Emergency pancreaticoduodenectomy for complex pancreaticoduodenal damage with multiple organ injuries following blunt abdominal trauma: A case report and literature review

Abstract

Introduction

Pancreaticoduodenectomy is a complex surgical procedure with significant potential for complications such as pancreatic fistula, bile leakage, intra-abdominal abscesses, and hemorrhage. Emergency pancreaticoduodenectomy (EPD) performed for traumatic injuries carries even greater risks due to the patient's severely unstable condition upon admission. While the literature recommends that EPD be reserved for hemodynamically stable trauma patients, there are scenarios where it may be the last resort to save the patient's life.

Case presentation

A 49-year-old male presented in the emergency department after a collision with a truck. He sustained extensive pancreaticoduodenal deconstruction combined with IVC, liver, right kidney, and right adrenal injuries following blunt abdominal trauma. Despite the patient's hemodynamic instability, the surgical team proceeded with EPD combined with IVC repair, right nephrectomy, adrenalectomy, cholecystectomy, and liver hemostasis. Postoperative complications included biliary leakage and intraabdominal abscess, all of which were successfully conservatively managed.

Clinical discussion

Upon entering the abdomen, the priority was rapid identification and control of the significant bleeding, particularly from the injured IVC. While additional procedures like nephrectomy and adrenalectomy were required, continued bleeding from the crushed pancreatic head left EPD as the only viable option to save the patient.

Conclusion

EPD can be a lifesaving procedure for a small portion of trauma patients with non-reconstructable pancreaticoduodenal injury, even in the setting of hemodynamic instability. However, it should only be performed at high-volume centers and by experienced hepato-pancreato-biliary surgeons.

Highlights

• •Emergency pancreaticoduodenectomy (EPD) can be lifesaving in severe pancreaticoduodenal trauma cases.
• •Successful EPD performed despite hemodynamic instability and multiple organ injuries.
• •EPD should be performed at high-volume centers by experienced HPB surgeons.

1. Introduction

Pancreaticoduodenectomy, first described in 1935 by Whipple [1], is a complex operation primarily used to treat periampullary cancers and, more recently, benign diseases such as chronic pancreatitis, duodenal gastrointestinal stromal tumor, and diverticula [2]. Emergency pancreaticoduodenectomy (EPD) is scarcely described in the literature as a lifesaving operation for severe pancreaticoduodenal injuries, uncontrollable bleeding, perforation, and iatrogenic injuries [3,4]. While the mortality rate of elective pancreaticoduodenectomy has significantly decreased to <5 %, the outcomes for EPD remain notably worse, with contemporary studies reporting mortality range 30 %–40 % [5]. Due to its rarity, data on EPD are limited, mostly involving non-trauma patients. The first report of traumatic EPD dates back to 1964 by Thal [6]. To date, the largest single-center experience with EPD for trauma consists of just 19 patients [7]. In a comprehensive review of 61 reports encompassing a total of 220 EPD cases performed for traumatic indications, Krige et al. calculated a pooled mortality rate of 34 % [8].

A recent comparative study found that a more conservative surgical approach, such as primary repair, drainage, duodenal exclusion, and partial pancreatectomy, may be preferable to EPD in certain cases of severe pancreaticoduodenal injuries [9]. Nonetheless, when faced with extensive, nonrepairable injuries affecting the pancreas, duodenum, common bile duct, or ampulla of Vater, EPD is often unavoidable. Most EPDs in these situations are performed within six hours of admission [9]. It is clear that deciding to perform an EPD for trauma is challenging for surgeons, and there is still no consensus on the timing of the operation. To contribute our experience to the literature, we present a case of severe pancreaticoduodenal injury managed with EPD. This case was reported in accordance with the SCARE criteria [10].

2. Presentation of case

A 49-year-old previously healthy male presented to the hospital three hours after his motorbike collided with a truck. He was conscious, with stable hemodynamics but severe abdominal pain. His abdomen was distended with guarding, and he had scratches on the chest wall and right abdomen. A pan CT scan revealed right rib fractures (9th–12th), grade IV liver injury, grade V kidney injury, and complex pancreaticoduodenal injury with significant free air and fluid in the intraperitoneal cavity (Fig. 1). No cranial injuries, extremity, or pelvic fractures were identified.

Fig. 1.

Preoperative CT scan: (a) Grade III-IV liver injury and free air and fluid intraperitoneal cavity; (b) totally disruption in the pancreaticoduodenal region; (c) Grade V renal injury.

Given the multiorgan injuries and signs of peritonitis, an urgent laparotomy was indicated. Upon entering the operating room, his pulse was 140 bpm, and blood pressure was 50/30 mmHg. Resuscitation and rapid intubation were followed by exploratory laparotomy through a midline incision, which revealed approximately three liters of haemoperitoneum. A central liver rupture, a dissected gallbladder, and a severe rupture of the pancreatic head and duodenum were noted. Despite gauze packing and a Pringle maneuver, hemorrhage control was unsuccessful.

Suspecting retroperitoneal bleeding, we performed the Cattell-Braasch technique to exposure of the retroperitoneum, facilitating access to control the bleeding from the inferior vena cava (IVC) and manage the complex injuries to the pancreas and duodenum. A 2-cm laceration was found on the anterior surface of the IVC, with a shattered upper pole of the right kidney, avulsion of the right renal pedicle, and a crushed right adrenal gland (Fig. 2). The descending part of the duodenum was disrupted, and the pancreatic head was extensively avulsed, with multiple active bleeding sites, including the disrupted gastroduodenal artery.

Fig. 2.

Intraoperative finding: The IVC was temporarily clamped with an allis (a), the hepatic pedicle was clamped temporarily (b), and the bleeding vessels were clipped (c). Massive disruption of duodenopancreatic complex was exposed (c).

The IVC was temporarily clamped to control the bleeding while the right renal pedicle and gastroduodenal artery were secured with Hem-o-lok®. The IVC was then sutured with 5–0 polypropylene, followed by right nephrectomy, right adrenalectomy, and cholecystectomy (Fig. 3a). Nevertheless, the active bleeding persisted from the crushed pancreatic head after multiple sutures around the avulsion areas. After a discussion with the anesthesia, we decided an EPD was the only chance to save the patient (Fig. 3b). Whipple's resection proceeded, exposing a main bile duct of approximately 5 mm in diameter and a 3 mm main pancreatic duct with a normal parenchyma. Primary reconstruction was also performed as a classical Whipple procedure.

Fig. 3.

After procedure: (a) Postoperative specimens included the right kidney, right adrenal gland, gallbladder, and duodenopancreatic complex; (b) primary reconstruction was performed as a classical Whipple procedure.

Regarding the liver, there was grade IV liver injury with disruption of segmental IV, V, and VIII. Hemostasis was achieved, but a bile leak was noted, the source of which was unclear. To avoid prolonging the surgery, the abdomen was closed with plans for possible drainage or a second surgery if needed. The operation lasted six hours, with an estimated blood loss of over 5 liters. The patient received 15 units of red blood cells, 14 units of fresh frozen plasma, 2 units of platelets, and 5 units of cryoprecipitate.

Postoperatively, the patient was stable and extubated on the second day. However, worsening infection and progressive abdominal pain on the eighth day led to a CT scan, revealing perihepatic fluid and a right renal fossa abscess (Fig. 4). Both were drained percutaneously, with bile fluid found in the perihepatic region and pus in the renal fossa. The patient was managed with antibiotics, antifungals, and daily drain irrigation. The abscess resolved, and the bile fistula closed spontaneously. Drains were removed, and the patient was discharged on postoperative day 30. Follow-up visits showed no symptoms, and he was able to return to normal activities.

Fig. 4.

Postoperative CT scan: There was a bile fluid collection (a) and the rupture extended towards the hepatic hilum (b); a residual abscess was revealed in the right renal fossa (c).

3. Discussion

Pancreatoduodenectomy (Whipple surgery [1]) may be necessary for patients with destructive pancreaticoduodenal injuries. Historically, EPD with reconstruction in severely injured patients led to high mortality rates due to complications like hypothermia, coagulopathy, and acidosis. Concomitant life-threatening injuries to major splanchnic vessels, including the IVC, portal vein, and superior mesenteric vein, frequently take priority in the acute management of severe pancreaticoduodenal trauma [11,12]. Furthermore, the technical complexities inherent to resecting and reconstructing complex pancreatic injuries demand specialized surgical skills [12,13]. Managing severe injuries to the pancreatic head and duodenum in hemodynamically unstable patients is challenging, even for the most experienced trauma and pancreatic surgeons.

Krige's study has shown that EPD can be lifesaving for hemodynamically stable patients with irreparable pancreatic head injuries. Additionally, the implementation of damage control surgery (DCS) prior to pancreatoduodenectomy can save some patients with multiple injuries [14]. DCS focuses on rapidly controlling hemorrhage and contamination, with the aim of stabilizing the patient for definitive surgery at a later stage [15,16]. This approach is particularly important in trauma patients undergoing emergency procedures like EPD, as it allows for stabilization before committing to complex and time-consuming surgeries [17]. Recent studies highlight the role of DCS in reducing mortality and improving outcomes in multi-organ trauma cases [16,[18], [19], [20]].

Nevertheless, Lupascu noted that EPD allows rapid hemorrhage control when less invasive methods (embolization or endoscopic intervention) are ineffective, unavailable, or unsafe [21]. In our case, in addition to the severe pancreaticoduodenal injury, the patient had severe injuries, including the rupture of the IVC, grade IV liver injury, grade V kidney injury, and adrenal gland rupture. The initial priority was rapid bleeding control using techniques such as the Cattell-Braasch maneuver, followed by IVC repair, nephrectomy, and clamping of the gastroduodenal artery. However, the bleeding from the crushed pancreatic head persisted. In this situation, performing an EPD was a difficult but necessary choice to save the patient's life. DCS principles were applied to manage the patient's hemodynamic instability before proceeding with the more definitive resection and reconstruction.

This case aligns with existing literature in demonstrating that EPD can be lifesaving for patients with extensive pancreaticoduodenal trauma when other options are insufficient. Studies such as those by Krige et al. support the view that EPD is a valid intervention in patients with irreparable injuries [7]. However, the rarity of such cases and the complexity of performing EPD in trauma patients, particularly those who are hemodynamically unstable, set this case apart. Unlike many reports that suggest EPD should be reserved for stable patients [11,17,22], our case demonstrates that, with careful application of damage control principles, EPD can be successfully performed even in unstable patients, albeit with significant postoperative risks.

Despite its benefits, major emergency surgery like EPD carries numerous risks and complications, including coagulopathy, bleeding, and leakage. The most concerning complication post-pancreatoduodenectomy is pancreatic fistula. Conzo stressed the importance of assessing postoperative complication risk factors for treatment and surgical method selection. Risk factors include patient-related factors (age > 70, male gender, jaundice, malnutrition), pancreatic factors (soft parenchyma, duct size), and surgical factors (operative time, type of resection, pancreatic stump management, intraoperative blood loss, and surgeon experience) [23]. In the context of EPD, the pancreatic parenchyma is often soft and normal, and the pancreatic duct is typically non-dilated, making the optimal management of the pancreatic remnant remains controversial. In such cases, particularly at low-volume centers or with hemodynamically unstable patients who cannot tolerate extended operative times, abandoning the pancreatic remnant may be a viable alternative [22]. In our case, the patient had clear risk factors for pancreatic fistula: excessive intraoperative blood loss, soft pancreatic parenchyma, and small duct size. However, based on our experience, we assessed that reconstruction could still be safely achieved while simultaneously avoiding a second surgery for the patient.

Postoperatively, the bile leakage was managed by percutaneous drainage and serial follow-up CT scan. Bile leakage from liver trauma often occurs with central liver rupture and is accompanied by infection and hyperbilirubinemia. Initially, bile-duct-enteric anastomosis edema can increase biliary pressure, causing leakage from the traumatic tear. As bile flow improves and pressure decreases, the leak may resolve spontaneously. In this case, the bile leak stopped after three weeks, and subsequent CT showed no fluid collection increase. Yuan found that major bile leaks post-liver trauma are rare, with an incidence below 5 %. Besides significant liver trauma, central liver injury and initial hepatic artery obstruction are significant bile duct injury risk factors [24]. For liver trauma patients with unusual fluid collections and non-specific symptoms, along with bilirubin levels above 43.6 μmol/l or any proposed risk factors, should be evaluated with endoscopic retrograde cholangiopancreatography (ERCP) to detect major bile leaks and allow for prompt therapeutic intervention. However, EPD had already been performed in our case, making ERCP more challenging, so we opted to treat it with percutaneous drainage.

4. Conclusion

Emergency pancreaticoduodenectomy is an extremely challenging but potentially lifesaving surgical intervention reserved for cases of severe pancreaticoduodenal trauma that cannot be managed through a less invasive strategy. This complex procedure should only be performed by surgeons with specialized hepatobiliary and pancreatic surgery expertise at dedicated trauma centers with the appropriate experience and capabilities.

Consent

Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Our institutions do not require ethical approval for reporting individual cases or case series.

Funding

The study did not receive external funding.

Guarantor

Manh Thang Tran M.D.

Research registration number

• 1.Name of the registry: Researchregistry.com
• 2.Unique identifying number or registration ID: researchregistry10609
• 3.Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.researchregistry.com/browse-the-registry#home/registrationdetails/66c0905fa846b20289484213/.

CRediT authorship contribution statement

Concept, consent, literature review, drafting of the initial and final manuscript, approval of the final manuscript - All authors.

Declaration of competing interest

We have no conflicts of interest to disclose.