Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum

Abstract

Background: This single-centre study evaluated the outcome of a pancreatoduodenectomy for Grade 5 injuries of the pancreas and duodenum.

Methods: Prospectively recorded data of patients who underwent a pancreatoduodenectomy for trauma at a Level I Trauma Centre during a 22-year period were analysed.

Results: Nineteen (17 men and 2 women, median age 28 years, range 14-53 years) out of 426 patients with pancreatic injuries underwent a pancreatoduodenectomy (gunshot n = 12, blunt trauma n = 6 and stab wound n = 1). Nine patients had associated inferior vena cava (IVC) or portal vein (PV) injuries. Five patients had initial damage control procedures and underwent a definitive operation at a median of 15 h (range 11-92) later. Twelve had a pylorus-preserving pancreatoduodenectomy (PPPD) and 7 a standard Whipple. Three patients with APACHE II scores of 15, 18, 18 died post-operatively of multi-organ failure. All 16 survivors had Dindo-Clavien grade I (n = 1), grade II (n = 7), grade IIIa (n = 2), grade IVa (n = 6) post-operative complications. Factors complicating surgery were shock on admission, number of associated injuries, coagulopathy, hypothermia, gross bowel oedema and traumatic pancreatitis.

Conclusions: A pancreatoduodenectomy is a life-saving procedure in a small cohort of stable patients with non-reconstructable pancreatic head injuries. Damage control before a pancreatoduodenectomy will salvage a proportion of the most severely injured patients who have multiple injuries.

Figure 1

Whipple specimen after resection of a grade 5 pancreatoduodenal injury with disruption of the ampulla and devitalization of the duodenum after blunt trauma in an 18-year-old schoolboy