Surgery: Current Research

Ezzedien Rabie, Surgery Curr Res 2014, 4:2

http://dx.doi.org/10.4172/2161-1076.1000166

Case Report

Open Access

An Unusual Case of Devastating Isolated Duodenal Injury treated by

Emergency Whipples Procedure: Possible Explanation
Ezzedien Rabie M*
Department of Surgery, Armed Forces Hospital, Southern Region, Saudi Arabia

Abstract
Pancreatic duodenal injuries have high mortality and morbidity rates, owing to the unforgiving nature of the
involved organs, particularly the pancreas, and the difficult procedures required for repair. In this report we describe
the clinical course of a patient who sustained a devastating injury to the duodenum with separation of the pancreatic
head, following a car accident. He was managed by emergent Whipples procedure with a successful outcome. This
is one of a few published reports on emergency pancreaticoduodenectomy in the setting of trauma. Additionally, we
question the mechanism of such injury, which spared the contagious pancreatic head.

Introduction
Blunt duodenal injuries are rare with an estimated incidence
of 0.2% of trauma cases, and are usually associated with injuries to
neighbouring structures. Out of 30 cases of traumatic rupture of the
duodenum, isolated injury was found in only three [1]. Lying in the
concavity of the duodenum, the pancreatic head is most likely involved
in such cases.

Case Report
A 22-year-old non restrained male driver was brought to the
emergency room after involvement in a vehicular accident. On
examination, he was fully conscious and haemo dynamically stable, but
in severe pain. There was a superficial wound in the forehead and the
chest and heart examinations were normal. Abdominal examination
showed severe tenderness with board like rigidity, especially in the right
upper quadrant.
His haemoglobin was 12.8 gm/dl, and the blood biochemistry
including urea, creatinine and electrolytes were normal.
A supine chest X ray was normal and CT scan showed a full
stomach with air anterior to the right kidney, aorta and inferior vena
cava (Figures 1 and 2).
A presumptive diagnosis of duodenal rupture was made and the
patient was prepared for an exploratory laparotomy.
On entering the abdomen, a big amount of frothy bile-stained
fluid was found in the right upper quadrant below the liver, and the

Figure 2: Free intraperitoneal and retroperitoneal air (yellow arrows).

duodenum appeared severely damaged with a bursting injury, especially

in the second part. Additionally, after kocherization, the head of the
pancreas appeared few mm apart from the C loop of the duodenum
(Figure 3), and bile continued to pour in the area, apparently from a
severed retroduodenal common bile duct. The whole retroperitoneum
in the area was bathed in frothy bile.
After considering the extent of the injury, a decision to perform an
emergency pancreaticoduodenectomy, seemed most appropriate. After
resection, continuity was restored in a Roux en Y fashion (Figure 4)
and the procedure was concluded with the construction of a feeding
jejunostomy and drains were inserted.
Postoperatively, somatostain was started in a dose of 200 g
subcutaneously every 8 hours. Apart from bile leak which started on the
first post operative day, the patient showed steady recovery. On the third
postoperative day, feeding through the feeding jejunostomy was started
and gradually oral feeding was introduced. MRCP, US scan and a gastro

*Corresponding author: Ezzedien Rabie M, Department of Surgery, Armed

Forces Hospital-Southern Region, PO Box 101-Khamis Mushait-Saudi Arabia, Tel:
00966 50775 3692; E-mail: ezzedien@hotmail.com
Received December 16, 2013; Accepted January 28, 2014; Published February
05, 2014
Citation: Ezzedien Rabie M (2014) An Unusual Case of Devastating Isolated
Duodenal Injury treated by Emergency Whipples Procedure: Possible Explanation.
Surgery Curr Res 4: 166. doi:10.4172/2161-1076.1000166
Figure 1: CT scan of the abdomen showing full stomach (yellow circle) and air
in the retroperitoneum (yellow arrows).

Surgery Curr Res

ISSN: 2161-1076 SCR, an open access journal

Copyright: 2014 Ezzedien Rabie M. This is an open-access article distributed

under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.

Volume 4 Issue 2 1000166

Citation: Ezzedien Rabie M (2014) An Unusual Case of Devastating Isolated Duodenal Injury treated by Emergency Whipples Procedure: Possible
Explanation. Surgery Curr Res 4: 166. doi:10.4172/2161-1076.1000166
Page 2 of 3

drainage alone, insertion of pancreatic duct stent through ERCP, distal

pancreatectomy with or without splenectomy, pancreatectojejunostomy
and at the end of the scale, pancreatoduodenectomy [9]. Although the
diagnosis may be difficult, the presence of retroperitoneal haemtoma
[8] or air [5] in the region of the duodenum on CT scan, is highly
suggestive of duodenal injury, as was seen in our patient.
Whipples procedure is a major undertake when performed for
selected patients in the elective setting. The task becomes even more
formidable when performed for trauma, where patient selection is not
an option.

Figure 3: Diagrammatic representation. Burst type of injury involving the

duodenum and causing separation of the head of the pancreas from the C
loop (green zone).

Figure 4: Diagrammatic representation. Restoration of the bowel continuity

in Roux en Y fashion with hepaticojejunostomy, gastrojejunostomy and
pancreaticojejunostomy

grafin study showed no free intraperitoneal collection and no bile leak

could be demonstrated. After two weeks, bile leak ceased, when the
drain was removed and the patient was discharged in good condition
for outpatient follow up. Four years later, he presented with diffuse
colicky abdominal pain and X ray showed dilated small bowel loops
with multiple fluid levels, suggestive of adhesive bowel obstruction. As
the condition failed to respond to conservative treatment, exploration
was performed. At laparotomy, a band was found strangling a loop of
the terminal ileum. The band was divided and the gangrenous loop
was excised with primary anastomosis. Thereafter, the patent was
discharged in good condition and remains well.

Discussion
Although the extent of pancreatic duodenal injuries may mandate a
Whipples procedure [2], this is a rare encounter and lesser techniques
should be considered first. For duodenal injuries, debridement and
suture repair [3-6] with or without pyloric exclusion have been utilized
with success [7]. Cases with substance loss have been managed by
pedicled ileal loop to bridges duodenal defects [8]. Additionally,
duodenal diverticulization and triple tube technique have proved
useful tools in the surgeons armamentarium. As for pancreatic injuries,
the choice of the procedure depends on the location of the injury,
the integrity of the pancreatic duct, the stability of the patient and
the presence of associated injuries. The range of procedures includes
Surgery Curr Res
ISSN: 2161-1076 SCR, an open access journal

In this regard, the procedure has been rarely performed for injuries
resulting from vehicular accidents. In their report on 301 consecutive
patients who underwent Whipples procedure, Standop et al. found only
6 cases done as an emergency procedure and none was performed for
a vehicular injury [10]. In another report on 48 cases with blunt major
pancreatic injury, only two underwent pancreatoduodenectomy, with
one (50%) mortality rate [9].
Although rarely performed, pancreaticoduodenectomy for
combined pancreatic and duodenal injuries is a well established tool in
the surgeons armamentarium [11]. However, with better understanding
of the anatomy of the pancreaticoduodenal region, pancreas sparing
duodenectomy could be performed for a variety of causes, including
isolated devastating duodenal injury [12]. In this technique, the
duodenum is first separated from the pancreas and resected, with
careful preservation of the blood supply. Bowel continuity is then
restored by gastrojejunostomy and the pancreatic and bile ducts are
anastomosed to the jejunum. This may be accomplished by a variety
of ways. If the portion of the duodenal wall containing the papilla
remains intact, it could be anastomosed to the jejunum. Alternatively,
the isolated papilla with a fringe of the surrounding douodenal wall
could be reimplanted into the jejunum or, as the third option, the bile
and pancreatic ducts could be separately anastomosed to the jejunum
[12]. In the case presented here, a standard Whipples procedure
was performed for two reasons. Firstly, despite the apparently intact
pancreatic head, possible ischaemic injury, resulting from its separation
from the duodenum, could not be absolutely excluded. Secondly, the
author is more comfortable with a standard procedure than a pancreatic
preserving duodenectomy.
The mechanism of injury in the patient presented here deserves a
special note. Generally, the mechanism of duodenal injury in trauma
patients is largely speculative. Anteroposterior compression of the
duodenum against the spine is the preferred explanation. Another
proposed mechanism is that deceleration generated by the impact,
creates inertial stresses between the moving duodenum and related
structures with shearing effects [5]. In our patient with a devastating
injury to the duodenum, there were no concomitant injuries to the
neighbouring structures, notably the pancreatic head, which only
parted from the duodenum. This happening could not be explained by
the aforementioned mechanisms.
In the search for an explanation, the author of this paper speculated
the following: compression of the full stomach (Figure 1) by the steering
wheel caused sudden passage of a large amount of gastric contents
into the duodenum through the patent pylorus, as by coincidence, the
cardia was closed. This led to a sudden distension and rapid rise of the
duodenal intraluminal pressure. This sudden distension lead to a burst
type of injury to the duodenum, dispelling the pancreatic head medially
and avulsing the ampulla of Vater (Figures 5A-5C), an injury which
has been rarely reported [13-15]. This trail of events is likened to the
pathogenesis of Boerhaaves syndrome [16], but in a prograde fashion.

Volume 4 Issue 2 1000166

Citation: Ezzedien Rabie M (2014) An Unusual Case of Devastating Isolated Duodenal Injury treated by Emergency Whipples Procedure: Possible
Explanation. Surgery Curr Res 4: 166. doi:10.4172/2161-1076.1000166
Page 3 of 3

seem unsafe. Some cases of isolated duodenal injuries, in the setting

of blunt trauma, may result from sudden distension of the duodenum
upon anteroposterior compression of the stomach.
References
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15. Cox MR, Eastman MC (1994) Traumatic duodenal rupture and avulsion of the
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Williams & Wilkins, Philadelphia 789-796.

Figure 5 A, B and C: sudden passage of excessive contents into the duodenum

from the compressed stomach, lead to duodenal distension and rupture.

Although difficult to prove, this mechanism may be the reason behind

some cases of duodenal injuries which occur without simultaneous
injuries to other contagious organs.

Conclusion
Although formidable, emergent Whipples procedure could be safely
done for duodenopancreatic injuries, when less extensive procedures

Citation: Ezzedien Rabie M (2014) An Unusual Case of Devastating Isolated

Duodenal Injury treated by Emergency Whipples Procedure: Possible
Explanation. Surgery Curr Res 4: 166. doi:10.4172/2161-1076.1000166

Surgery Curr Res

ISSN: 2161-1076 SCR, an open access journal

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