Damage Control Pancreatoduodenectomy for Severe Pancreaticoduodenal Trauma: A Multicentric Case Series in Colombia

INTRODUCTION

Severe trauma to the head of the pancreas and duodenum in a hemodynamically unstable patient with associated injuries is a complex situation to manage and is associated with a poor prognosis. In this entity, morbidity and mortality have resisted the improvements achieved with many other life-threatening injuries, with the largest series reporting mortalities 38–75%.^1–9

Usually, these pancreaticoduodenal trauma grades IV and V require an emergency pancreatoduodenectomy, an unusual procedure with great technical difficulty.^10–12 There are many technical challenges for resecting and reconstructing complex pancreatic injuries frequently requiring special surgical skills and expertise.

This surgery is indicated in pancreatic and duodenal injuries with a degree greater than III on the scale of the American Association for the Surgery of Trauma (AAST).^1,8 Further complicating the care is that these patients typically present with significant additional injuries. Operative intervention is frequently complicated by active intraperitoneal or retroperitoneal hemorrhage, and concomitant hollow viscus injuries may lead to gross contamination of the abdominal cavity.¹³

The outcomes of pancreaticduodenal trauma is determined by the grade of injury, extent, and magnitude of the associated hollow and solid organs injuries, presence and type of vascular injuries, degree of intra-abdominal contamination, develop of coagulopathy, presence of hypothermia, amount of blood loss and shock duration, time of resuscitation, pancreatic postoperative fistula, type of surgical intervention, that could be in one or two stages.¹⁴

Early mortality is due to major adjacent organ injuries or uncontrolled vascular bleeding from large splanchnic veins and vena cava. Late mortality is generally a consequence of infection or multiple organ failure.¹⁰

Several issues regarding the role of a pancreatoduodenectomy for major pancreatic injuries are unresolved. Therefore, we want to present our experience in the approach of emergency pancreatoduodenectomy in two hospitals in Bogota, Colombia, with a review of the literature.

MATERIALS AND METHODS

RESULTS

During the period from January 2012 to January 2018, 234 patients [210 (90%) men, 24 (10%) women, median age 22 years (range: 13–43 years)] had confirmed pancreatic injuries. Sixty-five injuries (28%) were caused by blunt trauma, 33 (14%) were caused by motor vehicle accidents, 21 (9%) were assaults, 11 (5%) were others, 126 (54%) were gunshot wounds, and 43 (18%) were stab wounds.

Of these, four (1.7%) patients had AAST grade V injuries involving the head of the pancreas and duodenum underwent damage control surgery in the first surgical time and then pancreatoduodenectomy with gastrointestinal reconstruction after physiological resuscitation in the ICU in a second time.

All patients had penetrating injuries due to low-velocity gunshot wounds. All patients were in cardiovascular shock on admission to hospital in spite of volume resuscitation by paramedical staff while in transit. On admission to the Trauma Unit, patients’ median recorded systolic blood pressure was 88 mm Hg (range: 60–116 mm Hg) and median pulse rate was 100/minute (range: 99–102/minute).

From the four patients with grades IV and V pancreatoduodenal trauma, 25% were women and 75% men, median age 17.5 years (range: 16–21 years). The lesion in all the cases was secondary to penetrating abdominal trauma by firearm projectile, resulting in 100% of the lesions with duodenal trauma grade V on the scale of AAST, with an average ISS of 39.5 points, with associated vascular trauma in all the cases.

In total, 75% presented lesion of the portal–spleen–mesenteric system in any of its ramifications, and a 25% had a lesion of the inferior vena cava. Regarding associated organ trauma, 75% presented hepatic trauma grades III to IV and 25% grade IV splenic trauma on the AAST scale. In total, 75% of the emergency pancreatoduodenectomy performed were made without preservation of the pylorus Kausch–Whipple technique, and only 25% were performed with preservation of the pylorus, Traverso–Longmire technique, due to the traumatic compromise of the pyloric tissue. The second stage of the surgery, 48–72 hours later, was performed always by the same general surgeon, because in our institution, there was lack of hepato-bilio pancreatic surgeons and no availability to transport the patient to other center. The reconstruction of the gastrointestinal tract in the second surgical time was performed in 50% with a Roux-en-Y and in 50% with a single intestinal loop, Imanaga technique.

The pancreaticojejunostomy was carried out in 25% with Blumgart technique (Fig. 1), in 50% telescoped technique, and in 25% duct occlusion technique (Fig. 2). It was managed with duct occlusion due to the minimal pancreatic remnant residual. With an average of surgical time in both stages of 430 minutes. Surgical average time in both stages of 430 minutes. Presurgical bleeding was of 1,300 cc and intraoperative bleeding of 1,825 cc approximately. All patients required blood products transfusion with an average of 5.5 units of red blood cell (RBC) and an average of 8.75 units of fresh frozen plasma (FFP). All the patients presented postoperative complications, 50% developed SSIs, 25% health-care-associated pneumonia, and 50% developed a POPF, of which one was type I, resolving only with medical management (antibiotic, total parenteral nutrition (TPN), and octreotide) and one type II, which required percutaneous drainage associated with medical management. Both POPFs resolve with total parenteral nutrition plus somatostatin analogs during the hospital stay of the patients. None of the patients required surgical re-intervention or endoscopic management.

No patient required surgical re-intervention. ICU stay of 12.25 days, hospital stay of 29.5 days mean. There were no mortalities. In Table 1, we present the demographic variables of the patients.

DISCUSSION

Traumatic destruction of the pancreaticoduodenal complex is a rare but life-threatening condition, occurs in less than 1–2% of the patients with blunt abdominal trauma²⁰ vs 10–30% penetrating abdominal trauma; spleen and liver are the most frequently injured organs reported on the literature in abdominal trauma.^8,21

Despite aggressive surgical intervention, even at high-volume trauma centers, patients still experience a high rate of complications, long ICU stays, and high overall mortality.¹³ Outcomes are determined primarily by the cause and the grade of the injuries, and number and severity of associated injuries and secondarily by complication related to the surgical and medical procedures; this also implies the need of emergency pancreatoduodenectomy in trauma, as seen in our case series.^22–26

This procedure was performed according to the indications described by McKone which are (I) extensive devitalization of the head of the pancreas and of the duodenum that cannot be repaired, (II) classification AAST grade V of pancreaticoduodenal trauma, and (III) damage to the ampulla of Vater with interruption of the main pancreatic duct.¹⁰

Van der Wilden et al., present simplified criteria for deferring surgery in order to decrease the high rates of mortality in this complex type of patients using, damage control principles (arrest hemorrhage, temporary control contamination, restore physiological balance), consist in identify massive non-reconstructable injuries involving pancreas, duodenum, common bile duct, or destruction of the ampulla of Vater are evident.²⁷.

Mortality of this type of lesions ranges between 9% and 34% and increases significantly when pancreatic compromise is related to injury of adjacent organs.^24,28

There is a close correlation between mortality, associated injuries, and the number of intra-abdominal organs injured when compared with survivors,²⁰ the most affected liver, colon, jejunum, duodenum, and ileum. As evidenced in our case series, liver injury is frequent and occurred in 75% and as well as spleen injury in 25% of cases without any mortality. In accordance with other series, most early deaths were due to associated non-controlled vascular injuries.²⁰ We believe that two-stage management with initial damage control and resection surgery (pancreatoduodenectomy) with subsequent physiological resuscitation in the ICU and a second surgical event to complete the gastrointestinal tract reconstruction is the ideal strategy for the management of this type of patients. Late deaths are related to sepsis, shock, or multiorgan failure,²⁰ so close postoperative observation in ICU is mandatory.

Emergency pancreatoduodenectomy in trauma is a surgical challenge for the surgeon as the patient is in a state of severe shock with multiple associated injuries, severe tissue edema, and a normal caliber pancreatic and bile duct. Nevertheless, in order to reduce early mortality, bleeding control and management of porto–spleen–mesenteric injuries is vital, as seen in our series all cases had associated vascular injury, of which 75% presented with an injury to the porto–spleen–mesenteric system and 25% inferior vena cava lesions.^6–8,10

The current concept of damage control surgery has been increasingly accepted, and there is consensus that patients who remain unstable due to persistent or unmanageable bleeding hypothermia, acidosis, or coagulopathy should undergo a damage control procedure with abdominal packing and subsequent re-exploration. This allows hemorrhage control, enteric and pancreatic leakage control, as well as biliary disruption management, as it was carried out in our case series.^{20,22,29–31} Although damage control surgery has improved survival rates, mortality remains high reported at 31%.²⁰

When ampulla of Vater is identified, it is useful to catheterize it with a 5-Fr tube to perform a retrograde cholangiopancreatography in order to rule out leaks and establish if a pancreatic, duodenal, or pancreaticoduodenal resection is required; this procedure can be done by preserving or resecting the pylorus, before terminating the first surgical time.^32,33

In the second surgical time, the definitive surgery of digestive tract reconstruction is carried out. In our study, reconstruction was accomplished in 50% of the cases with a Roux-en-Y and in 50% a single intestinal loop. The pancreaticojejunostomy was carried out in 25% of the cases with a Blumgart technique (Fig. 1), in 50% telescoped technique (Fig. 2), and in 25% duct occlusion technique due to the minimal pancreatic remnant residual as described by Asensio et al.^1,3,34 However, other factors that must be taken into account to make these decisions are the patient’s hemodynamic status, presence of active bleeding, acid–base status, hypothermia, and presence of coagulopathy; in order to establishing whether or not the patient is a candidate to a primary repair or if it requires an initial damage control, as was done in our series of patients.^{10,22,34–39}

When facing minor pancreaticoduodenal injuries, the therapeutic arsenal available to the surgeon includes different procedures and techniques that allow an approximation to this entity, such as primary repair, resection, primary anastomosis, jejunal patch, pyloric exclusion, and duodenal diverticulization; however, facing severe injuries such as those presented in our study, an emergency pancreatoduodenectomy should be carried out.^40–45

Krige et al. also suggest that the best method of dealing with the divided pancreatic duct and resection margin after distal pancreatectomy for trauma is unresolved, for that reason that group proposes ligation of the pancreatic duct at the transection margin with a transfixing suture and closure of the distal pancreatic resection margin with interrupted absorbable suture to achieve adequate hemostasis and minimize fistula formation.²⁰

Postoperative pancreatic fistula remains the main source of major morbidity and mortality after pancreatic resection, affecting between 13% and 41% of patients. Postoperative pancreatic fistula is associated with morbid sequelae including intra-abdominal sepsis and hemorrhage. All patients in this study present common risk factors most consistently shown to predict POPF after PD including soft gland, non-pancreatic cancer non-chronic pancreatitis pathology, small pancreatic duct diameter (%3C;3 mm), and high intraoperative blood loss (%3E;1000 mL).^9,48

Internal stents do not seem to significantly reduce the rates of POPF, with some studies demonstrating an increase in the rate of this complication especially in high-risk pancreas.^46–49 Stents may also be externalized through the abdominal wall to drain extracorporeally. A Cochrane review evaluating three randomized controlled trials comparing internal vs external stents failed to show superiority of one form of stent over the other in terms of POPF reduction.^9,47,48 External stents have been associated with a significantly longer length of hospital stay than internal stents, likely due to complications of the outpatient management of such a prosthesis.^9,13

Over the last decade, multiple type of resection and closure techniques have been described and evaluated for the pancreatic remnant during elective surgery in order to minimize complications such as pancreatic fistula;⁴⁶ nevertheless, none have reproducible results to reduce fistula rates in a meaningful way or statistical significance.²⁰

Cogbill⁵⁰ and Fitzgibbons⁴⁷ report a significant difference in pancreatic leak rates in trauma patient whose pancreatic stumps were either sutured or stapled after distal pancreatectomy.

Knaebel et al.⁴⁸ in a systematic review and meta-analysis reported a cumulative fistula rate of 32% after elective resection and found no significant relationship between the pancreatic remnant closure technique and the pancreatic leak rate.

In our case series, all patients were taken to emergency pancreatoduodenectomy in two stages. In total, 75% of the emergency pancreatoduodenectomy performed were made without preservation of the pylorus, Kausch–Whipple technique, and only 25% were performed with preservation of the pylorus, Traverso–Longmire technique, due to the traumatic involvement of the first portion of the duodenum and the pylorus.¹⁰ However, if there was any concern regarding a conventional Whipple technique or pancreatoduodenectomy with preservation of the pylorus with the Traverso–Longmire technique, it is important to consider the degree of traumatic tissue involvement to establish if the pylorus can be preserved. It is important to keep in mind that operative times, intraoperative bleeding, the need for transfusion, and mortality do not statistically differ between both approaches. There is a major difference in the incidence of delayed gastric emptying, which is more frequent in pancreatoduodenectomy with pylorus preservation, which results in a longer hospital stay due to the delayed oral intake, although in the long-term, the gastrointestinal physiology is better preserved with the Traverso–Longmire technique.^35,42,44,51

The reported incidence of overall complications following distal pancreatic resection for trauma ranges from 30 to 60% and is mainly the result of severe trauma with higher AAST grades, associated injuries, diagnostic delay exceeding 24 hours, and inadequate or inappropriate initial treatment.⁵²

The most frequent complications of these types of injuries are massive bleeding with the need for blood products transfusion as in our series due to pancreaticoduodenal and associated injuries; all patients required transfusion of blood products with an average of 5.5 units of RBC and 8.75 units of FFP. Next is POPF and intra-abdominal abscesses which occur in up to 90% of patients, as evidenced by the total of the series reported with 50% of SSI grades III and II, 25% health-care-associated pneumonia, and 50% developed POPF, of which one was type I and one type II.^2,3 Pancreatic leaks remain the Achilles’ heel of pancreatic resection, as reported by Krige et al.^20,52 The reported incidence of pancreatic fistula after distal pancreatectomy for trauma varies widely ranging from 8 to 69%.^20,50,52,53 In the present series, endoscopic and clinical follow-up management was used in all patients and included intraoperatively placed drains and additional percutaneous drains when necessary. Sharpe et al.,⁵⁴ Subramanian et al.,⁵⁵ and Ahmed et al.⁵⁶ present in their experience with traumatic pancreatic fistula close spontaneously within 8 weeks of conservative management.

No randomized controlled studies have been reported comparing initial damage control surgery with definitive treatment in a single surgical intervention.³⁶ However, the evidence taken from case series suggests that in patients with pancreaticoduodenal trauma, in extremis, two-stage surgery reduces mortality, as evidenced in our series of cases.^10,27

CONCLUSION

Emergency PD is a lifesaving operation in the context of complex pancreaticoduodenal injuries that can be treated by general and trauma surgeons with acceptable results. Damage control approach is the best options for this in extremis patients, two-stage surgery plus physiologic resuscitation in the ICU.

HIGHLIGHTS

• Pancreaticoduodenal injuries are an uncommon but important source of morbidity and mortality in the trauma patient.
• Surgical management of complex pancreatic and duodenal injuries is uncommon traumatic event that is associated with high injury severity, but survival occurs in most scenarios.
• Damage control with two-stage approach may decrease morbidity and mortality of patients with severe pancreaticoduodenal trauma.

ETHICAL APPROVAL

Approval from the institutional review board was not required for this study.

HUMAN AND ANIMAL RIGHTS

This article does not contain any studies with human participants or animals performed by any of the authors.

INFORMED CONSENT

For this retrospective review, formal consent is not required.

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