Surgical Management and Outcomes of Combined Pancreaticoduodenal Injuries: Analysis of 75 Consecutive Cases

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• 作者：Jake E. Krige ; MB ChB ; MSc ; FACS ; FRCS (Ed) ; FCS (SA)^a ; ^c ; ^{jej.krige@uct.ac.za" class="auth_mail" title="E-mail the corresponding author} ; Urda K. Kotze ; RN ; BA Cur^a ; ^c ; Mashiko Setshedi ; MB ChB ; FCP (SA) ; PhD^b ; Andrew J. Nicol ; MB ChB ; FCS (SA) ; PhD^a ; ^d ; Pradeep H. Navsaria ; MB ChB ; FACS ; FCS (SA) ; MMed^a ; ^d
• 关键词：AAST ; American Association for the Surgery of Trauma ; CPDI ; combined pancreaticoduodenal injury ; DCL ; damage-control laparotomy ; RTS ; Revised Trauma Score
• 刊名：Journal of the American College of Surgeons
• 出版年：2016
• 出版时间：May 2016
• 年：2016
• 卷：222
• 期：5
• 页码：737-749
• 全文大小：443 K

文摘

Combined pancreaticoduodenal injuries (CPDI) are complex and result in significant morbidity and mortality. Survival in CPDI after initial damage-control laparotomy (DCL) and pancreaticoduodenectomy was evaluated in a large cohort treated in a Level I trauma center. We hypothesized that bivariate analyses would accurately identify factors influencing morbidity and mortality.

Study Design

The records from a prospective database of 453 consecutive patients treated for pancreatic injuries between January 1990 and April 2015 were reviewed to identify those with CPDI. Primary and secondary end points assessed were death and morbidity.

Results

Seventy-five patients (69 men, median age 27 years, range 14 to 56 years) with CPDI, underwent 161 operations (range 1 to 9 operations). Twenty-nine patients with complex CPDI underwent a DCL and 46 had definitive treatment during the initial operation. Nineteen had a pancreaticoduodenectomy, either during the initial operation (n = 13) or after the DCL (n = 6). Postoperative complications occurred in 63 (84%) patients. Twenty-one (28%) patients died, including 15 (43%) of 35 patients with associated vascular injuries. Sixteen (84%) of the 19 patients who had a pancreaticoduodenectomy survived. Significantly more complications related to bleeding, disseminated intravascular coagulation, and hypovolemic shock occurred in those patients who eventually died and significantly more abdominal sepsis and fistulas occurred in patients who survived. Mortality was related to associated vascular injuries overall (p < 0.01), major visceral venous injuries (p < 0.011), and the combination of vascular plus the total number of associated organs injured (p < 0.046).

Conclusions

Despite using DCL in CPDIs, morbidity (84%) and mortality (28%) remain substantial. Careful selection of patients undergoing pancreaticoduodenectomy resulted in 84% survival. Associated vascular injuries, major visceral venous injuries, and combined vascular and associated organs injured influenced outcomes and mortality.