoduodenectomy (PD) for trauma were analyzed. Twenty patients underwent a PD. Six had an initial damage control procedure. Thirteen had a pylorus-preserving PD and 7 a standard Whipple resection because injury to the pylorus precluded a pylorus-preserving resection. Twelve patients had a pancreatojejunostomy and 8 a pancreatogastrostomy, 3 of whom had a duodenojejunal hepaticojejunal sequence of anastomoses to allow endoscopic biliary stent retrieval. Three patients died postoperatively of multi-organ failure. All 17 survivors had postoperative complications: 5 patients developed pancreatic fistula, 2 had gastric outlet obstruction, 2 had bile leaks, 2 had duodenal anastomotic leaks, all of which resolved with conservative treatment. Pancreatic and biliary reconstructions performed under adverse conditions after a trauma PD required a variety of technical modifications. The pylorus does not have to be sacrificed and posterior gastric implantation is a safe option for an edematous pancreas.
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Western Trauma Association critical decisions in trauma: management of pancreatic injuries. J Trauma Acute Care Surg 2014; 75:941-6. [PMID: 24256664 DOI: 10.1097/ta.0b013e3182a96572] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Phelan HA, Minei JP. Pancreatic trauma: diagnostic and therapeutic strategies. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2005; 8:355-63. [PMID: 16162301 DOI: 10.1007/s11938-005-0038-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The management of pancreatic trauma provides trauma surgeons with diagnostic and therapeutic challenges. The two most important facts that must be established are the location of the injury in relation to the superior mesenteric artery and vein and the status of the main pancreatic duct. If a pancreatic injury is discovered at the time of exploration and no main ductal injury is found, debridement and wide drainage are adequate therapy regardless of the location of the injury. If the status of the duct cannot be confidently determined and the injury lies to the left of the vessels, a single attempt at cholecystocholangiography should be performed. If this is unsuccessful, distal pancreatectomy with splenectomy with no further attempts at ductal imaging are our treatments of choice. Splenic salvage may be considered in the pediatric population. If the injury lies to the right of the vessels and the status of the duct is not able to be diagnosed with thorough exploration, we recommend endoscopic retrograde cholangiopancreatography (ERCP), either intraoperatively or on an urgent basis postoperatively, with wide closed suction drainage prior to closure of the abdomen. If the ERCP shows intact pancreatic and common bile ducts, expectant management is warranted. If the duct is injured, the patient is returned to the operating room for debridement of the injury, oversewing of the proximal pancreatic duct, and a distal pancreaticojejunostomy. Use of ERCP to stent this injury type has been reported but has yet to be rigorously studied. If the ampulla is destroyed or the pancreatic head is devascularized, pancreaticoduodenectomy is required either at the original surgery or after patient stabilization if damage control laparotomy is necessary. If a stable trauma patient has findings on a computed tomography suggestive of an isolated pancreatic injury, we still recommend laparotomy using the previously mentioned algorithm. All patients with pancreatic injury should have feeding access placed intraoperatively beyond the ligament of Treitz, with our choice being a nasal-jejunal feeding tube. Postoperative pancreatic fistulae should be managed with adequate closed suction drainage, octreotide, and observation for a period of at least 4 to 8 weeks prior to contemplation of surgical intervention.
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Affiliation(s)
- Herb A Phelan
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Asensio JA, Petrone P, Roldán G, Kuncir E, Demetriades D. Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries. J Am Coll Surg 2004; 197:937-42. [PMID: 14644281 DOI: 10.1016/j.jamcollsurg.2003.07.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (Whipple's procedure) is a formidable procedure when undertaken for severe pancreaticoduodenal injury. The purposes of this study were to review our experience with this procedure for trauma; to classify injury grades for both pancreatic and duodenal injuries in patients undergoing pancreaticoduodenectomy according to the American Association for the Surgery of Trauma-Organ Injury Scale for pancreatic and duodenal injury; and to validate existing indications for performance of this procedure. STUDY DESIGN We performed a retrospective 126-month study (May 1992 to December 2002) of all patients admitted with proven complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy. RESULTS Eighteen patients were included; mean age was 32 +/- 12 years (SD), mean Revised Trauma Score was 6.84 +/- 2.13 (SD), and mean Injury Severity Score was 27 +/- 8 (SD). There were 17 penetrating injuries (94%) and 1 blunt injury (6%). One of 18 patients had an emergency department thoracotomy and died (100% mortality); 5 of the remaining 17 patients required operating room thoracotomies, and only 1 survived (80% mortality). There was 1 AAST-OIS pancreas grade IV injury, and there were 17 pancreas grade V injuries and 18 AAST-OIS duodenum grade V injuries. Indications for pancreaticoduodenectomy were: massive uncontrollable retropancreatic hemorrhage, 13 patients (72%); massive unreconstructable injury to the head of the pancreas/main pancreatic duct and intrapancreatic portion/distal common bile duct, 18 patients (100%); and massive unreconstructable injury, 18 patients (100%). Mean estimated blood loss was 6,888 +/- 7,866 mL, and overall survival was 67% (12 of 18 patients). CONCLUSIONS Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy (Whipple's procedure) are uncommon but highly lethal; virtually all are classified as AAST-OIS grade V for both pancreas and duodenum. Current indications for performance of pancreaticoduodenectomy are valid and should be strictly applied during procedure selection.
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Affiliation(s)
- Juan A Asensio
- Division of Trauma and Critical Care, Department of Surgery, University of Southern California, LAC+USC Medical Center, Los Angeles, CA 90033, USA
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Chrysos E, Athanasakis E, Xynos E. Pancreatic trauma in the adult: current knowledge in diagnosis and management. Pancreatology 2003; 2:365-78. [PMID: 12138225 DOI: 10.1159/000065084] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Although pancreatic trauma, isolated or not, is uncommon, it carries significant morbidity and mortality because of the delay in recognition and consequent treatment. METHODS The current knowledge of pancreatic injury, concerning the incidence, mechanism of induction, diagnosis, treatment, complications and outcome, is herein presented based on a literature review and our limited experience. RESULTS The diagnosis of pancreatic trauma entails a high index of suspicion because neither clinical nor laboratory evaluation provide pathognomonic elements. Patients with penetrating injuries are usually evaluated during laparotomy, while those with a blunt trauma can be managed conservatively, provided they are in a stable condition, there is no pancreatic duct involvement and care is intensive. At laparotomy, minor pancreatic injuries are best managed by drainage. Distal pancreatectomy is best suited for distal pancreatic trauma with ductal involvement. For severe trauma, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, duodenal diversion operations and Whipple's procedure are all indicated according to the preoperative evaluation and intraoperative findings. Independent of the procedure to be performed, drainage is mandatory. CONCLUSION Because pancreatic injury is rare, most general surgeons lack experience and ability to deal with such injured patients. Therefore, an experienced and skilled surgeon should govern the management of pancreatic trauma in order to minimize the incidence of morbidity and mortality.
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Affiliation(s)
- Emmanuel Chrysos
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
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Koniaris LG, Mandal AK, Genuit T, Cameron JL. Two-stage trauma pancreaticoduodenectomy: delay facilitates anastomotic reconstruction. J Gastrointest Surg 2000; 4:366-9. [PMID: 11058854 DOI: 10.1016/s1091-255x(00)80014-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A case of a gunshot wound to the head of the pancreas and superior mesenteric vein requiring pancreaticoduodenectomy is discussed. Managing such an injury is challenging, first because of the ongoing hemorrhage and second because of the technical difficulty in working with a normal pancreas and bile duct. In the case presented herein, enteric reconstruction was performed 72 hours after the initial surgery. A delay in reconstruction resulted in tissue changes that facilitated enteric reconstruction A two-stage pancreaticoduodenectomy may be considered if the surgeon is faced with an unstable patient.
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Affiliation(s)
- L G Koniaris
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Kurisu A, Kobayashi H, Kawashima K. Pancreaticogastrostomy after pancreaticoduodenectomy: a rational approach to severe combined pancreaticoduodenal injury. THE JOURNAL OF TRAUMA 1999; 46:970-2. [PMID: 10338427 DOI: 10.1097/00005373-199905000-00038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- A Kurisu
- Department of Surgery, Musashino Red-Cross Hospital, Tokyo, Japan
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Asensio JA, Demetriades D, Hanpeter DE, Gambaro E, Chahwan S. Management of pancreatic injuries. Curr Probl Surg 1999; 36:325-419. [PMID: 10410646 DOI: 10.1016/s0011-3840(99)80003-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- J A Asensio
- Division of Trauma and Critical Care, Department of Surgery University of Southern California, USA
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12
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Fabre JM, Arnaud JP, Navarro F, Bergamaschi R, Cervi C, Marrel E, Domergue J. Results of pancreatogastrostomy after pancreatoduodenectomy in 160 consecutive patients. Br J Surg 1998; 85:751-4. [PMID: 9667699 DOI: 10.1046/j.1365-2168.1998.00648.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The advantages of pancreatogastrostomy over pancreatojejunostomy after pancreaticoduodenectomy are still debated. This study analyses the results of pancreatogastrostomy to identify factors that could influence immediate outcome. METHODS During a 10-year period, 160 consecutive patients underwent a pancreatogastrostomy. There were 109 men (68 per cent) and 51 women (32 per cent) with a mean(s.d.) age of 59(10) (range 22-82) years; 27 patients were older than 70 years. The following parameters were assessed: mortality rate, morbidity, reasons for reoperation, length of hospital stay, duration of nasogastric tube and drainage. RESULTS Hospital mortality rate was 3 per cent; overall morbidity rate was 30 per cent. The reoperation rate was 12 per cent, mainly because of bleeding at the pancreatic margin. Delayed gastric emptying occurred in 36 patients. The overall rate of pancreatic fistula was 2.5 per cent. Age, sex, indications for pancreatoduodenectomy, and the texture of the pancreatic remnant did not influence the occurrence of pancreatic fistula or delayed gastric emptying. CONCLUSION This study confirmed that pancreatogastrostomy is a safe procedure with low mortality and morbidity rates.
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Affiliation(s)
- J M Fabre
- Department of Digestive Surgery, CHU Montpellier, France
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Mistry BM, Durham RM. Delayed pancreatoduodenectomy followed by delayed reconstruction for trauma. Br J Surg 1996; 83:527. [PMID: 8665250 DOI: 10.1002/bjs.1800830431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- B M Mistry
- Department of Surgery, St Louis University Health Sciences Center, Missouri 63110-0250, USA
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Maher MM, Yeo CJ, Lillemoe KD, Roberts JR, Cameron JL. Pancreas-sparing duodenectomy for infra-ampullary duodenal pathology. Am J Surg 1996; 171:62-7. [PMID: 8554153 DOI: 10.1016/s0002-9610(99)80075-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical management of distal duodenal pathology is challenging because of the duodenum's retroperitoneal location and its shared blood supply with the pancreas. For infra-ampullary pathology, surgical treatment may include local excision, pancreaticoduodenectomy, or pancreas-sparing duodenectomy (PSD). PATIENTS AND METHODS We retrospectively reviewed the management of 24 patients with infra-ampullary duodenal pathology treated by PSD between 1985 and 1994 at The Johns Hopkins Hospital. RESULTS There were 16 men and 8 women with a mean age of 51.2 +/- 4.4 years. The indications for elective PSD in 19 patients were neoplasms (n = 15), Crohn's disease (n = 2), and other (n = 2). Of the neoplasms, 13 were malignant (11 adenocarcinoma, 1 lymphoma, 1 liposarcoma) and 2 were being (1 villous adenoma, 1 benign stromal tumor). Five patients had PSD as an emergency procedure for penetrating trauma. The mean follow-up is 24.2 +/- 5.8 months (range 1 to 122). In the group undergoing elective PSD, the mean length of operation was 5.3 +/- 0.4 hours, and the estimated blood loss was 569 +/- 121 mL. In the entire series, there was 1 postoperative death from an anastomotic leak and 1 reexploration for anastomotic bleeding. Pancreas-sparing duodenectomy in patients with trauma or benign duodenal pathology resulted in a good outcome in all. In those 11 patients with duodenal adenocarcinoma, 7 have died, 2 have had recurrences, and 2 are disease free. Actuarial and disease-free, 2-year survival rates in the 11 patients with duodenal adenocarcinoma were 33% and 14%, respectively. CONCLUSIONS Pancreas-sparing duodenectomy is a safe and effective treatment in patients with distal duodenal benign neoplasms or trauma, and PSD appears to have limited effectiveness for malignant distal duodenal pathology.
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Affiliation(s)
- M M Maher
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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