Fools rush in where angels fear to tread: damage control surgery for severe pancreatic trauma

Here is my highlight from the Journal HPB for November which relates to an analysis of damage control surgery for major pancreas trauma. This is a must read paper on the very difficult problem of major pancreas trauma from South Africa.

The pancreas is usually considered to be well protected however, it’s anatomical relationships mean that when the head of the gland is injured there are frequently severe associated injuries to vasculature or important structures such as the bile duct and duodenum. Major trauma to the pancreatic head therefore, represents a life-threatening situation for the patient and a complex management issue for the surgeon.

In this issue of HPB, Krige and colleagues from Cape Town, South Africa present a wealth of experience of pancreatic trauma. The article refers to a cohort of more than 400 pancreatic trauma cases with focus on 19 with the most severe grade 5 injuries. The mechanism of injury included penetrating trauma from gunshot and stab wounds as well as blunt trauma from road traffic accidents. Approaches to management were tailored to the individual patient needs. A number of these cases were associated with major haemorrhage from vena cava or portal vein injuries which required control prior to dealing with pancreatic injury itself.

The concept of damage control surgery originated in South Africa and this series includes a number of patients who had two or more stage procedures after initial damage control of the pancreatic injury. This measured approach seems entirely sensible given the potential difficulties of reconstruction after pancreaticoduodenectomy in an unstable patient. This approach is a good learning point and must have contributed to the excellent survival rate of 84% in these patients at the extreme end of the pancreatic trauma scale.

pancreastrauma

Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum (pages 1043–1049)

Jake E. Krige, Andrew J. Nicol and Pradeep H. Navsaria

Article first published online: 19 MAY 2014 | DOI: 10.1111/hpb.12244

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