World J Surg DOI 10.1007/s00268-016-3525-y

ORIGINAL SCIENTIFIC REPORT

Non-trauma Emergency Pancreatoduodenectomies: A Single-Center Retrospective Analysis Michael F. Nentwich1 • M. Reeh1 • F. G. Uzunoglu1 • K. Bachmann1 M. Bockhorn1 • J. R. Izbicki1 • Y. K. Vashist1

•

Ó Socie´te´ Internationale de Chirurgie 2016

Abstract Objective To retrospectively assess the frequency and indications for emergency pancreatoduodenctomies in a tertiary referral center. Methods Pancreatoduodenectomies between January 2005 and January 2014 were retrospectively assessed for emergency indications defined as surgery following unplanned hospital admission in less than 24 h. Data on indications and on the intraoperative as well as the post-operative course were collected. Results Out of 583 pancreatoduodenectomies during the interval, a total of 10 (1.7 %) were performed as an emergency surgery. Indications included uncontrollable bleeding, duodenal and proximal jejunal perforations, and endoscopic retrograde cholangiopancreatography-related complications. Three of the 10 (30.0 %) patients died during the hospital course. In one patient, an intraoperative mass transfusion was necessary. No intraoperative death occurred. All but one patient were American Society of Anesthesiologists class three or higher. In two cases, the pancreatic remnant was left without anastomosis for second-stage pancreatojejunostomy. Median operation time was 326.5 min (SD 100.3 min). Hospital stay of the surviving patients was prolonged (median 43.0 days; SD 24.0 days). Conclusion Emergency pancreatoduodenectomies are non-frequent, have a diverse range of indications and serve as an ultima ratio to cope with severe injuries and complications around the pancreatic head area.

Introduction Commonly, pancreatic resections are performed under elective conditions and after a thorough pre-operative workup. Thereby, a pancreatoduodenectomy already in an elective setting is a demanding procedure, though with reduced mortality rates over time but still with significant morbidity [1]. Seldom, emergency pancreatic resections

& Michael F. Nentwich [email protected] 1

Department of General, Visceral and Thoracic Surgery, University Medical Center of Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany

are indicated, and then are usually reserved for trauma patients [2–4]. Yet, there are rare events in which a pancreatoduodenectomy is the only approach to manage severe complications in and around the pancreatic head area. These complications can arouse from sequelae of pancreatitis, duodenal ulcers, and iatrogenic injuries resulting in duodenal perforation, hemorrhage, and a general septic distress. Reports of emergency pancreatoduodenectomies in non-trauma patients are scarce and inherently limited by the low number of cases [5, 6]. To add to the small body of literature on these rare events, this article presents and discusses the indications for an emergency pancreatoduodenectomy in non-trauma patients in a consecutive series of pancreatic head resections at the University Medical Center Hamburg-Eppendorf.

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World J Surg Table 1 The patient-specific details Patient no.

Sex

Indication to surgery

Age (yr)

OR time

Blood loss (ml)

ASA score

Mortality

Hospital stay (d)

1

F

Perforated and bleeding duodenal diverticula

79

363

100–500

3

-

13

2

M

Duodenal perforation

65

313

[1000

4

?

36

3

F

Perforated pancreatic head cancer

63

340

[1000

3

-

69

4

M

Adrenal tumor infiltration with unstoppable bleeding

46

493

501–999

3

-

43

5

M

Pancreatic pseudo-cyst bleeding

65

540

[1000

5

?

32

6

M

Pancreatic pseudo-cyst bleeding

63

278

501–999 (2EKs)

3

-

29

7

M

Post-ERCP distal bile duct injury, free air

58

352

100–500

3

-

65

8

M

Post-ERCP distal bile injury

80

299

100–500

3

-

26

9

M

Proximal jejunal perforation following necrotizing pancreatitis and multiple surgeries for small bowel perforations and toxic megacolon

43

271

Mass transfusion required

4

?

154

10

M

Post-ERCP duodenal perforation

62

214

2

-

74

-/? In-hospital mortality no/yes

Patients and methods

Results

Between January 2005 and January 2014, a total of 583 pancreatoduodenectomies were performed at the University Medical Center Hamburg-Eppendorf. Pancreatoduodenectomies were performed as a classic KauschWhipple procedure with formation of a pancreatojejunostomy by a single-layer running monofilament suture. Emergency pancreatoduodenectomies were selected from a database and defined as unscheduled third-hospital referrals or emergency ward presentations followed by surgery within 24 h from arrival as well as in-hospital patients with unplanned emergency surgery. The surgeries were all performed by a total of six different specialized senior surgeons, including the head of the department. Collected data included patient sex, age, surgical details such as blood loss and length of surgery, indications for surgery, length of hospital stay, and mortality. Numerical variables were summarized by the sample mean and range. Categorical variables were summarized with number and percentage. Associations between categorical and/or continuous data were calculated using Fisher’s exact test or Mann–Whitney U Test as appropriate. Statistical significance was assigned at two-sided p values \ 0.05. Statistical data analysis was done using the SPSS 18 software package (SPSS Inc., Chicago, IL, USA). Due to the very heterogeneous patient collective as well as the overall low number of patients, further analyses for survival prediction could not be performed.

Out of the 583 pancreatoduodenectomies, 10 fulfilled the inclusion criteria as an emergency surgery. The patientspecific details are given in Table 1. Median patient age was 63 (SD 11.9) years, with a total of 8 (80.0 %) male patients. The indications for emergency pancreatoduodenectomy included duodenal and proximal jejunal perforation in seven cases, three of them as post-ERCP complications, and bleeding complications in three patients. The mortality rate was 30.0 %, with three patients out of 10 that died during the hospital course. All patients died due to multi-organ failure. No patient died during the initial emergency pancreatoduodenectomy. In one patient, a mass transfusion was needed because of diffuse retroperitoneal bleeding and laceration of the portal vein. All patients but one (ASA 2) were ASA class 3 or higher. The median operation time was 326.5 min (SD 100.3 min) and the median length of hospital stay of the surviving patients was 43.0 days (SD 24.0). Upper gastrointestinal bleeding with drop of Hb-levels and melena led to further endoscopic examination in the first patient at an external hospital. Esophago-gastro-duodenoscopy (EGD) revealed duodenal diverticula filled with coagulated blood and covered with fibrin. Because of postinterventional clinical deterioration an abdominal CT-scan was initiated, showing signs of duodenal perforation. The patient was referred to our institution and emergency explorative laparotomy revealed multiple duodenal diverticula, one being perforated intra-abdominally and another one filled with a large amount of clotted blood. The extent

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of diverticula disease together with the pancreatic head parenchyma destruction because the perforation did not allow a pancreas-sparing resection. The patient then had an uneventful course and was referred to further geriatric rehabilitation. The second patient presented in the emergency ward with abdominal discomfort, persistent melena for 3 weeks, and abdominal distention. Emergency esophago-gastroduodenoscopy showed a circumferential pyloric ulcer with free abdominal perforation. The clinical condition dramatically worsened after the intervention and the patient was directly brought to the operating room (OR) in an acute shock. Abdominal exploration revealed a long-existing duodenal perforation with an almost entirely autolytic duodenum and destruction of the pancreatic head necessitating a pancreatoduodenectomy. After a sequela of complications including insufficiencies of the hepaticojejunostomy and diffuse retroperitoneal bleedings with subsequent re-operations and completion pancreatectomy, the patient died in multi-organ failure. Patient 3 was referred from an outside hospital where she was initially treated for a bleeding duodenal ulcer. There, the patient underwent a Billroth-II-resection after an initial duodenotomy and jejunogastrostomy, which was complicated by an anastomotic insufficiency. Histopathologic examination revealed a perforated pancreatic head cancer as causative for the bleeding ulcer. At arrival, the patient was clinically unstable and laparotomy revealed a biliary peritonitis due to a duodenal stump insufficiency. In knowledge of the histo-pathologic results, a pancreatoduodenectomy was performed. Because of an affection of the mesenteric root by the long-lasting peritonitis, resection had to be extended with a right-sided hemicolectomy. The post-operative course was complicated by recurrent anastomotic insufficiencies necessitating a salvage total pancreatectomy. A laparostoma was treated by vacuumdressings. Because of the perforated tumor and reduced overall condition, the patient was referred to a palliative care unit and subsequently died there. Patient 4 had a long-lasting history of a right-sided metastatic adrenal carcinoma, which had been resected years ago. The patient then had received multiple systemic and locally ablative therapies. At the time of presentation, tumor had recurred and infiltrated the duodenum, leading to uncontrollable bleeding. After radiologic-interventional coiling, emergency surgery was performed resecting the duodenal tumor infiltration. In the course, the patient underwent re-operations because of an insufficiency of the pancreatojejunostomy, finally resulting in a completion pancreatectomy. Possibly due to an additional small bowel resection, the patient developed an enterocutaneous fistula, which could be managed conservatively using vacuum-

dressings. The patient was referred to the oncology ward and was subsequently discharged home. Patient 5 was referred from an outside clinic because of an extensive retroperitoneal bleeding from a pancreatic pseudo-cyst. The unstable patient was brought to the OR and a pancreatoduodenectomy was performed. The pseudocyst had eroded the mesenteric root and had formed an inflamed tissue block which also necessitated a right-sided hemicolectomy. Additionally, an intraoperative thrombectomy of the portal and inferior caval vein was performed because of a pre-existing portal thrombosis. The patient had a complicated course including a nosocomial pneumonia, developed a pancreatic fistula, a myocardial infarction, and died in multi-organ failure. Patient 6 presented with a large pseudo-cyst in the pancreatic head area (12 cm diameter), cholestasis, though already a stent in situ, and recurrent drop of Hb-levels. The patient underwent initial surveillance and endoscopy with gastro-cystic drainage via a transgastric pigtail-catheter insertion. Again, melena developed necessitating repeated blood transfusions. On CT-scan, no obvious bleeding source could be visualized and the patient underwent abdominal exploration revealing a huge pseudo-cyst that had eroded the portal vein and the gastroduodenal artery. The pancreatic head as well as the second duodenal part was almost completely destroyed by the ongoing inflammatory process. Additionally, a necrotising pancreatitis of the body and the tail complicated the situs. Therefore, a duodenopancreatectomy and a necrosectomy of the pancreatic corpus were performed. Because of the lack of suturable parenchyma, the pancreatic remnant was left without anastomosis for a later second-stage pancreatojejunostomy. The patient developed a wound infection. After 7 months, he was re-admitted for reconstruction which was complicated by an insufficiency of the jejunopancreatic anastomosis and the formation of an entero-cutaneous fistula. Patient 7 underwent an elective laparoscopic cholecystectomy for symptomatic cholecystolithiasis. During the hospital stay, the patient developed crampy pains and a dilated ductus choledochus. ERCP was performed and could extract a congested gallstone. During this procedure, a perforation of the duodenum in the papillary area occurred. The patient was then referred to our institution, CT scans showed massive intra- and extraperitoneal air collections and the patient underwent emergency surgery. Abdominal exploration revealed a distal bile duct injury as well as a duodenal perforation and an acute pancreatitis. The extent of injury to both the duodenum and the distal intrapancreatic bile duct necessitated a pancreatoduodenectomy. In the course, the patient developed a retroperitoneal abscess which did not resolve after CT-

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guided drain placement, necessitating a surgical intervention. The patient was then discharged home. In patient 8, two ERCPs had been performed because of distal bile duct congestion. The first ERCP was unsuccessful and ERCP was repeated. After extracting two gallstones, the procedure had to be stopped because of a profound swelling of the papilla vateri. The patient then deteriorated and became septic. Computed tomography revealed free intra-abdominal air. The patient was referred to our institution and underwent emergency exploration. Surgery revealed a biliary peritonitis because of a distal bile duct perforation in the anterior part with involvement of the pancreatic head and a pancreatoduodenectomy was performed. The patient developed a pancreatic fistula as well as a wound infection. Additionally, the course was complicated by recurrent lung embolisms. After stabilization, the patient was referred to a geriatric rehabilitation center. Patient 9 was referred from another hospital with an open abdomen and a history of an initial subtotal colectomy because of a suspected toxic megacolon due to an ulcerative colitis. After the initial surgery, the patient developed an acute necrotising pancreatitis which led to a distal spleno-pancreatectomy. In the course, multiple revision surgeries were necessary because of repeated small bowel perforations. The patient was referred to our institution for the treatment of a proximal jejunal perforation. On arrival, the patient was sedated and intubated but hemodynamically stable on low catecholamine levels, therefore a non-emergency exploration was scheduled for the following day. Overnight, the condition critically worsened with high catecholamine-needs and increasing serum lactate levels. Therefore, an emergency laparotomy was carried out and revealed a long perforation of the proximal jejunum. Additionally, the upper abdomen and retroperitoneum showed massive fibrous changes due to the necrotising pancreatitis as well as multiple interenteric abscesses and an insufficiency of the rectal stump. Because of the severe inflammation and large perforation, an emergency pancreatoduodenectomy was performed and the pancreatic remnant had to be left without anastomosis for a second-stage pancreatojejunostomy. During surgery, an extensive diffuse bleeding necessitated mass transfusion and the abdomen was packed. The patient then underwent several re-operations because of recurrent anastomotic insufficiencies, developed recurrent seizures, a CMV colitis, and subsequently died after a longer period of hospitalization. Patient 10 underwent an elective ERCP because of a suspected choledochocele. During ERCP, a papillotomy was performed. Because of post-interventional progressive abdominal pain and rising serum inflammation parameters a CT-scan was initiated, thus revealing a suspected

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duodenitis and an exudative-necrotizing pancreatitis. The patient was in shock, underwent emergency surgery, and abdominal exploration showed a dorsal duodenal perforation with an extensive retroperitoneal phlegmone and an acute pancreatitis of the head area with focal necrosis. Because of the large retroperitoneal phlegmone, the duodenal defect without the possibility to suture and the beginning necrotizing pancreatic head pancreatitis, a pylorus preserving duodenopancreatectomy was performed. The patient subsequently underwent planned abdominal lavages, developed a pancreatic fistula as well as a wound infection, but stabilized clinically and could then be discharged home.

Discussion Performing a PD in an emergency situation is a rare event and then mainly reserved for trauma patients with severe pancreatic injury. But already in trauma patients, a pancreatic or a combined pancreaticoduodenal injury occurs only in about 0.5–5.0 % of all cases [7]. The causes are mainly penetrating rather than blunt traumas and a PD in this setting is associated with mortality rates ranging between 10 and 40 %. [2, 8]. In non-trauma patients, the rates for emergency PD range between 1 and 2 percent of all performed PDs [5, 6]. Due to the scarcity of emergency PDs in the non-trauma setting, the body of literature is manly based on case reports. The main two indications for emergency PD in our series were severe bleeding complications, as also reported in several case reports [9–12], and perforations. Generally, the first approach toward an intraluminal duodenal bleeding is done by endoscopic means. Thereby, being both diagnostic and therapeutic, bleeding that usually arouses from ulcers and eroded arteries can be identified. Interventions such as clip ligation or catecholamine injection can control the bleeding and stabilize the patient. If repeated blood transfusions are necessary, definite surgical suture ligation with closure of the gastroduodenal artery is indicated [13]. In the cases presented herein, the bleeding in one case originated from a pancreatic pseudo-cyst and in the other one from a tumor infiltration into the duodenum. These bleeding sites were either not accessible for endoscopic treatment or tumor infiltration was too pronounced to be treated effectively. An alternative method of bleeding control was used in the latter case by interventional-radiographic coil-embolization, a technique with well-gained reputation in pancreatic surgery for the treatment of postpancreatic resection bleeds. Bleeding complications arousing from sequelae of a chronic pancreatitis have been reported with a frequency of about 4 % in an analysis by

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Udd et al. In their series, interventional coil-embolization led to a bleeding control success rate of 67 % [14]. Integration of radiologic coil embolisation in the management of post-pancreatectomy bleeding helps to stabilize the patient and may avoid a surgical re-operation [15–17]. In our case, the interventional embolisation could stabilize the patient, but did not control the bleeding as repeated blood transfusions were needed. Perforations of either the duodenum or the distal bile duct indicated emergency surgery in most of the other cases presented herein. Thereby, perforations were based on large duodenal ulcers, tumor perforations, or iatrogenic injuries during ERCP. Perforation is a serious complication of peptic ulcers, occurs in about 5–10 % of all cases, and is associated with a septic shock in about 20 % [18]. The usual approach toward a perforated duodenal ulcer is done by abdominal exploration, closure of the perforation, and extensive abdominal irrigation [19]. Thereby, the extent of surgery varies with the extent of perforation and complications. Ulcer penetration into the pancreas is rare, but occurred in a patient of this series. The long-lasting perforation and inflammation in this indolent patient led to the deterioration of the pancreatic head and the duodenal wall to an extent that did not allow a parenchyma sparing resection and reconstruction. In three of our cases, ERCP-induced injury to the distal bile duct led to emergency surgery. In the literature, perforation rates in ERCP range between 0.1 and 0.6 %. Thereby, perforations occur more frequently in therapeutic than in only diagnostic procedures [20, 21]. Our patients also underwent combined diagnostic and therapeutic ERCPs with repeated manipulations in and around the distal biliary tract system and showed perforations of the anterior distal bile duct with consecutive pancreatic injury, and, in one case, additionally a perforation of the duodenum. Thereby, the strategies toward ERCP-associated perforations vary with the site and extent of perforation. Usually, an intra-abdominal duodenal perforation requires surgery, whereas retroperitoneal perforations might as well be managed conservatively [22, 23]. Anterior injuries to the distal bile duct or the common biliopancreatic tract are rare and often it is the clinical condition and course of the patient that indicates the necessity of a surgical intervention. In the cases herein, an acute clinical deterioration occurred after the procedure. Surgery revealed the extreme extent of injury, which is uncommon to be that pronounced. The indications for an emergency pancreatoduodenectomy vary among this series and are not only based on a single parameter or diagnostic finding, but rather on a combination of the clinical patient condition together with the diagnostic findings. The varying indications and

individual therapeutic decision making are also seen in other series with emergency surgeries mainly because of ERCP/endoscopy-related complications and uncontrollable bleeding. [5, 6]. These cases are comparable to the ones presented herein, showing that a pancreatoduodenectomy in an emergency situation seems to be associated with a higher mortality, attributable to the in extremis presentation. In two of the patients presented herein, the formation of a pancreatic anastomosis was avoided because the pancreatic remnant together with severely associated surrounding damage was judged to be prone to further insufficiencies. As a variant of damage-control surgery, the two-stage strategy of pancreatoduodenectomy followed by formation of a pancreatojejunostomy after clinical stabilization is seldom necessary but can bridge severely ill patients [24–26].

Conclusion An emergency pancreatoduodenectomy in a non-trauma patient is a rare procedure with diverse indications and rather high mortality rates which are possibly related to the severity of primary injury and its associated clinical deterioration. The decision of performing an emergency pancreatoduodenectomy is usually not a planned one, but serves as an ultima ratio when being confronted with severe injuries around the pancreatic head. Compliance with ethical standards Conflicts of interest The author has no conflict of interest.

References 1. Mezhir JJ (2013) Management of complications following pancreatic resection: an evidence-based approach. J Surg Oncol 107:58–66 2. Asensio JA, Petrone P, Roldan G et al (2003) Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries. J Am Coll Surg 197:937–942 3. Lin BC, Chen RJ, Fang JF et al (2004) Management of blunt major pancreatic injury. J Trauma 56:774–778 4. Lin BC, Fang JF, Wong YC et al (2007) Blunt pancreatic trauma and pseudocyst: management of major pancreatic duct injury. Injury 38:588–593 5. Z’Graggen K, Strobel O, Schmied BM et al (2002) Emergency pancreatoduodenectomy in nontrauma patients. Pancreas 24:258–263 6. Standop J, Glowka T, Schmitz V et al (2010) Emergency KauschWhipple procedure: indications and experiences. Pancreas 39:156–159 7. Ragulin-Coyne E, Witkowski ER, Chau Z, et al (2013) National trends in pancreaticoduodenal trauma: interventions and outcomes. HPB

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World J Surg 8. Velmahos GC, Tabbara M, Gross R et al (2009) Blunt pancreatoduodenal injury: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Arch Surg 144:413–419 (discussion 419–420) 9. Parray FQ, Lone IM, Chowdri NA et al (2011) Emergency pancreaticoduodenectomy in duodenal paraganglioma: case report. ISRN Surg 2011:268674 10. Stratigos P, Kouskos E, Kouroglou M et al (2007) Emergency pancreatoduodenectomy (whipple procedure) for massive upper gastrointestinal bleeding caused by a diffuse B-cell lymphoma of the duodenum: report of a case. Surg Today 37:680–684 11. Maeda H, Okabayashi T, Kobayashi M et al (2006) Emergency pancreatoduodenectomy for pancreatic metastasis from renal cell carcinoma in a patient with von Hippel-Lindau disease: a case report. Dig Dis Sci 51:1383–1387 12. Sakakima Y, Inoue S, Fujii T et al (2004) Emergency pyloruspreserving pancreatoduodenectomy followed by second-stage pancreatojejunostomy for a gastrointestinal stromal tumor of the duodenum with an intratumoral gas figure: report of a case. Surg Today 34:701–705 13. Zittel TT, Jehle EC, Becker HD (2000) Surgical management of peptic ulcer disease today–indication, technique and outcome. Langenbeck’s Arch Surg 385:84–96 14. Udd M, Leppaniemi AK, Bidel S et al (2007) Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis. World J Surg 31:504–510. doi:10.1007/s00268-006-0209-z 15. Sato N, Yamaguchi K, Shimizu S et al (1998) Coil embolization of bleeding visceral pseudoaneurysms following pancreatectomy: the importance of early angiography. Arch Surg 133:1099–1102

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16. Blanc T, Cortes A, Goere D et al (2007) Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated? Am J Surg 194:3–9 17. Choi SH, Moon HJ, Heo JS et al (2004) Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg 199:186–191 18. Druart ML, Van Hee R, Etienne J et al (1997) Laparoscopic repair of perforated duodenal ulcer. A prospective multicenter clinical trial. Surg Endosc 11:1017–1020 19. Lunevicius R, Morkevicius M (2005) Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer. World J Surg 29:1299–1310. doi:10. 1007/s00268-005-7705-4 20. Anderson MA, Fisher L et al (2012) Complications of ERCP. Gastrointestinal endoscopy 75:467–473 21. Salminen P, Laine S, Gullichsen R (2008) Severe and fatal complications after ERCP: analysis of 2555 procedures in a single experienced center. Surg Endosc 22:1965–1970 22. Lai CH, Lau WY (2008) Management of endoscopic retrograde cholangiopancreatography-related perforation. Surgeon 6:45–48 23. Enns R, Eloubeidi MA, Mergener K et al (2002) ERCP-related perforations: risk factors and management. Endoscopy 34:293–298 24. Miyagawa S, Makuuchi M, Kawasaki S et al (1994) Second-stage pancreatojejunostomy following pancreatoduodenectomy in high-risk patients. Am J Surg 168:66–68 25. Cho A, Arita S, Koike N et al (2005) Two-staged hepato-pancreatoduodenectomy and interventional pancreaticojejunostomy. Hepatogastroenterology 52:1886–1888 26. Gupta V, Wig JD, Garg H (2008) Trauma pancreaticoduodenectomy for complex pancreaticoduodenal injury. Delayed reconstruction. JOP: J Pancreas 9:618–623