Management of Pancreaticoduodenal Injuries

Abstract

The nature of the pancreatic or duodenal injury itself influences mortality, and is co-dependent on the presence of multiple other injuries, which account for most of the early mortality. Intra-abdominal sepsis leading to multiple organ failure accounts for most of the late deaths, indicating the importance of early haemodynamic stabilization, adequate debridement of devitalized tissue and wide drainage. Most duodenal injuries can be adequately managed with primary repair or resection and anastomosis. The presence of a pancreatic injury certainly increases the likelihood of an anastomic leak from a duodenal repair. With a significant associated pancreatic injury a more conservative initial approach to the duodenal injury may be more appropriate. Pancreatic injuries should be treated by debridement and simple drainage unless there is clinically obvious duct involvement. For distal injuries with duct involvement, a distal pancreatectomy is indicated. In injuries to the pancreatic head with clinical duct involvement, complex procedures such as pancreaticoduodenectomy should not be performed in the unstable patient with multiple injuries. Debridement and wide external drainage may be implemented and the resulting fistula dealt with at a later operation, if necessary. Large, complex, combined pancreaticoduodenal injuries may require temporary duodenal ligation or a pancreaticoduodenectomy and subsequent reconstruction.

Two-stage pancreatic head resection after previous damage control surgery in trauma: two rare case reports

“…Although this could be considered a late timing since it might correspond to a high peritoneal inflammatory reaction after a biliary peritonitis, it has been reported that in abdominal sepsis caused by secondary peritonitis, the acute phase proteins synthesis stimulated by cytokines recover to normal values only after day 12 of the post-operative period [31]. The fact that, in both cases, there were no inaccessible exsanguinant lesions involving both the retropancreatic portal nor the superior mesenteric vein, allowed this 15-day delay between the two stages of pancreatoduodenectomy; under those circumstances, that period would have been considered excessive [32]. Moreover, there is no recommendation in literature concerning the timing of the definitive procedure.…”

Pancreaticoduodenal arterial hemorrhage following blunt abdominal trauma treated with transcatheter arterial embolization

“…Pancreaticoduodenal trauma is rare but has a significant morbidity (36%–60%) and mortality (18%–23%). [4] The outcome depends on early diagnosis, which is essentially based on a high index of suspicion. Management of pancreaticoduodenal trauma and isolated PDAH is problematic due to the complex anatomical relations of the duodenum, pancreas, biliary tract, and major vessels, and difficulties in the diagnosis and determination of the treatment strategies.…”

“…However, surgical treatment is associated with significant morbidity because of surgery-related complications. [4] Therefore, in the case of isolated PDAH without any major organ or intestinal injury, TAE should be considered as the first treatment approach. However, TAE for the pancreaticoduodenal artery (PDA) is technically challenging and sometimes impossible as it is difficult to predict the origin and to localize the artery on angiography and embolize the involved artery completely due to the abundant vascular supply and multiple potential collateral channels.…”

Traumatic pancreatic transection - Case reports

“…The clinical triad of upper abdominal pain, leukocytosis and raised amylase may not always be evident during the first 24 hours or even later in pancreaticoduodenal injuries 2 . After initial investigation following general principles of Advanced trauma life support (ATLS), patients should undergo FAST scan and CECT although both of these tests have low sensitivity of 40% to 50% for pancreatic injury 4,5 . In such cases, CECT abdomen may show hard signs such as parenchymal lacerations and soft signs like peripancreatic fluid.…”