British Journal of Surgery 1996,83,527
Case report
Delayed pancreatoduodenectomy followed by delayed reconstruction for trauma
B . M . M I S T R Y and R . M . D U R H A M Department of Surgery, St Louis University Health Sciences Centel; 3635 Vi ta Avenue, St Louis, Missouri 63110-0250, USA Correspondence to: Dr B. M. Mistry
Abdominal packing is frequently used as a temporary measure to control bleeding in patients with severe intra- abdominal haemorrhage accompanied by coagulopathy, hypothermia and acidosis’,’. Pancreatic resection followed by delayed reconstruction has been performed successfully in trauma3. A case is reported of delayed pancreatic resection and delayed reconstruction for a gunshot wound to the abdomen.
Case report A 15-year-old boy was brought to the emergency room with a single gunshot wound in the epigastrium. The exit wound was located on the back just to the right of the second lumbar spinous process. The patient was hypotensive. Resuscitation was commenced and he was taken to the operating theatre. A resuscitative left anterior thoracotomy with cross-clamping of the descending thoracic aorta was performed. At laparotomy the patient had a massive haemoperitoneum, with injuries to the second part of the duodenum, head of pancreas and intra- pancreatic portion of the common bile duct, together with the right renal artery and the renal vein at its junction with the inferior vena cava. Right nephrectomy was combined with repair of the inferior vena cava in the form of a venorraphy. By now the patient had developed hypothermia, coagulopathy and acidosis. To shorten the surgical procedure, the injured portion of the duodenum was excised, the distal stomach and second portion of the duodenum were closed with a stapler and the distal common bile duct was ligated. The abdomen was packed, and the patient was taken to the surgical intensive care unit.
After resuscitation over the next 30 h, the abdomen was re- explored. The patient underwent pancreatoduodenectomy with stapled closure of the distal stomach and proximal jejunum, cholecystectomy and drainage of the common bile duct, gastrostomy, feeding jejunostomy and ligation of the occluded inferior vena cava. Two large closed suction drains were placed close to the pancreas. The postoperative course was complicated by the development of a biliary leak (requiring percutaneous placement of a stent through the left hepatic duct), pancreatic fistula, adult respiratory distress syndrome requiring 4 weeks of ventilatory support, and intra-abdominal abscess requiring percu- taneous drainage guided by computed tomography.
Planned reconstruction was performed 10 weeks after pancreatoduodenal resection. A side-to-side gastrojejunostomy and an end-to-side choledochojejunostomy were performed. The pancreas was not anastornosed. The abdomen was closed with polyglactin mesh and later required skin grafting. The patient was discharged 4-5 months later on a regular diet with pancreatic enzyme supplements but with no evidence of diabetes mellitus.
Discussion In patients with severe blood loss, several recent studies have stressed the need to limit the initial operative pro- cedure to the arrest of major bleeding, the control of spillage of gastrointestinal secretions and urine, and the correction of coagulopathy, hypothermia and acidosis.
The management of pancreatoduodenal trauma is complex and is dictated by the condition of the patient, the severity of the pancreatoduodenal injury itself and the nature of associated injuries. Since the first reported case in 1961, 186 cases of pancreatoduodenectomy for trauma have been reported4. Of these, only one patient had undergone delayed pancreatic reconstruction, 36 h after the initial resection. The present patient underwent pancreatoduodenectomy 30 h after the initial damage- control laparotomy, and planned reconstruction 70 days later. Pancreatoduodenectomy continues to be an important therapeutic option for severe pancreatoduo- denal injury5.
Principles of management in haemodynamically unstable patients include control of haemorrhage as a first priority. Major resections such as pancreatoduodenectomy can be delayed until the patient is stabilized. Further reconstruction can be delayed until recovery from critical illness.
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1988; 54: 361-4. Paper accepted 17 August 1995
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