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Noorbakhsh S, Wagner V, Arientyl V, Orlin S, Koganti D, Fransman RB, Bishop ES, Castater CA, Nguyen J, De Leon Castro A, Davis MA, Smith RN, Todd SR, Sciarretta JD. Pancreaticoduodenectomy in high-grade pancreatic and duodenal trauma. Injury 2024; 55:111721. [PMID: 39084919 DOI: 10.1016/j.injury.2024.111721] [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: 03/21/2024] [Revised: 06/07/2024] [Accepted: 07/05/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION High-grade pancreaticoduodenal injuries are highly morbid and may require complex surgical management. Pancreaticoduodenectomy (Whipple procedure) is sometimes utilized in the management of these injuries, but guidelines on its use are lacking. This paper aims to present our 14-year experience in management of high-grade pancreaticoduodenal injuries at our busy, urban trauma center. METHODS A retrospective review was performed on patients (ages >15 years) presenting with high-grade (AAST-OIS Grades IV and V) injuries to the pancreas or duodenum at our Southeastern Level 1 trauma center. Inclusion criteria included high-grade injury and requirement of Whipple procedure based on surgeon discretion. Patients were divided into two groups: (1) those who underwent Whipple procedures during the index operation and (2) Whipple candidates. Whipple candidates included patients who received Whipples in a staged fashion or who would have benefited from the procedure but either died or were salvaged to another procedure. Demographics, injury patterns, management, and outcomes were compared. Primary outcome was survival to discharge. RESULTS Of 66,272 trauma patients in this study period, 666 had pancreatic or duodenal injuries, and 20 met inclusion criteria. Of these, 6 had Whipples on the index procedure and 14 were Whipple candidates (among whom 7 had staged Whipples, 6 died before completing a Whipple, and 1 was salvaged). Median (IQR) age was 28 (22.75-40) years. Patients were 85 % male, 70 % Black. GSWs comprised 95 % of injuries. All patients had at least one concomitant injury, most commonly major vascular injury (75 %), colonic injury (65 %), and hepatic injury (60 %). In-hospital mortality among Whipple patients was 15 %. CONCLUSIONS Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy are rare but life-threatening. In such patients, hemorrhage was the leading cause of death in the first 24 h. Approximately half underwent damage control surgery with staged Whipple Procedures. However, pancreaticoduodenectomy at the initial operation is feasible in highly selective patients, depending on the extent of injury, physiologic status, and resuscitation.
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Affiliation(s)
- Soroosh Noorbakhsh
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States.
| | - Victoria Wagner
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Vanessa Arientyl
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Stormy Orlin
- Mercer University School of Medicine, 1550 College St, Macon, GA, 31207, United States
| | - Deepika Koganti
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Ryan B Fransman
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Elliot S Bishop
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Christine A Castater
- Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States; Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA, 30310, United States
| | - Jonathan Nguyen
- Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States; Morehouse School of Medicine, 720 Westview Dr SW, Atlanta, GA, 30310, United States
| | | | - Millard A Davis
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Randi N Smith
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - S Rob Todd
- Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
| | - Jason D Sciarretta
- Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA, 30307, United States; Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, United States
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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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Aoki Y, Sasanuma H, Kimura Y, Saito A, Morishima K, Kaneda Y, Endo K, Yoshida A, Kihara A, Sakuma Y, Horie H, Hosoya Y, Lefor AK, Sata N. Pancreas-preserving double pancreaticogastrostomy after traumatic injury to the head of the pancreas: a case report. J Int Med Res 2021; 48:300060520962967. [PMID: 33059503 PMCID: PMC7580157 DOI: 10.1177/0300060520962967] [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] [Indexed: 11/15/2022] Open
Abstract
Traumatic injury to the main pancreatic duct requires surgical treatment, but optimal management strategies have not been established. In patients with isolated pancreatic injury, the pancreatic parenchyma must be preserved to maintain long-term quality of life. We herein report a case of traumatic pancreatic injury with main pancreatic duct injury in the head of the pancreas. Two years later, the patient underwent a side-to-side anastomosis between the distal pancreatic duct and the jejunum. Eleven years later, he presented with abdominal pain and severe gastrointestinal bleeding from the Roux limb. Emergency surgery was performed with resection of the Roux limb along with central pancreatectomy. We attempted to preserve both portions of the remaining pancreas, including the injured pancreas head. We considered the pancreatic fluid outflow tract from the distal pancreatic head and performed primary reconstruction with a double pancreaticogastrostomy to avoid recurrent gastrointestinal bleeding. The double pancreaticogastrostomy allowed preservation of the injured pancreatic head considering the distal pancreatic fluid outflow from the pancreatic head and required no anastomoses to the small intestine.
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Affiliation(s)
- Yuichi Aoki
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Hideki Sasanuma
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Yuki Kimura
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Akira Saito
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Kazue Morishima
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Yuji Kaneda
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Kazuhiro Endo
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Atsushi Yoshida
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Atsushi Kihara
- Department of Pathology, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Yasunaru Sakuma
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Hisanaga Horie
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Yoshinori Hosoya
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
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Di Saverio S, Franchi C, Kremel D, Lark ME, Todero S, Damaskos D. Technique for pancreas-sparing total duodenectomy and reconstruction of a neoduodenum using a free interposed jejunal limb with ampullojejunostomy and Roux-en-Y anastomosis. Br J Surg 2021; 108:e71-e73. [PMID: 33704403 DOI: 10.1093/bjs/znaa097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 11/12/2022]
Affiliation(s)
- S Di Saverio
- Department of General Surgery, University of Insubria, American Association for the Surgery of Trauma (ASST) Sette Laghi, Varese, Italy
| | - C Franchi
- Department of General Surgery, University of Insubria, American Association for the Surgery of Trauma (ASST) Sette Laghi, Varese, Italy
| | - D Kremel
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M E Lark
- University of Toledo Medical Center, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - S Todero
- St Orsola-Malpighi University Hospital, Alma Mater University of Bologna, Bologna, Italy
| | - D Damaskos
- Department of General Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Somasekar RDR, Sankar AS, Krishna PS. Primary reinforcement with rectus abdominis muscle flap-a salvage technique for a tenuous post traumatic duodenal perforation- a case report. Int J Surg Case Rep 2020; 74:91-94. [PMID: 32836211 PMCID: PMC7452464 DOI: 10.1016/j.ijscr.2020.07.080] [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: 06/03/2020] [Revised: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The conventional techniques for management of complex duodenal injuries are duodenal diverticularisation, pyloric exclusion or triple tube decompression. We here present a salvage technique of primary reinforcement with pedicled rectus abdominis muscle flap (RAMF) for a tenuous post traumatic duodenal perforation (PTDP). The majority of the studies in the literature are on the use RAMF for the secondary repair of peptic duodenal perforations. PRESENTATION OF CASE A 38 year old male presented with an acute abdomen, three days after sustaining a blunt abdominal trauma. The clinical and radiological findings in the abdomen were subtle and not contributory. An emergency laparotomy with a high index of suspicion revealed a large perforation in the anterolateral wall of the second portion of the duodenum with a friable unhealthy wall and shearing of the serosa around the perforation site. The entire omentum was unhealthy, contused with areas of gangrene and omentectomy done. The perforation site was closed using 3.0 vicryl and reinforced with a pedicled right RAMF based on the superior epigastric artery. The patient recovered uneventfully and was discharged. DISCUSSION The addition of conventional diversion techniques to primary duodenorrhaphy is sophisticated, time consuming and adds morbidity. CONCLUSION RAMF is a good tissue substitute to buttress tenuous duodenal injuries presenting late with inflamed, friable perforation sites and associated tissue loss, where duodenorrhaphy alone may not be successful. RAMF is a valuable salvage technique when the omentum is not available and the local tissue condition negates the effectiveness of other simpler techniques.
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Affiliation(s)
- R D R Somasekar
- Department of Surgical Gastroenterology, GMKMCH, BRS Residency, Vidyalaya Road, Salem, 636007, India.
| | - A Siva Sankar
- Department of Surgical Gastroenterology, GMKMCH, Nitesh Hospitals, Sewapet, Salem, 636002, India.
| | - P Sai Krishna
- Department of Surgical Gastroenterology, GMKMCH, Room No 210, PG Hostel, Salem, 636002, India.
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Pancreas-sparing duodenectomy in a patient with acute corrosive injury. Updates Surg 2012; 65:309-11. [PMID: 22623118 DOI: 10.1007/s13304-012-0159-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 05/09/2012] [Indexed: 01/07/2023]
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Moritz K, Weinrich M, Kröger JC, Klar E. [Pancreas-preserving duodenectomy in acute situations. Surgical treatment of an iatrogenic hemorrhage in the duodenal wall]. Chirurg 2011; 82:723-6. [PMID: 21800189 DOI: 10.1007/s00104-011-2144-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report the case of a 24-year-old patient who underwent a duodenal biopsy due to the suspicion of graft-versus-host disease following allogeneic stem cell transplantation 3 months previously. The patient developed severe upper abdominal pain after the biopsy. A computed tomography scan revealed diffuse hemorrhaging in the duodenal wall and mesenteric root. Following supraselective angioembolization to stop the bleeding a control computed tomography scan was carried out the following day and revealed increasing destruction of the duodenal wall due to a dissecting aneurysm. A pancreas-preserving duodectomy was carried out.
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Affiliation(s)
- K Moritz
- Klinik und Poliklinik für Chirurgie, Abteilung für Allgemeine, Thorax-, Gefäss- und Transplantationschirurgie, Universitätsklinikum Rostock, Schillingallee 35, Rostock, Germany.
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Penninga L, Svendsen LB. Pancreas-preserving total duodenectomy: a 10-year experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:717-23. [DOI: 10.1007/s00534-011-0382-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Luit Penninga
- Surgery and Transplantation, Dept C-2122, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 3344, Rigshospitalet; Copenhagen University Hospital; Blegdamsvej 9 2100 Copenhagen Denmark
| | - Lars Bo Svendsen
- Surgery and Transplantation, Dept C-2122, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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