Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries

Abstract

Damage control laparotomy and delayed secondary pancreatoduodenectomy is a live-saving procedure in the small cohort of patients who have dire pancreatic and vascular injuries. When used appropriately, the staged resection and reconstruction allows survival in a previously unsalvageable group of patients who have severe physiological derangement.

Clinical update on management of pancreatic trauma

“…Largely, experience stems from institutional series with highvolume trauma related to penetrating mechanisms. 17,52,56,57,59 The OIS scoring system describes the anatomical relation of the injury with a focus on the location (head, body, tail) and the duct (involved, non-involved). This system neglects the overall injury burden to the patient, including the physiological state at presentation, which is usually highly predictive of outcome.…”

“…For details, see description in the main body of the text damage control surgery is warranted as a life-saving procedure for these injured patients. 59,75,76 A 'trauma Whipple' is rarely indicated, and only 47 cases were identified when reviewing the NTDB for the years 2008-2010. 17 Indeed, in the two largest series to date, only 15 Whipple procedures were done for pancreatic trauma in Seattle, Washington over a 15-year period 77 and 19 in Cape Town, South Africa over a 22-year period.…”

The consequences of major visceral vascular injuries on outcome in patients with pancreatic injuries: a case-matched analysis

“…Damage control laparotomy (DCL) was defined as an abbreviated emergency trauma laparotomy that required temporary abdominal closure and secondary definitive surgery. 15 Morbidity was documented as systemic, intra-abdominal or specifically related to the pancreatic injury. Mortality was defined as in-hospital death due to any cause.…”

“…Our general approach to complex pancreatic injuries has been described previously. [5][6][7]10,15 Initial resuscitation was according to Advanced Trauma Life Support (ATLS) guidelines. Rapid preoperative evaluation included relevant physical examination, endotracheal intubation when necessary, insertion of resuscitation lines, selected trauma abdominal and cardiac sonography and chest radiographs.…”

“…PD was restricted to patients who had non-reconstructable injuries due to destruction of the head of the pancreas, duodenum or ampulla (AAST grade 4 and 5) and was done as a primary procedure during the initial operation if the patient was stable or as a secondary staged procedure after the DCL. 7,15 After resection suction drains were routinely placed.…”