Resection and reconstruction in high-grade pancreatic head injuries

Abstract

This study by Chui et al adds further important evidence in the treatment of high-grade pancreatic injuries and endorses the concept of the model of pancreatic trauma care designed to optimize treatment, minimize morbidity and enhance survival in patients with complex pancreatic injuries. Although the authors have demonstrated favorable outcomes based on their limited experience of 5 patients who underwent a pancreaticoduodenectomy (PD), including 2 patients who were “unstable” and did not have damage control surgery (DCS), we would caution against the general recommendations promoting index PD without DCS in “unstable” grade 5 pancreatic head injuries.

Key Words: Pancreas, Injury, Surgery, Pancreaticoduodenectomy

Core Tip: This study by Chui et al adds further important evidence in the treatment of high-grade pancreatic injuries and endorses the concept of the model of pancreatic trauma care designed to optimize treatment, minimize morbidity and enhance survival in patients with complex pancreatic injuries.

TO THE EDITOR

We read with interest the article by Chui et al[1] reporting their 20-year experience in Sydney with 14 patients who had undergone surgery for high-grade pancreatic injuries. The authors are to be congratulated on their excellent results with a 92.9% survival rate in a cohort of pancreatic injuries with predominantly blunt trauma. The authors report that 7 patients in their series had grade III and 7 had either grade IV or V pancreatic injuries; 9 underwent a distal pancreatectomy, and 5 required a pancreaticoduodenectomy (PD). Three patients were hemodynamically unstable at presentation, two of whom underwent damage control laparotomies, followed by a distal pancreatectomy[1]. Notably, all 5 patients who underwent a PD had the operation as the primary index procedure, despite the fact that two were “unstable” and had received 2 and 7 units pRBC pre-operatively[1].

There is universal recognition that grade IV and V pancreatic injuries are notoriously difficult to handle and challenge even the most experienced surgeons in well-resourced high-volume trauma referral centers[2,3]. In view of their impressive results, it would be important for the authors to clarify their decision to perform a primary PD in a “unstable” patient as their management deviates from accepted practice and norms. The crux of our concern is that the prevailing surgical sentiment recommends that initial abbreviated damage control surgery (DCS) is preferable and more expedient under these circumstances.

In our experience with 19 pancreaticoduodenectomies for trauma we found that DCS was necessary in 5 patients in whom complex pancreatic injuries were aggravated by severe associated injuries and major blood loss, acidosis, coagulopathy, hypothermia and persisting hypotension in spite of vigorous resuscitation[4]. These five patients had a median Apache II score of 11 and received a median of 10 u (range 8–12) pRBC[4]. Two factors may however reflect institutional bias. Firstly, in a geographically large country such as South Africa where distances are vast, the “tyranny of distance” impacts on decisions and trauma management. Under these circumstances DCS in a small rural hospital becomes imperative in a shocked patient to control bleeding and contamination before a 600 mile Air Ambulance flight to a Level One Trauma Centre for definitive care. Secondly, despite optimal resources and involvement of an experienced pancreatic surgical team, patient physiology may be depleted after staunching massive blood loss and multiple transfusions, especially after major venous and other essential organ repairs. To then embark on a PD after stabilizing a patient in extremis is counterintuitive to surgical principles and practice. This situation may of course not pertain in Sydney where spatial and transport logistics may differ from ours. In addition, their description and definition of “unstable” may be temporal and measured prior to effective pre-operative resuscitation and surgery and may not encompass or include shocked or exsanguinating patients. A patient who required two units pRBC pre-operatively would not be classified as “unstable” after resuscitation in our series.

Severe injuries involving the pancreas head continue to be a considerable cause of morbidity and mortality[2,4]. We agree with the authors’ assessment that an individualized and multidisciplinary approach using modern resuscitation and expert consultation when needed is the most prudent treatment model for complicated high grade V pancreatic patients. We have previously recommended that our own facility practice with close collegial cooperation between trauma and HPB surgeons in complex injuries with a low threshold to involve an experienced HPB surgical team day or night should be central in the modern pancreatic trauma management paradigm[5]. Familiarity with and competence in pancreatic head surgery bring essential special organ-specific surgical skills and expertise, including IOUS, endoscopic proficiencies, both for the experienced operative assessment and the technical dexterities required for resection and reconstruction of complex pancreatic injuries[3,5].

We have grappled with the problem of deficiencies in scoring models when comparing pancreatic injury data between institutions in order to make meaningful assessments and accurate interpretations for the benefit of patient management and improved outcome, i.e., comparing like with like in pancreaticodudenectomies for trauma. We developed and validated a novel pancreatic injury mortality score (PIMS), calculated from five variables identified from stepwise logistic regression analyses (age > 55, shock on admission, associated vascular injury, number of associated injuries and AAST pancreatic injury scale) to identify patients at greatest risk of in-hospital mortality after a major pancreatic injury[6]. Cut-off scores were used to generate three risk groups and the rate of mortality within low (PIMS 0-4), medium (PIMS 5-9), and high risk (PIMS 10-20) groups. PIMS is simple, quick and easily understandable, increases clinical risk prediction for patients with complex pancreatic and can be used as a benchmark for survival and for comparative institutional and international studies[6]. Validating this score in trauma patients undergoing PD in Sydney may add clinically valuable information in these challenging and high-risk patients.

This study by Chui et al[1] adds further important evidence in the treatment of high-grade pancreatic injuries and endorses the concept of the model of pancreatic trauma care designed to optimize treatment, minimize morbidity and enhance survival in patients with complex pancreatic injuries. Although the authors have demonstrated favourable outcomes based on their limited experience of 5 patients who underwent a PD, including 2 patients who were unstable and did not have DCS, we would still caution against the general recommendations promoting index PD and limiting DCS in “unstable” Grade 5 pancreatic head injuries.