Gastric serosal patch in distal pancreatectomy for injury: a neglected technique

Copyright ELSEVIER

Injury Vol. 28, No. 2, pp. 127-129, 1997 0 1997 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383/97 $17.00 + 0.00

PII: SOO20-1383(96)00157-X

Gastric serosal patch in distal pancreatectomy injury: a neglected technique Y. Kluger,

R. Alfici,

Department Israel

of Surgery

B. Abbley,

D. Soffer and D. Aladgem

and Trauma Services, Sourasky

Distal pancreatectomy to manage disruption of the body and tail of the pancreas is a well-established surgical procedure. Fistula formation after distal pancreatectomy for injury may be as high as 24 per cent, and its treatment, although non-operative, prolongs hospitalization and increases the patient’s discomfort. We describe the gastric serosal patch technique designed to cover the pancreatic stump after distal pancreatectomy in injured patients. Although this procedure has been previously described, it did not receive appropriate acclaim. Our experiencesuggests that this technique may eliminate fistula formation and other complications, thereby reducing patient discomfort, morbidity and hospital stay. 0 1997 Elsevier Science Ltd.

Injury,

Vol. 28, No. 2, 127-129,

for

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Medical Center, Sackler School of Medicine,

Tel-Aviv,

reduces the complication rate of the operation and the discomfort of the patient.

Technique After performing a distal pancreatectomy with or without splenectomy, TA-30 staples are applied to the stump. The distal pancreas is mobilized and sutured to the posterior serosal wall of the stomach circumventing the tail of the pancreas using 2.0 interrupted silk suture. A number 10 Jackson Pratt closedsystem drainage catheter is placed in the area of the serosal patch prior to abdominal closure. If there is no drainage of pancreatic secretion after 6 days, the drain may be removed.

Case reports Introduction Distal pancreatectomy with or without splenectomy for the management of distal pancreatic injuries is often accompanied by an array of complications. Regardless of the method of closure of the stump of the distal pancreas, up to 45 per cent of patients develop complications’. Intra-abdominal abscess, pancreatic fistulae, haemorrhage, pancreatitis and pseudocysts have all been described following the procedure. Although some of these complications carry less morbidity and mortality than the others, they are an inconvenience to the patient and increase the overall costs of their medical care. This article describes four cases in which the gastric serosal patch technique was employed for the management of pancreatic stumps following distal pancreatectomies. In each case, whether or not a splenectomy was performed or other hollow-viscus organ damage existed, there were no pancreasrelated complications following the distal pancreatectomy, a good result when compared with the frequent rate of intra-abdominal abscess(up to 34 per cent)’ and pancreatic fistulae (14-24 per cent) following pancreatic injuries treated by distal pancreatectomy alonez”. This technique, in our experience,

Case 1 A 57-year-old previously healthy man sustained multiple injuries in a road traffic accident. On initial assessment, he was hypotensive and agitated; chest, cervical spine and pelvic X-rays were all normal. A diagnostic peritoneal lavage was positive so the patient was transferred to the operating room. A splenectomy was performed for a grade III splenic laceration and a 40% distal pancreatectomy for a grade III injury of the body of the pancreas. A gastric serosal patch technique was applied. Recovery was uneventful. Case 2 A 25-year-old woman presented to the Emergency department after falling from a three-storey building. She was fully orientated and had a Glasgow Coma Score of 15. A chest X-ray was normal. Pelvic x-ray showed fractures of the right superior and inferior pubic rami. A complete spinal X-ray series showed fractures of C6, T5 and Ll. Abdominal CT detected a grade II splenic laceration and free fluid in the abdominal cavity. A large retroperitoneal haematoma was noted to stretch from the pelvis to the border of the left kidney. The abdomen was explored and a splenectomy performed. Because of a large injury of the tail of the pancreas

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a 25 per cent distal pancreatectomy was also performed. A gastric serosal patch was applied. The patient was transferred to the ICU and stabilized haemodynamically following the administration of 10 units of blood, 6 units of fresh frozen plasma and 12 units of platelets. The spinal fracture was stabilized at the level of Ll using Harrington rods. Recovery was uneventful. Cuse 3 An B-year-old man was brought to the Emergency department after sustaining multiple blows to the abdomen following an attack by a gang. The patient was alert (Glasgow Coma Score of 15) and had a blood pressure of 110/70 mmHg and a pulse of 116 beats per min. There were no penetrating abdominal wounds but the patient complained of diffuse abdominal pain. Cervical spinal, chest, and pelvic X-rays were normal. He was subsequently intubated because of agitation induced by intoxication. An abdominal CT scan showed free fluid extending from the subhepatic space to the pelvis. The liver and spleen were intact. Exploratory laparotomy revealed 500 ml of fresh blood in the peritoneum, a large haematoma in the retroperitoneum, and free bile, which was seen extruding posterior to the duodenum. Following the discovery of a complete transection of the bile duct and inability to locate the papilla of Vater through a duodenotomy, a distal pancreatectomy was performed (sparing the spleen) in an attempt to visualize the pancreatic duct with intra-operative pancreatography. After this was completed a gastric serosal patch was applied. A retrocolic gastrojejunostomy and cholecystojejunostomy with pyloric exclusion of the stomach from the duodenum was also performed. Recovery was uneventful and he was discharged 10 days following the operation. Cuse 4 A 24-year-old, previously healthy man presented to the Emergency department after a fall from a height. He was hypotensive on admission. He had sustained a right pneumothorax and had a positive diagnostic peritoneal lavage. A splenectomy and 25 per cent distal pancreatectomy using a gastric serosal patch were performed for a grade IV splenic laceration and a grade III pancreatic tail laceration. Recovery was uneventful.

Discussion For the last two decades distal pancreatectomy for the management of pancreatic tail and body injuries has been a well-accepted procedure. This was popularized after the observation that similar pancreatic injuries managed by drainage alone are fraught with a high incidence of complications (50 per cent mortality and 100 per cent morbidity)“. Distal pancreatectomy does not eliminate complications, but may render them more manageable. In a multi-centre study of distal pancreatectomy in injured patients, 45 per cent suffered complications’. Less common complications following distal pancreatectomy include endocrine and exocrine insuffiself-limiting pancreatitis, pseudocyst ciency, formation, and pancreatic haemorrhage’. These may

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resolve spontaneously, require percutaneous drainage, or result in death as noted in some cases of pancreatic haemorrhage”. Different techniques for pancreatic stump closure are used, but all are prone to fistula formation. The incidence of pancreatic fistula formation following distal pancreatectomy for injury has been reported as 3-24 per cent ‘~~8~.Recent reports documented 14 per cent fistula formation with 89 per cent of them closing spontaneously’. This necessitated prolonged hyperalimentation to maintain adequate nutritional support while enhancing fistula closure. Some authors have advocated somatostatin analogues to hasten the closure of long-standing fistulae7-9. Operative closure of some fistulae has been successfully performed by Martin et a1.9. Death has been reported when both a pancreatic fistula and abdominal abscess have occurred concomitantly”. Fistula formation carries a significant risk of further morbidity and mortality. According to recent reports, intra-abdominal abscess occurs with a frequency of 3-39 per cent of patients following distal pancreatectomy for injury’m”,5, and its incidence increases in patients with associated hollow viscus injuries’. Treatment of these abscesses involves either abdominal CT or ultrasonography-guided percutaneous drainage, or drainage at laparotomy. If a pancreatic abscess coexists with necrotic pancreatic tissue, non-viable tissue debridement with open treatment and appropriate drainage is required5. Despite aggressive management, pancreatic abscesses, particularly when in association with sepsis and pancreatic necrosis, pose significant morbidity and mortality risks. In the four cases described, no pancreatic complications were observed. The gastric serosal patch technique may help to prevent complications following distal pancreatectomy. Although this technique has previously been described by S. Austin Jones, it is not yet established as a routine procedure”‘. The gastric serosal patch technique for the coverage of the pancreatic stump in our limited experience has had a dramatic effect on lowering the complication rate after distal pancreatectomy and perhaps deserves to be looked at again in a multicentre study.

Conclusion We recommend the use of gastric serosal patches in patients who are undergoing distal pancreatectomy for injury. The adjunct treatment of gastric serosal patch technique in distal pancreatectomy may reduce patients’ morbidity, inconvenience and medical costs by preventing common complications such as fistula formation.

References 1 Cogbill TH, Moore EE, Morris JA et al. Distal pancreatectomy for trauma: a multicenter multicentre experience. J Trauma 1991; 31: 1600.

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Cogbill TH, Moore EE and Kashuk JL. Changing trends in the management of pancreatic trauma. Arch Surg 1982; 117: 722. Fitzgibbons TJ, Yellin AE, Maruyama MM et al. Management of the transected pancreas following distal pancreatectomy. Surg Gynecol Obstef 1982; 154: 225. Flynn WJ Jr, Cryer HG and Richardson JD. Reappraisal of pancreatic and duodenal injury management based on injury severity. Arch Surg 1990; 125: 1539. Malangoni MA, Richardson JD, Shallcross JC et al. Factors contributing to fatal outcome after treatment of pancreatic abscess. Am Surg 1986; 203: 605. Heitsch RC, Knutson CO, Fulton RL et al. Delineation of critical factors in the treatment of pancreatic trauma. Surgery 1976; 80: 523. Pederzoli I’, Bassi C, Falconi M et al. Conservative treatment of external pancreatic fistulas with parenteral nutrition alone or in combination with continuous intra-

venous infusion of somatostatin, glucagon, or calcitonin. Surg Gymml Obstef 1986; 163: 428. 8 Prinz RA, Pickleman J and Hoffman JP. Treatment of pancreatic cutaneous fistulas with a somatostatin analog. Am J Surg 1988; 155: 36. 9 Martin FM, Rossi RL, Munson JL et al. Management of pancreatic fistulas. Arch Surg 1989; 124: 571. 10 Schwartz SI and Ellis H. Injuries to the pancreas. In: Schwartz SI and Ellis H, eds. M&got’s Abdominal Opevafiorrs, 8th Ed. Norwalk: Appleton-Century-Crofts, 1985, p. 2045.

IP-3aper accepted 2 October 1996. Requests for reprints should be nddressed to: Dr Yoram Kluger Head of Trauma Services, Tel Aviv Medical Center, 6 Weizman street, Tel Aviv, Israel. MD,