Pancreatoduodenectomy for Trauma: Applying Novel Reconstruction Techniques

This single center study evaluated the technical modifications and outcome of reconstruction after pancreaticoduodenectomy for trauma. Prospectively recorded data including reconstructive techniques used in patients who underwent a pancreatoduodenectomy (PD) for trauma were analyzed. Twenty patients underwent a PD. Six had an initial damage control procedure. Thirteen had a pylorus-preserving PD and 7 a standard Whipple resection because injury to the pylorus precluded a pylorus-preserving resection. Twelve patients had a pancreatojejunostomy and 8 a pancreatogastrostomy, 3 of whom had a duodenojejunal hepaticojejunal sequence of anastomoses to allow endoscopic biliary stent retrieval. Three patients died postoperatively of multi-organ failure. All 17 survivors had postoperative complications: 5 patients developed pancreatic fistula, 2 had gastric outlet obstruction, 2 had bile leaks, 2 had duodenal anastomotic leaks, all of which resolved with conservative treatment. Pancreatic and biliary reconstructions performed under adverse conditions after a trauma PD required a variety of technical modifications. The pylorus does not have to be sacrificed and posterior gastric implantation is a safe option for an edematous pancreas

Endoscopic treatment of persistent thoracobiliary fistulae after penetrating liver trauma

AbstractBackgroundThis study evaluated the outcomes of patients with complex or persistent thoracobiliary fistulae following penetrating liver trauma, who underwent endoscopic biliary intervention at a tertiary referral centre.MethodsAll patients who underwent endoscopic retrograde cholangiography (ERC) and endoscopic biliary intervention for traumatic thoracobiliary fistulae between 1992 and 2008 were evaluated. Bile duct injuries were classified according to their biliary anatomic location on cholangiography and type of pulmonary communication.ResultsTwenty-two patients had thoracobiliary (pleurobiliary, n=19; bronchobiliary, n=3) fistulae. The site of the bile duct injury was identified in 20 patients on cholangiography. These 20 patients underwent either sphincterotomy and biliary stenting (n=18) or sphincterotomy alone (n=2). In 17 patients the fistulae resolved after the initial endoscopic intervention. Three patients required secondary stenting with replacement of the initial stent. Three patients developed mild pancreatitis after stenting and one stent migrated and was replaced. All fistulae healed after endoscopic treatment. In 18 patients the stents were removed 4 weeks after bile drainage ceased. Three of the 22 patients required a thoracotomy for infected loculated pleural collections after initial catheter drainage.ConclusionsEndoscopic retrograde cholangiography is an accurate and reliable method of demonstrating post-traumatic thoracobiliary fistulae and endoscopic biliary intervention with sphincterotomy and stenting in this situation is safe and effective. Surgery in patients with thoracobiliary fistulae should be reserved for fistulae which do not heal after endoscopic biliary stenting or for patients who have unresolved pulmonary or intra-abdominal sepsis as a result of bile leak