Journal Name: Case Reports International Type of Article ... · An extensive Cattell–Braash...

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Early View Article: Online published version of an accepted article before publication in the final form.

Journal Name: Case Reports International

Type of Article: Case Reports

Title: Trauma pancreatoduodenectomy: How and why?

Authors: Jorge Pereira, Débora Aveiro, Júlio Constantino, Ana Oliveira, Luis Filipe

Pinheiro

doi: To be assigned

Early view version published: September 16, 2015

How to cite the article: Pereira J, Aveiro D, Constantino J, Oliveira A, Pinheiro. Trauma

pancreatoduodenectomy: How and why?, Case Reports International. Forthcoming 2015.

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TYPE OF ARTICLE: Case Report 1

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TITLE: Trauma pancreatoduodenectomy: How and why? 3

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AUTHORS: 5

Jorge Pereira 1, 6

Débora Aveiro2, 7

Júlio Constantino 3, 8

Ana Oliveira 4, 9

Luis Filipe Pinheiro, 5 10

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AFFILIATIONS: 12

1Surgeon, Serviço de Cirurgia 1, Centro Hospitalar Tondela-Viseu, Viseu, Portugal. 13

E-mail: [email protected] 14

2Resident, Serviço de Cirurgia 1, Centro Hospitalar Tondela-Viseu, Viseu, Portugal. 15


3Surgeon, Serviço de Cirurgia 1, Centro Hospitalar Tondela-Viseu, Viseu, Portugal. 17


4Consultant, Serviço de Cirurgia 1, Centro Hospitalar Tondela-Viseu, Viseu, 19

Portugal. E-mail: [email protected] 20

5Department director, Serviço de Cirurgia 1, Centro Hospitalar Tondela-Viseu, Viseu, 21

Portugal. E-mail: [email protected] 22

23

CORRESPONDING AUTHOR DETAILS 24

Jorge de Almeida Pereira 25

Serviço de Cirurgia 1, Centro Hospitalar Tondela-Viseu 26

Avenida Rei D.Duarte, 3504-509 Viseu, Portugal 27

Tel: +351 96 636 4759 28


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Short Running Title: Trauma pancreatoduodenectomy 31


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Guarantor of Submission : The corresponding author is the guarantor of 33

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ABSTRACT 67

Introduction 68

Blunt duodenopancreatic trauma is a rare clinical entity, occurring in less than 2% of 69

all cases of closed abdominal trauma. However, duodenopancreatic injury has high 70

morbidity and mortality rates, especially when severe. While most injuries need only 71

simple surgical techniques, such as debridement or drainage, grade V injuries often 72

require more complex solutions. These may include major pancreatic resection, such 73

as the technically demanding Whipple procedure, which may need to be performed 74

by surgical teams without adequate preparation, in an unstable patient, often at late 75

hours. 76

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Case Report 78

We present the case of a 51-year-old man who sustained blunt abdominal trauma 79

with complex duodenopancreatic injury when he was hit by a motor vehicle. The 80

patient was initially managed with damage control laparotomy; 81

pancreaticoduodenectomy was performed in a second operation, with acceptable 82

results. 83

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Conclusion 85

Treatment of complex duodenal and pancreatic injury may require 86

pancreaticoduodenectomy. The use of damage control techniques allows restoration 87

of the patient’s physiological parameters prior to the extensive surgical procedure. 88

89

Keywords: Abdominal injuries, Pancreatic trauma, Pancreatoduodenectomy, 90

Damage Control, Surgery 91

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INTRODUCTION 99

Blunt duodenopancreatic trauma is a rare clinical entity, occurring in less than 2% of 100

all cases of closed abdominal trauma [1]. However, duodenopancreatic injury has 101

high morbidity (19 to 74,5%) and mortality rates (9 to 34%), especially in cases of 102

severe trauma [1, 2]. 103

The American Association for the Surgery of Trauma classifies pancreatic and 104

duodenal trauma separately into 5 grades (Tables 1 and 2) [3]. Simultaneous 105

involvement of the pancreas and duodenum, often with associated injury to the 106

common bile duct, is classified as Grade V, the most severe form of this injury. The 107

proximity of the structures involved often necessitates a common solution [2, 4, 5]. 108

While most pancreatic and duodenal injuries need only simple surgical debridement 109

or drainage [4, 5], grade V injuries often require more complex solutions. These 110

include major pancreatic resection, such as the technically demanding Whipple 111

procedure, which may need to be performed by surgical teams without adequate 112

preparation, in an unstable patient, often at late hours. These factors undoubtedly 113

affect the outcomes of the procedure [2, 5–7]. 114

115

CASE REPORT 116

A 51-year-old man was admitted to the emergency department with abdominal pain 117

and hematemesis 6 hours after sustaining blunt abdominal trauma in a motor vehicle 118

collision. The patient initially walked to the Basic Emergency Department of his 119

neighborhood and was later transferred to our hospital. He showed no mental status 120

changes or respiratory symptoms. The patient was hemodynamically stable. He had 121

pain on abdominal palpation, with evident signs of peritoneal irritation. FAST exam 122

was positive for free intraperitoneal fluid. Aside from a history of chronic alcoholism, 123

the patient’s medical history did not contain relevant previous diseases or surgeries. 124

Laboratory test results included: hemoglobin, 13 g/dL; white cell count, 34,000/mL; 125

International Normalized Ratio, 0.9; amylase, 243; pH, 7.13; lactate, 4.1 mmol/L; 126

pO2, 119 mmHg. A chest X-ray showed no changes. Because the patient was 127


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hemodynamically stable, abdominal computed tomography was performed. This 128

exam revealed the presence of a bulky periduodenal hematoma involving the head 129

of the pancreas and air bubbles in the retroperitoneum. The arterial phase revealed 130

active bleeding into the stomach (Figure 1), indicating that surgical management was 131

warranted. 132

Laparotomy revealed moderate hemoperitoneum along with a bulky zone 1 133

retroperitoneal hematoma and a laceration of the anterior aspect of the duodenal 134

bulb. An extensive Cattell–Braash maneuver revealed the retroperitoneal hematoma 135

extending along the root of the mesentery as well as transection of the duodenum 136

between the first and the second portions, extending through the pancreas to the 137

isthmus and including the common bile duct (Figures 2–4). 138

By this time, the patient’s acidosis had worsened and he was hypothermic (pH 7,03 139

and temperature 35ºC). Volume replacement was started with crystalloids and later 140

with 3 units of packed red blood cells and 2 units of fresh frozen plasma. The 141

surgeons decided to proceed with a damage control procedure to achieve 142

hemostasis, bile duct drainage with an endoluminal tube, pyloric exclusion through a 143

gastrotomy and extensive retroperitoneal drainage. A laparostomy was performed, 144

using the Barker technique. The patient was admitted to the Intensive Care Unit 145

where supportive care was initiated. His physiological parameters improved and 146

hemodynamic stability was attained. After 56 hours he was afebrile; re-exploration 147

revealed an uncontaminated abdomen without edema of the bowel loops. It was 148

decided that pancreaticoduodenectomy without preservation of the pylorus should be 149

performed, because of extensive damage to the duodenopancreatic complex. The 150

hospital’s hepatobiliary surgical team performed this operation. Two additional units 151

of packed red cells and 2 units of fresh frozen plasma were administered during 152

surgery. The patient was already receiving broad-spectrum antibiotic therapy with 153

meropenem. On the eighth postoperative day he developed a fever. Repeat 154

computed tomography revealed a retrogastric abscess, which was subsequently 155

drained percutaneously. The patient started an oral diet on postoperative day 9. He 156

was discharged from the Intensive Care Unit 20 days after surgery. After 20 days in 157

the general ward, under vigorous physical rehabilitation, the patient was discharged 158


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home. There have been no complications, metabolic or otherwise, in 2 years of 159

follow-up. 160

DISCUSSION 161

Proximal pancreatic injury involving the pancreatic and bile ducts as well as the 162

duodenum is difficult to handle, with no consensus on the ideal approach [2–7]. 163

Opting for a major surgery, such as pancreaticoduodenectomy, is not easy, because 164

very high mortality rates have been reported, up to 46,2% in some case series [2]. 165

Fortunately, most pancreatic and duodenal injuries can be repaired with simple 166

debridement, suturing or drainage, with acceptable morbidity and mortality [2, 4, 5]. 167

Pancreaticoduodenectomy is performed in less than 10% of surgeries for 168

duodenopancreatic trauma [8]. 169

There are few indications for trauma pancreaticoduodenectomy. This technique is 170

justified only in patients with severe combined injuries of the duodenopancreatic 171

complex that involve the bile duct and in those with uncontrollable bleeding from 172

vessels adjacent to these structures [2, 4–6]. Pancreaticoduodenectomy should not 173

be attempted in unstable trauma patients. It is a major, complex operation, requiring 174

several hours to complete, and will not be tolerated by an unstable patient with shock 175

and coagulopathy. Pancreaticoduodenectomy should only be performed in a second 176

stage, after an initial damage control procedure to control hemorrhage and 177

contamination [2, 5]. This approach allows recovery of the patient's physiological 178

parameters in an intensive care environment. 179

Given the technical complexity and results of pancreaticoduodenectomy, some 180

authors suggest that the second intervention should be assisted or performed by 181

experienced hepatobiliary surgeons [9]. This second intervention may be delayed for 182

48 hours, allowing the assembly of the appropriate staff for the 183

pancreaticoduodenectomy reconstruction phase. 184

Pancreaticoduodenectomy after trauma is technically similar to that performed for 185

neoplasia. Resection is often facilitated by the dissection started by the trauma itself 186

and also by the damage control procedures required for exploration, such as the 187

Cattell–Braash maneuver. After control of bleeding, control of contamination 188

presents some important challenges. Pyloric exclusion techniques may be needed to 189

prevent contamination from the stomach in patients with duodenal lesions [2, 8]. 190


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Temporary duodenal repair is also suitable, when possible. The bile duct can be 191

cannulated or ligated [5]. Ligation of the biliary tract may cause widening, which will 192

be helpful during reconstruction, especially if the bile duct is very thin. In such cases, 193

the duct can be widened up to 5 mm in diameter in 48 hours. Pancreatic diversion is 194

more difficult, especially if there is disruption of the main pancreatic duct or 195

destruction of the papilla. The solution can be wide drainage of the retroperitoneum 196

with Jackson–Pratt-type closed-suction drains. In the trauma patient, resection of the 197

uncinate process is not necessary because there is no indication for 198

lymphadenectomy [5]. This simplifies the procedure, allowing the surgeon to work 199

away from the mesenteric vessels and section the medial portion with a vascular 200

stapling device [10]. The gallbladder should be spared initially, as it may be used in 201

biliodigestive reconstruction if the biliary duct is too thin [5]. Lastly, the pancreatic 202

stump must be addressed. Trauma patients have normal, soft pancreatic tissue and 203

a thin main pancreatic duct. With the need for blood transfusion products, the risk of 204

pancreatic fistula increases significantly [11]. Ligation of the stump in elective 205

situations has been shown not to reduce the rate of pancreatic fistula formation and 206

should not be performed, although there are few reports of trauma 207

pancreaticoduodenectomy. However, in some situations, pancreatic stump ligation 208

may be the only possible option [5]. Pancreatico-digestive reconstruction with 209

jejunum or stomach is feasible and safe. Although the literature favors 210

pancreaticogastric over pancreaticojejunal reconstruction, results depend on 211

surgeon’s experience; both approaches are recommended and should be used at 212

the surgeon's discretion and according to personal experience [5]. Total 213

pancreatectomy has also been reported, obviating the problem of pancreatic fistula, 214

but creating significant morbidity; this procedure should be used only in very select 215

elective cases [5]. 216

Data regarding morbidity after trauma pancreaticoduodenectomy is scarce [2, 4, 5]. 217

The rate of global postoperative complications is high, ranging from 8% to 86% [2, 4, 218

5, 9]. Pancreatic fistula is the most frequent pancreatic complication, occurring in 219

between 2% and 37% of patients [2, 5]. In addition to the septic complications of 220

pancreatic fistula, it may cause pseudocyst formation or cataclysmic bleeding 221

resulting from digestion of adjacent vessels, usually the stump of the gastroduodenal 222


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artery [2]. Up to 7% of patients with fistula require additional surgery to treat the 223

complication [2]. Pancreatic abscess is also important and contributes significantly to 224

postoperative mortality. The incidence of pancreatic abscess ranges between 10% 225

and 25%; it is lethal in 27% of cases. The best way to deal with this complication is 226

imaging-guided percutaneous drainage [2]. 227

Like elective pancreaticoduodenectomy, the trauma procedure usually does not 228

produce metabolic complications. Animal models and human experience have 229

shown that more than 80% to 90% of the pancreas must be removed to result in 230

diabetes or malabsorption; pancreatic head removal is well tolerated [2]. 231

232

CONCLUSION 233

Treatment of complex duodenal pancreatic injury may require 234

pancreaticoduodenectomy. The use of damage control techniques allows restoration 235

of the patient’s physiological parameters so that he or she can withstand the 236

extensive surgical insult of the procedure. 237

238

CONFLICT OF INTEREST 239

There is no identifiable conflict of interest to report. The authors have no financial or 240

proprietary interest in the subject matter or materials discussed in the manuscript. 241

242

AUTHOR’S CONTRIBUTIONS 243

Jorge Pereira 244

Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 245

data 246

Group 2 - Drafting the article, Critical revision of the article 247

Group 3 - Final approval of the version to be published 248

Débora Aveiro 249


data 251



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Júlio Constantino 255


data 257



Ana Oliveira 260


data 262



Luis Filipe Pinheiro 265


data 267



270

REFERENCES 271

1. Bradley E, Young P, Chang M, Allen J, Baker C, Meredith W, et al. Diagnosis and 272

Initial Management of Blunt Pancreatic Trauma. Annals of Surgery. 273

1998;227(6):861-869. 274

2. Potoka D, Gaines B, Leppäniemi A, Peitzman A. Management of blunt pancreatic 275

trauma: what’s new?. Eur J Trauma Emerg Surg. 2015;. 276

3. Moore E, Cogbill T, Malangoni M, Jurkovich G, Champion H. Scaling system for 277

organ specific injuries. Current Opinion in Critical Care. 1996;2(6):450-462. 278

4. Subramanian A, Dente C, Feliciano D. The Management of Pancreatic Trauma in 279

the Modern Era. Surgical Clinics of North America. 2007;87(6):1515-1532. 280

5. Degiannis E, Glapa M, Loukogeorgakis S, Smith M. Management of pancreatic 281

trauma. Injury. 2008;39(1):21-29. 282

6. Søreide K. Pancreas injury: The good, the bad and the ugly. Injury. 283

2015;46(5):827-829. 284

7. Yilmaz T, Hauer T, Smith M, Degiannis E, Doll D. Operative techniques in 285

pancreatic trauma—A heuristic approach. Injury. 2013;44(1):153-155. 286


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8. FELICIANO D, MARTIN T, CRUSE P, GRAHAM J, BURCH J, MATTOX K et al. 287

Management of Combined Pancreatoduodenal Injuries. Annals of Surgery. 288

1987;205(6):673-680. 289

9. van der Wilden G, Yeh D, Hwabejire J, Klein E, Fagenholz P, King D et al. 290

Trauma Whipple: Do or Don’t After Severe Pancreaticoduodenal Injuries? An 291

Analysis of the National Trauma Data Bank (NTDB). World Journal of Surgery. 292

2013;38(2):335-340. 293

10. D’souza M, Singh K, Hawaldar R, Shukla P, Shrikhande S. The Vascular Stapler 294

in Uncinate Process Division during Pancreaticoduodenectomy: Technical 295

Considerations and Results. Digestive Surgery. 2010;27(3):175-181. 296

11. Oneil Machado N. Pancreatic Fistula after Pancreatectomy: Definitions, Risk 297

Factors, Preventive Measures, and Management—Review. International Journal 298

of Surgical Oncology. 2012;2012:1-10. 299

300

SUGGESTED READING 301

1. Hirshberg A, Mattox K. Top knife. Castle Hill Barns, Shrewsbury, UK: Tfm Pub.; 302

2005. 303

2. Boffard K. Manual of definitive surgical trauma care. London: Hodder Arnold; 304

2011. 305

3. Asensio J, Trunkey D. Current therapy of trauma and surgical critical care. 306

Philadelphia: Mosby/Elsevier; 2008. 307

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TABLES 319

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Table 1: Grading of pancreatic injury (from Moore et al.) 321

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Grade I Hematoma: mild contusion without duct injury

Laceration: superficial laceration without duct injury

Grade II Hematoma: major contusion without duct injury or tissue loss

Laceration: major laceration without duct injury or tissue loss

Grade III Distal transection or parenchymal injury with duct injury

Grade IV Proximal transection or parenchymal injury

Grade V Massive disruption of pancreatic head

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Advance one grade for multiple injuries up to grade III. Proximal pancreas is to the 324

patients’ right of the superior mesenteric vein. 325

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Table 2: Grading of duodenal injury (from Moore et al.) 327

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Grade I Hematoma: involving single portion of the duodenum

Laceration: partial thickness, no perforation

Grade II Hematoma: involving more than one portion of the duodenum

Laceration: disruption of <50% of circumference

Grade III Laceration: disruption of 50 to 75% circumference of D2

Laceration: disruption of 50 to 100% circumference of D1, D3, and

D4

Grade IV Laceration: disruption of >75% circumference of D2

Laceration: involving the ampulla or distal common bile duct

Grade V Laceration: massive disruption of the duodenopancreatic complex

Vascular: devascularization of the duodenum

329

Abbreviations: D1, D2, D3, D4: anatomic portions of the duodenum 330

Advance one grade for multiple injuries up to grade III. D1-first position of 331

duodenum; D2-second portion of duodenum; D3-third portion of duodenum; D4-332

fourth portion of duodenum 333

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FIGURE LEGENDS 344

Figure 1: Abdominal computed tomography. (A) and (B): Scan without contrast 345

showing free fluid and a bulky periduodenal hematoma. (C) and (D): Scan with 346

intravenous contrast, showing (C) fresh blood in the stomach and (D) air bubbles in 347

the retroperitoneum. 348

Figure 2: Postoperative sketch made by the surgeon showing the injuries sustained: 349

anterior laceration of first portion of the duodenum and transection involving the 350

second portion of the duodenum, head of the pancreas and bile duct. 351

Figure 3: Intraoperative image showing the duodenal transection. 352

Figure 4: Intraoperative image showing the bile duct injury and drainage. 353

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FIGURE 355

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Figure 1: Abdominal computed tomography. (A) and (B): Scan without contrast 357

showing free fluid and a bulky periduodenal hematoma. (C) and (D): Scan with 358

intravenous contrast, showing (C) fresh blood in the stomach and (D) air bubbles in 359

the retroperitoneum. 360


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Figure 2: Postoperative sketch made by the surgeon showing the injuries sustained: 363

anterior laceration of first portion of the duodenum and transection involving the 364

second portion of the duodenum, head of the pancreas and bile duct. 365

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Figure 3: Intraoperative image showing the duodenal transection. 367


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Figure 4: Intraoperative image showing the bile duct injury and drainage. 369

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