{'fraction_non_alphanumeric': 0.024407753050969132, 'fraction_numerical': 0.004785833931562575, 'mean_word_length': 5.102189781021898, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 1, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Pancreaticoduodenectomy with Vena Cava Ligation for Penetrating Trauma: An Interesting Case of Survival

We present a case in which a 39-year-old man sustained a gunshot wound to the abdomen with entry near the right upper quadrant. The patient initially presented to an outside facility and was transferred to our Level 1 trauma center for definitive treatment. Before transfer, CTabdomen/pelvis had been obtained, which reportedly demonstrated hemoperitoneum and a fracture of L3 vertebra, although images were not available for review on arrival. On initial evaluation in the trauma bay, the patient was alert with Glasgow Coma Scale score of 14, although he seemed intoxicated. He was hemodynamically stable after transfusion of 3 units of packed red blood cells initiated at the transferring facility. The patient was taken emergently for exploratory laparotomy. Intraoperatively, the patient was found to have a liver laceration, a perforation in the second portion of the duodenum, a disruption of the pancreatic head, a perforated gallbladder, a transection of the common bile duct, perforations of the cecum and transverse colon, and injury of the inferior vena cava (IVC). The liver injury was controlled successfully with hemostatic packing. A right hemicolectomy was performed, leaving the bowel in discontinuity. The first and second portions of the duodenum were resected because the pancreatic head and common bile duct were already avulsed. The common bile duct was able to be identified and marked with a suture for future reconstruction. Cholecystectomy was performed in the standard fashion. As these procedures were completed, an expanding zone I hematoma was observed; on exploration, the patient was found to have near-complete transection of the IVC. Because the remaining tissue was in poor condition because of ballistic injury, as well as the contaminated nature of the operation, the decision was made to ligate the vessel, which was performed successfully. A temporary abdominal closure device was applied. The patient was then admitted to the surgical ICU for resuscitation. Compression wraps were applied to the lower extremities in anticipation of severe edema, which never occurred. On hospital day 2, the patient was brought back to the operating room for definitive management of his injuries. The devitalized portion of the pancreatic head was resected along with the remaining duodenum. Reconstruction was performed by creating an end-to-end pancreaticojejunostomy, an end-to-side choledochojejunostomy, and a roux-en-y gastrojejunostomy. Intestinal continuity was restored by creating an ileocolostomy. Large drains were placed, and again a temporary abdominal closure device was applied. The third and final operation involved fine-tuning of the biliary anastomosis, which was found to be leaking. A T tube was placed across the anastomosis to serve as a stent as well as an access for future imaging studies. Omental flaps were placed to buttress the anastomoses. A nasojejunal feeding tube was placed intraoperatively for feeding access. The abdomen was closed at the conclusion of this operation. Postoperatively, the patient had a prolonged hospital course, requiring treatment for clostridium difficile colitis, right lower extremity deep venous thrombosis, and operative fixation of his unstable L3 fracture. He also had a pancreatic leak, which was successfully managed nonoperatively. He was ultimately discharged to a rehabilitation facility with drains and T tube in place. During his rehabilitation course, the patient complained of abdominal pain and was brought to the emergency department for evaluation. CT abdomen/ pelvis was performed at that time, which did not reveal any acute pathology. However, the patient was noted in this study to have a duplicated IVC draining his left iliofemoral system, which remained intact (Fig. 1). Since that time, the patient has followed up in the trauma clinic several times. He has had his T tube and Address correspondence and reprint requests to Sarah E. Rollins, M.D., Department of Surgery, ETSU College of Medicine, PO Box 70575, Johnson City, TN 37614. E-mail: serollins@gmail.com.