Pancreatic injury in damage control laparotomies: Is pancreatic resection safe during the initial laparotomy?
OBJECTIVE
While damage control (DC) techniques such as the rapid control of exsanguinating haemorrhage and gastrointestinal contamination have improved survival in severely injured patients, the optimal pancreatic injury management strategy in these critically injured patients requiring DC is uncertain. We sought to characterise pancreatic injury patterns and outcomes to better determine optimal initial operative management in the DC population.


METHODS
A two-centre, retrospective review of all patients who sustained pancreatic injury requiring DC in two urban trauma centres during 1997-2004 revealed 42 patients. Demographics and clinical characteristics were analysed. Study groups based on operative management (pack+/-drain vs. resection) were compared with respect to clinical characteristics and hospital outcomes.


RESULTS
The 42 patients analysed were primarily young (32.8+/-16.2 years) males (38/42, 90.5%) who suffered penetrating (30/42, 71.5%) injuries of the pancreas and other abdominal organs (41/42, 97.6%). Of the 12 patients who underwent an initial pancreatic resection (11 distal pancreatectomies, 1 pancreaticoduodenectomy), all distal pancreatectomies were performed in entirety during the initial laparotomy while pancreaticoduodenectomy reconstruction was delayed until subsequent laparotomy. Comparing the pack+/-drain and resection groups, no difference in mechanism, vascular injury, shock, ISS, or complications was revealed. Mortality was substantial (packing only, 70%; packing with drainage, 25%, distal pancreatectomy, 55%, pancreaticoduodenectomy, 0%) in the study population.


CONCLUSIONS
The presence of shock or major vascular injury dictates the extent of pancreatic operative intervention. While pancreatic resection may be required in selected damage control patients, packing with pancreatic drainage effectively controls both haemorrhage and abdominal contamination in patients with life-threatening physiological parameters and may lead to improved survival. Increased mortality rates in patients who were packed without drainage suggest that packing without drainage is ineffective and should be abandoned.
Seamon
Mark J
MJ
Division of Trauma and Surgical Critical Care, Department of Surgery, Temple University School of Medicine, Philadelphia, PA, United States. mark.seamon@tuhs.temple.edu
Kim
Patrick K
PK
Stawicki
S Peter
SP
Dabrowski
G Paul
GP
Goldberg
Amy J
AJ
Reilly
Patrick M
PM
Schwab
C William
CW
D000293:Adolescent; D000328:Adult; D016009:Chi-Square Distribution; D004322:Drainage; D005260:Female; D006489:Hemostatic Techniques; D006801:Humans; D007813:Laparotomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000293:injuries* / Q000601:surgery*; D010180:Pancreatectomy / Q000379:methods; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000601:surgery*; D014948:Wounds, Gunshot / Q000601:surgery; D014949:Wounds, Nonpenetrating / Q000601:surgery; D014951:Wounds, Stab / Q000601:surgery; D055815:Young Adult