Modified Whipple on an 18-month-old with traumatic pancreatic transection and duodenal rupture

Abstract

The emergence of the Whipple procedure revolutionized operative management of pancreatic disease since its introduction (Fernandez-del Castillo et al., 2012 [ 1 ]). This operation classically involves removal of the head of the pancreas along with the duodenum, gallbladder, a portion of the bile duct, and part of the stomach (Warshaw and Thayer, 2004; Evans et al., 2007 [ 2 , 3 ]). We report a beneficial outcome of a modified Whipple on a paediatric trauma patient post- motor vehicle accident (MVA). After Advanced Trauma Life Support (ATLS) was initiated and haemodynamic stability was achieved, exploratory laparotomy revealed pancreatic transection and duodenal rupture. Partial pancreaticoduodenectomy, pancreaticoduodenostomy, cholecystojejunostomy, and pyloric-sparing gastrojejunostomy were performed. Post-operative acute pancreatitis resolved with antibiotics and supportive care. While paediatric abdominal trauma does not typically warrant a Whipple, patients with severe injury to the pancreas and neighboring organs with major vascular injury may offer no other intra-operative choice (Adams, 2014; Thatte and Vaze, 2014; Debi et al., 2013 [ [4] , [5] , [6] ]). Our patient's growth was followed post-operatively. At a 20-year post-operative follow-up, he reported no further hospitalizations or complications such as diabetes, biliary stricture, gallstones, or growth retardation. We review the literature to expose the novelty of using a Whipple to treat paediatric abdominal trauma, and the advantages of a pylorus-preserving Whipple. Indications for damage control surgery and non-operative management were contrasted with those for definitive surgery to reconstruct the biliary tree to further elucidate why the latter option was chosen.