The Role of Pancreatoduodenectomy in the Management of Complex Pancreatic Trauma

Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum

“…In this cohort of patients reconstruction is frequently technically difficult as the ducts are non-dilated and the surrounding organs damaged or oedematous which necessitates modification of conventional biliary and pancreatic anastomoses. 1,2,4,11 Unlike previous publications, a novel feature in this study was the ability to do a PPPD in a substantial proportion of injured patients. Importantly, in those patients who, in addition to maximal injuries to the pancreas, also had severe injuries to adjacent vascular, biliary, enteric, colonic or solid organs and had persistent shock, an initial damage control operation was followed by a delayed pancreatoduodenectomy and reconstruction when the patient was stable.…”

“…12,13 However, the mortality rate for a Whipple resection in severely injured and unstable patients is prohibitive, and in this and other series, those who survive also have a high post-operative complication rate. 1,14 When faced with a devitalized head of the pancreas and duodenum, an avulsed ampulla or a near-complete traumatic resection, a surgeon may have no recourse but to proceed and complete the resection provided the patient is haemodynamically stable and the necessary surgical expertise is available. 2,4 McKone has proposed specific indications for a pancreatoduodenectomy for trauma: (i) extensive devitalization of the head of the pancreas and duodenum in whom there is no prospect of a repair; (ii) ductal disruption in the pancreatic head with AAST grade 5 injuries of the duodenum and distal common bile duct; (iii) injury to the ampulla of Vater, with disruption of the main pancreatic duct from the duodenum.…”

“…1,2 Previous reports indicate that outcome is determined by the complexity and site of the pancreatic injury, the number, extent, and magnitude of the associated injuries, the amount of blood loss and duration of shock, the rapidity and efficacy of resuscitation, and the speed and quality of surgical intervention. [2][3][4][5][6][7] Overall morbidity rates for maximal pancreatoduodenal injuries are substantial and mortality is directly proportional to the number of injuries sustained and is highest in the elderly and those who are haemodynamically unstable.…”

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

“…In the small cohort of patients with irretrievable pancreatic head injuries, the only rational surgical option for salvage is a pancreaticoduodenal resection and reconstruction [23]. However, the mortality of an emergency pancreatoduodenectomy in critically injured patients is disproportionately high and exceeds 30 % in collected series [23,24].…”

“…In the small cohort of patients with irretrievable pancreatic head injuries, the only rational surgical option for salvage is a pancreaticoduodenal resection and reconstruction [23]. However, the mortality of an emergency pancreatoduodenectomy in critically injured patients is disproportionately high and exceeds 30 % in collected series [23,24]. The main factor responsible for this high mortality is the number and severity of the associated vascular injuries coupled with inappropriately prolonged surgery in haemodynamically unstable patients [1,2].…”