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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.
Disclaimer: This manuscript has been accepted for publication. This is a pdf file of the Early View Article. The Early View Article is an online published version of an accepted article before publication in the final form. The proof of this manuscript will be sent to the authors for corrections after which this manuscript will undergo content check, copyediting/proofreading and content formatting to conform to journal’s requirements. Please note that during the above publication processes errors in content or presentation may be discovered which will be rectified during manuscript processing. These errors may affect the contents of this manuscript and final published version of this manuscript may be extensively different in content and layout than this Early View Article.
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TYPE OF ARTICLE: Case Report 1
2
TITLE: Trauma pancreatoduodenectomy: How and why? 3
4
AUTHORS: 5
Jorge Pereira 1, 6
Débora Aveiro2, 7
Júlio Constantino 3, 8
Ana Oliveira 4, 9
Luis Filipe Pinheiro, 5 10
11
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
E-mail: [email protected] 16
3Surgeon, Serviço de Cirurgia 1, Centro Hospitalar Tondela-Viseu, Viseu, Portugal. 17
E-mail: [email protected] 18
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
E-mail: [email protected] 29
30
Short Running Title: Trauma pancreatoduodenectomy 31
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TITLE: Trauma pancreatoduodenectomy: How and why? 65
66
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
77
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
84
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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TITLE: Trauma pancreatoduodenectomy: How and why? 97
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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
Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 250
data 251
Group 2 - Drafting the article, Critical revision of the article 252
Group 3 - Final approval of the version to be published 253
254
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Júlio Constantino 255
Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 256
data 257
Group 2 - Drafting the article, Critical revision of the article 258
Group 3 - Final approval of the version to be published 259
Ana Oliveira 260
Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 261
data 262
Group 2 - Drafting the article, Critical revision of the article 263
Group 3 - Final approval of the version to be published 264
Luis Filipe Pinheiro 265
Group1 - Conception and design, Acquisition of data, Analysis and interpretation of 266
data 267
Group 2 - Drafting the article, Critical revision of the article 268
Group 3 - Final approval of the version to be published 269
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
320
Table 1: Grading of pancreatic injury (from Moore et al.) 321
322
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
323
Advance one grade for multiple injuries up to grade III. Proximal pancreas is to the 324
patients’ right of the superior mesenteric vein. 325
326
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Table 2: Grading of duodenal injury (from Moore et al.) 327
328
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
354
FIGURE 355
356
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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361
362
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
366
Figure 3: Intraoperative image showing the duodenal transection. 367
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368
Figure 4: Intraoperative image showing the bile duct injury and drainage. 369