Two-Stage Pancreatoduodenectomy in Which Pancreatojejunostomy Performed in First Stage for Pancreatic Trauma

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1 CASE SERIES Two-Stge Pncretoduodenectomy in Which Pncretojejunostomy Performed in First Stge for Pncretic Trum SShinjiro Koyshi, Kohei Segmi, Hiroyuki Hoshino, Msfumi Ktym, Stoshi Koizumi, Tkehito Otsuo Division of Gstroenterologicl nd Generl Surgery, St. Mrinn University School of Medicine, Jpn ABSTRACT We report 2 cses of two-stge pncretoduodenectomy for injuries to the pncretic hed, in which the pncretojejunostomy ws performed first. Cse #1 ws cused y trffic ccident nd cse #2 y low to the domen. Both injuries to the pncretic hed were clssified s Americn Assocition for the Surgery of Trum Orgn Injury Score grde V. In the initil surgeries, ll the reconstruction modlities except for cholngiojejunostomy were performed. A modifiction of Child s method ws used for the reconstruction. The pncretic duct ws converted into n incomplete externl dringe. A complete dringe tue ws inserted into the common heptic duct vi the liver, nd the stump ws sutured nd closed. The ile duct nd jejunum were sutured for nstomosis in stge 2. In this stge, only cholngiojejunostomy ws performed. Only the nterior hlf circumferences of the ile duct nd jejunum were nstomosed. Both ptients survived nd experienced no complictions. INTRODUCTION Pncres is ntomiclly complex nd ecuse of its physiologicl chrcteristic of generting potent externl secretions, the mortlity rte due to pncretic trum is high t % [1, 2, 3]. Moreover, pncretic trum is reltively rre; therefore, reserch hs provided little high-level evidence [4]. The severity of pncretic injuries cn e ctegorized using the Americn Assocition for the Surgery of Trum Orgn Injury Score (AAST-OIS) [5]. Pncretic hed injuries tht re indicted for PD re pncretic injuries tht re ccompnied y n injury to the min pncretic duct, which re clssified s AAST-OIS grde V. However, the Estern Assocition for the Surgery of Trum s Mngement of Adult Pncretic Injuries sttes tht no dt exists tht would serve s evidence for recommending PD [6]. Nevertheless, some pncretic injuries tht re ccompnied y n injury to the min pncretic duct exhiit severe dmge to the pncretic prenchym, which mkes non-opertive mngement impossile. If only performing restortive surgery would Received July 24th, Accepted August 07th, 2017 Keywords Pncres; Pncreticoduodenectomy; Pncreticojejunostomy Arevition AAST-OIS Americn Assocition for the Surgery of Trum Orgn Injury Score; CT computed tomogrphy; GDA gstroduodenl rtery; PD Pncreticoduodenectomy Correspondence Shinjiro Koyshi Division of Gstroenterologicl nd Generl Surgery St. Mrinn University School of Medicine Sugo, Miyme-ku, Kwski Kngw , Jpn Tel Fx E-mil kohruiyori@mrinn-u.c.jp e risky, PD my e indicted. Therefore, while only smll numer of ptients will require PD, they do exist. The mortlity rte of PD for trum ws out 50% until the 1980s [7, 8]. Though this hs recently improved to 13-15% [9, 10], it is still considered uncceptle. Often when ptient s overll condition is poor, only dmgecontrol surgery is performed initilly, then resection nd reconstruction re performed in stge 2 [9, 10, 11]. However, reltively good results hve een reported in smll numer of cses when resection is performed in the initil surgery [12, 13]. Here, we report 2 cses of twostge PD for injuries to the pncretic hed in which the pncretojejunostomy ws performed first. CASE PRESENTATION Cse #1 A Twenty-eighty-yer-old mn who ws injured when the two-wheeled vehicle he ws riding ws struck y n utomoile. When eing trnsported y mulnce, his consciousness ws cler, his lood pressure ws 164/125 mmhg, nd his pulse rte ws 70/min. Full-ody contrst-enhnced computed tomogrphy (CT) reveled injuries to the pncretic hed nd mjor pncretic duct, leeding from the gstroduodenl rtery (GDA), nd lood congestion in the pncreticoduodenl region. A dignosis of AAST-OIS grde V ws mde (Figures 1, 1, 1c). No injuries outside the pncreticoduodenl region were oserved. The GDA rupture ws close to where it rnched from the common heptic rtery. The injuries to the mjor pncretic duct nd pncretic hed were complex, nd the GDA rupture ws severe; therefore, emergency surgery ws performed. First, the GDA ws ligted to stop 420

2 c Figure 1. (). Ruptured pncres t the pncretic hed (rrow). (). Bleeding from the gstroduodenl rtery (rrow). (c). Mrkedly reduced contrst effect t the pncretic hed (rrow). the leeding. The min pncretic duct ws ruptured t the right mrgin of the portl vein (Figures 2, 2). The pncretic hed ws severely crushed; thus, pyloruspreserving PD ws plnned. The pncres ws resected t the left mrgin of the portl vein. Reconstruction fter the resection ws performed using modifiction of Child s method. With side-to-end pncreticojejunostomy with modified Blumgrt method, the pncretic duct is converted into n incomplete externl dringe, in which the drins outside the ody through to the jejunum nstomosed the pncres. The common heptic duct ws closed, nd 6 Fr complete dringe tue ws inserted vi the liver. Moreover, the jejunum, proposed s the site of nstomosis in the stge 2 surgery, ws sutured to the seromusculr lyer of the posterior wll of the common heptic duct stump (Figures 3, 3, 3c). Finlly, n end-to-side duodenojejunostomy ws performed (Figure 4). The procedure lsted 5 hours nd there ws 932 g of leeding. No postopertive complictions were oserved nd the ptient ws dischrged 25 dys lter. Two months post-dischrge, he ws re-hospitlized for the cholngiojejunostomy in stge 2. This surgery ws performed vi 10 cm incision in the upper domen. The nterior hlf circumferences of the common heptic duct (closed stump) nd jejunum, which hd een fixed in the first surgery, were opened nd only the nterior wlls were nstomosed (Figures 5, 5). Stge 2 lsted 2 hours nd there ws 30 g of leeding. No complictions were oserved. Cse# 2 A Forty-yer-old mn whose pncretic hed ws injured y kick to the domen in fight t drinking estlishment. His consciousness ws cler ut his lood pressure ws 50/30 mmhg, his pulse rte ws 116/min, nd he ws in shock. After trnsfusion of 1000 ml, the lood pressure improved to 105/72 mmhg; consequently, contrst-enhnced CT ws performed. CT reveled leeding from the pncretic hed nd duodenum, nd extensive injuries to the min pncretic duct (Figures 6, 6, 6c). A dignosis of AAST-OIS grde V ws mde nd emergency surgery ws performed. There were no injuries outside the pncreticoduodenl region. A lrge mount of lood ws oserved in the dominl cvity ut the only source of the leeding ws ner the pncretic hed. The pncres ws deeply ruptured to the right of the right mrgin of the portl vein, nd injuries to the min pncretic duct were lso oserved (Figure 7). Hemtom nd extensive congestion from the GDA injury were oserved in the re of the pncretic hed. Bsed on these findings, pyloruspreserving PD ws plnned. As in cse 1, the pncretic duct ws converted into n incomplete externl dringe, nd the ile duct ws closed, converted into complete externl dringe, nd fixed to the jejunum. Up to the duodenojejunostomy ws performed in procedure tht lsted 4 hours 7 minutes with 3139 g of leeding. No complictions were oserved fter the initil surgery. Stge 2 ws performed 27 dys lter. Similr to cse 1, only the 421

3 Figure 2. (). The min rnch of the gstroduodenl rtery showing rupture nd leeding t the pncretic hed (rrow). (). The pncres, including the min pncretic duct, ws ruptured t the right mrgin of the portl vein (rrow). c Figure 3. (). A 6 Fr complete dringe tue ws inserted into the common heptic duct vi the liver (rrow). (). The common heptic duct stump ws sutured nd closed, nd the posterior wll of the common heptic duct stump ws sutured to the jejunum (rrow). (c). Schem. Arrow: sutured ile duct stump. Arrow hed: dringe tue (in the ile duct). Dotted-line rrow: fixed ile duct stump nd jejunum posterior wll. nterior hlf circumferences of the ile duct nd jejunum, which hd een fixed in the first surgery, were opened nd nstomosed. Stge 2 lsted 2 hours 19 minutes, with 269 g of leeding. No postopertive complictions were oserved nd the ptient ws dischrged. DISCUSSION In the 2 cses of PD for injuries to the pncretic hed we experienced, the ptients were generlly stle nd leeding ws promptly controlled fter the procedures were strted. Becuse this mde dequte time ville, resection nd reconstruction, prt from the cholngiojejunostomy, could e performed. In cses without cogultion disorders, hypothermi, or cidosis, it my e possile to perform two-stge PD, with the pncretojejunostomy performed first. In this procedure, pncreticojejunostomy nd duodenojejunostomy re performed in stge 1, nd cholngiojejunostomy is performed in stge 2. The 2 cses we experienced survived without ny complictions, exhiiting good results. Reports of two-stge PD for trum in the literture include those in which only gstrointestinl reconstruction is performed in the first surgery [12] 422

4 Figure 4. (). Schem t the end of the initil surgery (modified Child s method). The ile duct nd jejunum were not reconstructed. Arrow: complete externl dringe tue in the ile duct. Arrow hed: incomplete dringe tue in the pncretic duct. Figure 5. Stge 2 surgery. (). Only the nterior wlls of the hlf circumferences of the common heptic duct nd jejunum, which hd een fixed in the first surgery, were opened nd nstomosed. (). Schem. Only the nterior wlls re nstomosed. Figure 6. Contrst-enhnced CT. (). The pncres ws ruptured t the pncretic hed. (). Reduced contrst effect t the pncretic hed. 423

5 Figure 7. A lrge mount of lood ws oserved in the dominl cvity. The pncres ws deeply ruptured to the right of the right mrgin of the portl vein nd injuries to the min pncretic duct were lso oserved (rrow). nd those in which only gstrointestinl reconstruction nd cholngiojejunostomy re performed in the first surgery, nd pncretic-gstrointestinl reconstruction is performed in the second surgery [14]. However, t our hospitl, we performed pncreticojejunostomy nd gstrointestinl reconstruction in the first surgery nd cholngiojejunostomy in the second surgery. The most pertinent issue with PD is the pncretic-gstrointestinl nstomosis [15]. Complictions t this site, i.e. pncretic fistul, cn e life-thretening, so we elieve it is etter to get the dngerous pncretic-gstrointestinl nstomosis over with in the first surgery. Bile mixing with pncretic fluid is thought to increse the severity of pncretic fistul; therefore, converting the ile duct into complete externl dringe ensures tht in cse of pncretic fistul formtion, it will not ecome criticl. The second surgery cn then e performed sfely nd securely, ecuse it only involves nstomosis of the ile duct nd jejunum. In contrst, if pncretic-gstrointestinl nstomosis is performed in the second surgery, the first surgery involves dissecting the pncres nd converting it into complete externl dringe. Thus, ny dhesions tht occur from the first surgery need to e detched in the second surgery efore the pncreticojejunostomy cn e performed, which cn mke the procedure more complicted. In fct, Gupt et l. reported tht in 1 of 5 cses of two-stge PD, in which the pncreticojejunostomy ws not performed first, the stge two pncreticojejunostomy hd to e ndoned [12]. At times, one-stge PD is possile, ut this should only e performed if etter results cn e otined thn from two-stge PD. In trum ptient whose condition hs temporrily worsened, if severe pncretic fistul occurs ecuse of PD, the ptient s life my not e svle. Therefore, to ensure tht pncretic fistul would not ecome criticl even if one occurred, we did not perform cholngiojejunostomy in the first surgery to prevent pncretic fluid nd ile from intermingling t the nstomosis site. Further, the second surgery ws not performed in the erly stges, when pncretic fistul my occur (3-4 weeks fter the first surgery). Cholngiojejunostomy ws performed once the possiility of pncretic fistul formtion hd completely disppered (t lest 1 month fter the first surgery). In cse 2, the ptient strongly desired the second surgery to e performed s soon s possile, so it ws crried out fter witing for 1 month. From the stndpoint of ensuring criticl complictions do not occur due to PD, we elieve tht in trum ptients, it is etter not to complete the PD even if there is mple time. Surgeries performed y experienced heptopncreticoiliry (HPB) specilists, who re trined in pncretic surgery techniques, hve fewer complictions nd re sfer [16, 17, 18]. PD cn e performed with reltive sfety t high-volume centers tht re ccustomed to deling with complictions, nd surgeries for pncretic trum should e performed y HPB surgeons [17]. PD is surgicl modlity tht should e voided for injuries to the pncretic hed. However, it should e performed if PD is necessry to sve life. In such cses, simple modlities nd surgicl techniques the surgeon is ccustomed to should e chosen, nd n HPB surgeon should prticipte in the procedure. Conflict of Interest The uthors hve declred tht no competing interests exist. 424

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