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Emergency Backwards Whipple for Bleeding: Formidable and Definitive Surgery 时间:2017-07-03 13:13 来源:未知作者:admin 点击: 次 Abstract:Introduction. During the past decades, the safety of pancreatoduodenectomy has improved, with low mortality and reduced morbidity, particularly in centers with extensive experience. Emergency pancreatoduodenectomy is an uncommon event, for treatment of pancreaticoduodenal trauma, bleeding, or perforation. We herein present a single center experience concerning nontrauma emergency pancreatoduodenectomy for pancreaticoduodenal bleeding. Methods. From January 2007 to December 2015, from a population of 134 PD (70 males and 64 females, mean age 62.2, range 34–82), 5 patients (3.7%; 2 males and 3 females, mean age 64, range 57–70) underwent one-stage emergency pancreatoduodenectomy for uncontrollable nontrauma pancreaticoduodenal bleeding in our tertiary center. Results. All the 5 patients underwent a backwards Whipple with a morbidity of 60% and a mortality of 20% (1/5). The other 4 patients were recovered and discharged with a median postoperative length of stay of 17 days (range 14–23). Conclusion. Emergency pancreatoduodenectomy is a definitive life-saving procedure allowing for a rapid control of bleeding when other less invasive approaches (transcatheter arterial embolization or interventional endoscopy) are exhausted, unavailable, or unsafe. It should be particularly considered in neoplastic disease and tailored by surgeons with a high level of experience in pancreatic surgery.
1. Introduction
Pancreatoduodenectomy (PD) is a complex and challenging operation, routinely performed as an elective surgery, mostly to treat pathology of the bile ducts, pancreas, and duodenum. The surgical morbidity and mortality rates of PD have significantly improved during the past decades likely due to increased surgical experience and improved management of complications. In centers with extensive experience, it has become a routine and safe procedure, allowing broadening of indications. On the other hand, emergency pancreatoduodenectomy (EPD), which has been rarely reported as a life-saving procedure for acute pancreaticoduodenal trauma or massive uncontrollable bleeding from ulcers, tumors, diverticula, ruptured aneurysms, or bleeding pseudocysts, is still a very uncommon procedure and an added challenge for the surgeon [1–19]. Given the urgent nature of peripancreatic hemorrhage and complexity of this surgery, the outcome of EPD may be relatively poor [15]. The procedure is often performed under unstable hemodynamic condition and even in shock [1]. The aim of our study is to review and report our institutional experience with EPD in the particular setting of pancreaticoduodenal uncontrollable nontrauma bleeding as there has been no other reported series so far.
2. Material and Methods
From January 2007 to December 2015 from a population of 134 PD (70 males and 64 females, mean age 62.2, range: 34–82), 5 patients (3.7%, 2 males and 3 females, mean age 64, range: 57–70) underwent emergency one-stage Whipple procedure for different indications of pancreaticoduodenal massive bleeding. Emergency resection was defined as a PD carried out on the same day of massive bleeding occurrence or deterioration. Intraoperative records were reviewed for operative time, intraoperative blood loss, and transfusion of packed red blood cells. Postoperative records were evaluated for length of postoperative stay and postoperative complications.
2.1. Technical Approach
All the patients were operated by the same senior surgeon using a right backwards Whipple procedure. We preferred this approach as far as it offers rapid and early control over the peripancreatic vasculature (superior mesenteric artery (SMA), portal vein, and pancreaticoduodenal arcades), which is the key point in hemorrhagic emergency. Technical details of this modified posterior approach to the SMA and mesopancreas (MP) were widely exposed in one of our previous publications [20]. In brief, the key points are the following: