Emergency pancreaticoduodenectomy with delayed reconstruction for bleeding

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  • Emergency Pancreaticoduodenectomywith Delayed Reconstruction for Bleeding

    A Life Saving Procedure

    Jean-Jacques Tuech,* Patrick Pessaux, Nicolas Regenet,Roberto Bergamaschi, and Jean-Pierre Arnaud

    Department of Digestive Surgery, Angers University Hospital, 4 rue Larrey, 49000, Angers, France

    SummaryEmergency pancreaticoduodenectomy with delayed reconstruction can be performed as a life saving pro-

    cedure in case of massive bleeding uncontrolled with conventional hemostatic techniques. The authors reportherein the case of a 39-yr-old patient with an acute episode of chronic pancreatitis-induced massive bleed-ing successfully treated by this unorthodox technique.

    The concept of damage control surgery with abbreviated laparotomy and planned reconstruction couldbe useful in selected cases outside the trauma setting.

    Key Words: Pancreaticoduodenectomy, emergency; reconstruction, delayed; damage control.

    IntroductionEmergency pancreaticoduodenectomy with

    delayed reconstruction is exceptional surgery thatcan be performed in settings of severe bleeding withrapid development of shock in patients who havesustained major trauma (1,2). Exceedingly rare, aswas the case of our patient, is when an emergencyWhipple resection is carried out as a life saving pro-cedure outside the trauma setting. We report hereinone patient who underwent this procedure follow-ing an acute episode of chronic pancreatitis-inducedmassive bleeding.

    Case ReportA 39-yr-old man was admitted for an acute episode

    of chronic pancreatitis. On CT scan, an nonho-mogenous mass was found in the head of the pan-creas. Four days after admission hemorrhagic shockled to urgent laparotomy. Coagulation factors werenormal prior to laparotomy. The cause of the pro-fuse bleeding into the peritoneal cavity was erosivelesions of anteriorsuperior and posteriorsuperiorpancreaticoduodenal arteries. There was no sign ofcirrhosis of the liver and the pancreatic necrosis waslimited to the head of the pancreas. Hemostasis couldnot be achieved by multiple stitches in the inflamedpancreas. Therefore, the duodenum and head of thepancreas were mobilized from the retroperitoneumand compression was exerted at this point. The gas-troduodenal and superior pancreaticoduodenal arter-ies were ligated. Persistence of bleeding led us toperform a transection of the pancreas in order to con-trol the inferior pancreaticoduodenal arteries. The

    International Journal of Pancreatology, vol. 29, no. 1, 5962, 2001 Copyright 2001 by Humana Press Inc.All rights of any nature whatsoever reserved.0169-4197/01/29:5962/$11.00

    59

    Received February 25, 2001; Revised and Accepted April 11,2001.

    *Author to whom all correspondence and reprint requestsshould be addressed: Jean-Jacques Tuech, M.D., Department ofDigestive Surgery, Angers University Hospital, 4 rue Larrey49000, Angers France. Email: tuechjjchuangers@ yahoo.com

  • 60 Tuech et al.

    International Journal of Pancreatology Volume 29, 2001

    hemorrhage was controlled but the viability of theduodenum and the head of the pancreas was jeop-ardized and led us to perform a pancreaticoduo-denectomy. A stapler was applied to the distalstomach, which was retracted, and the common bileduct was divided above the entry of the cystic duct.Despite 17 U of red blood cells and 17 U of freshfrozen plasma, the patient remained unstable andhypothermic and developed a coagulopathy and meta-bolic acidosis. In view of this lethal triad, the deci-sion was made to terminate the procedure andaggressively correct all metabolic derangements. Theduodenojejunal junction was divided. The main pan-creatic duct was identified and cannulated with a stentaround which a nonabsorbable purse-string suturewas fashioned. Two milliliters of acrylate glue (Braun,Mensungen, Germany) were injected under very lowpressure withdrawing the catheter. The purse-stringwas tightened. Drains placed into the common bileduct and gastric stump were brought out through theabdominal wall. An end-jejunostomy with foleycatheter completed the procedure. Three round sili-cone closed-suction drains were placed.

    In the surgical intensive care unit (SICU),vigourous efforts were made to rewarm the patient;the return of core temperature to normal required 8 h. The patient recovered after a 48-h-long periodof shock. The postoperative course was marked bya pancreatic fistula that resolved with conservativedrainage. Parenteral feeding was used during 21 dand after enteral nutrition was given through the endjejunostomy. The length of stay in the SICU was 15 d; the overall hospital stay was 55 d.

    Reconstruction was performed 88 d after the pan-creaticoduodenectomy; it involved a single-layerhand-sewn hepaticojejunostomy and gastrojejunos-tomy on a single jejunal loop. The difficulty of thissecond procedure was due to adhesions; the threedrains (common bile duct, stomach, jejunum) wereused as guides and 2.5 h of dissection were neces-sary before performing the anastomoses. Two drainswere placed in the vicinity of the biliary and gas-trojejunal anastomoses. There was no blood replace-ment required at reoperation. The postoperativecourse was uneventful.

    With 19 mo of follow-up, the patient remains well. Mild steatorrhea and insulin-independent dia-betes are being treated with pancreatic enzymes anddiet, respectively.

    DiscussionPancreaticoduodenectomy is the last resort to

    control hemorrhage from the pancreatic head area.Management options are provided in Fig. 1. Surgi-cal management is associated with high risk for thepatient, whereas percutaneous transvascularembolization is a relatively noninvasive method with low risk (3). The goal is the definitive arrest ofbleeding or stabilization of the patient to enable acontrolled surgical procedure. For our patient, arte-riography and embolization could not be performedbecause of the severity of the shock.

    Emergency pancreaticoduodenectomy withdelayed reconstruction is exceptional surgery. To ourknowledge, only two cases (1,2) have been previ-ously reported. This unorthodox technique has beenperformed successfully in the trauma setting (1,2)and for our patient outside the trauma setting. Themortality for pancreaticoduodenectomy with recon-struction in the emergency trauma setting is about30% (4), contrasted to the 8% death rate follow-ing elective resection (5,6). The concept of stagedsurgery in critically ill patients is not new; it is aplanned approach to a complex problem but rarelyinvolves pancreaticoduodenectomy.

    The triad of hypothermia, acidosis, and coagu-lopathy has been recognized as a lethal combina-tion. When confronted with such patients, ourphilosophy is to control hemorrhage and abdominalcontamination using the simplest technique and ter-mination of the procedure until all metabolicderangements are corrected. We feel that recon-struction is contraindicated until that time. Whennormal physiology has been restored, reoperationfor reconstruction can take place. In this patient, afterfailing to control hemorrhage, a pancreaticoduo-denectomy was performed. However, given the meta-bolically unstable condition of the patient and thefact that completing reconstruction would lengthenthe surgical procedure, it was decided to terminatethe operation and resuscitate the patient. Thisinvolved maximizing hemodynamics, rewarming,correction of coagulopathy, and complete ventila-tory support.

    In the two cases previously reported (1,2), gas-tro-intestinal continuity was reestablished at 36 h and70 d, respectively. For our patient, continuity wasrestored 88 d later, and was performed anatomically

  • International Journal of Pancreatology Volume 29, 2001

    distant from the pancreatic fistula. Because we do notuse glue obstruction routinely, our inexperience mayhave contributed to the occurrence of the fistula. How-ever, the fistula did not require reintervention andresolved with drainage and parenteral feeding.

    In conclusion, the principles of management inthis instance of hemodynamically unstable patientsinclude control of hemorrhage as a first priority. Weadapted the abbreviated laparotomy and plannedreconstruction technique from the experience withpancreatic trauma (7,8). Thus, although this unortho-

    dox technique would only be useful in a very fewcases outside the trauma setting, this case demon-strates that the occasional nontrauma patient maybenefit.

    References1 Eastkick L, Fogler RJ, Shaftan GW. Pancreaticoduo-

    denectomy for trauma: delayed reconstruction: a casereport. J Trauma 1990; 30: 503505.

    2 Mystry BM, Durham RM. Delayed pancreaticoduodenec-tomy followed by delayed reconstruction for trauma. BrJ Surg 1996; 86: 527.

    Fig. 1. Management options for massive bleeding from the pancreatic head area.

    Pancreaticoduodenectomy: Delayed Reconstruction 61

  • 3 Stsslein F, Zimmermann L, Bulang T. Embolization inthe treatment of bleeding complications in pancreatitis. J Hepatobiliary Pancreat Surg 1998; 5: 344347.

    4 Jordan GL. Pancreatic trauma. In Howard JL et al: surgi-cal diseases of the pancreas, Philadelphia, Lea & Febiger,1987; pp: 875897.

    5 Cameron JL, Pitt HA,Yeo CJ, Lillemoe KD, Kaufman HS,Coleman J. One hundred and forty five consecutive pan-creaticoduodenectomy without mortality. Ann Surg 1993;217: 430438.

    6 Wade TD, El Ghazzawy AG, Virgo KS, Johnson FE. Thewhipple resection for cancer in US department of veteransaffairs hospitals. Ann Surg 1995; 221: 241248.

    7 Burch JM, Ortiz VB, Richardson RJ, Martin RR, MattoxKL, Jordan GL. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg 1992;215: 476484.

    8 Rotondo MF, Zonies DH. The damage control sequenceand underlying logic. Surg Clin North Am 1997; 77:761777.

    International Journal of Pancreatology Volume 28, 2001

    62 Tuech et al.

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