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

Abstract

This single-centre study evaluated the efficacy of damage control surgery and delayed pancreatoduodenectomy and reconstruction in patients who had combined severe pancreatic head and visceral venous injuries. Prospectively recorded data of patients who underwent an initial damage control laparotomy and a subsequent pancreatoduodenectomy for severe pancreatic injuries were evaluated to assess optimal operative sequencing. During the 20-year study period, 312 patients were treated for pancreatic injuries of whom 14 underwent a pancreatoduodenectomy. Six (five men, one woman, median age 20, range 16-39years) of the 14 patients were in extremis with exsanguinating venous bleeding and non-reconstructable AAST grade 5 pancreatoduodenal injuries and underwent a damage control laparotomy followed by delayed pancreatoduodenectomy and reconstruction when stable. During the initial DCS, the blood loss compared to the subsequent laparotomy and definitive procedure was 5456ml, range 2318-7665 vs 1250ml, range 850-3600ml (p<0.01). The mean total fluid administered in the operating room was 11,150ml, range 8450-13,320 vs 6850ml, range 3350-9020ml (p<0.01). The mean operating room time was 113min, range 90-140 vs 335min, range 260-395min (p<0.01). During the second laparotomy five patients had a pylorus-preserving pancreatoduodenectomy and one a standard Whipple resection. Four of the six patients survived. Two patients died in hospital, one of MOF and coagulopathy and the other of intra-abdominal sepsis and multi-organ failure. Median duration of intensive care was 6days, (range 1-20days) and median duration of hospital stay was 29days, (range 1-94days). 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.