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A Multicentric Case Series in Colombia ORIGINAL ARTICLE Damage Control Pancreatoduodenectomy for Severe Pancreaticoduodenal Trauma: A Multicentric Case Series in Colombia Luis F Cabrera1, Mauricio Pedraza2, Sebastian Sanchez3, Paula Lopez4, Felipe Bernal5, Jean Pulido6, Patricia Parra7, Carlos Lopez8, Luis M Marroquin9, Juliana Ordoñez10, Gabriel Herrera11 ABSTRACT Introduction: Emergency pancreatoduodenectomy is a procedure that is indicated for the management of severe pancreaticoduodenal trauma after damage control surgery. Objectives: To present our experience of pancreaticoduodenal trauma management with emergency pancreatoduodenectomy and damage control surgery. Materials and methods: Retrospectively recorded data of patients with severe pancreaticoduodenal trauma who underwent a pancreatoduodenectomy and damage control for trauma at a high-volume trauma center. Results: In a period of 6 years, four patients (three men and one woman, median age 17.5 years, range: 16–21 years) with severe pancreaticoduodenal trauma underwent a pancreatoduodenectomy and damage control procedure (gunshot n = 4), and in a second surgical procedure underwent gastrointestinal tract reconstruction. In total, 75% incidence of surgical site infection (SSI) was reported, 25% health- care-associated pneumonia, and 50% postoperative pancreatic fistula (POPF). Intensive care unit (ICU) of 12.25 and hospital stay of 29.5 days mean and no mortality. Conclusion: An emergency pancreatoduodenectomy can be a lifesaving procedure in patients with non-reconstructable duodenopancreatic injuries. Damage control surgery in pancreaticoduodenal trauma is an alternative for management although with high risk of morbidity. Keywords: Abdominal trauma, Advanced trauma life support care, Duodenum, Multiple trauma, Pancreas, Trauma severity indices. RESUMEN Introducción: La pancreatoduodenectomía de emergencia es un procedimiento que está indicado para el tratamiento del trauma duodenal pancreático severo después de la cirugía de control de daños. Objetivos: Presentar nuestra experiencia en el manejo del trauma duodenal pancreático con pancreatoduodenectomía de emergencia y cirugía de control de daños. Materiales y métodos: Datos registrados retrospectivamente de pacientes con traumatismo duodenal pancreático grave que se sometieron a una pancreatoduodenectomía y control de daños por traumatismo en un Centro de Trauma de alto volumen. Resultados: En un período de 6 años, cuatro pacientes (3 hombres y 1 mujer, mediana de edad de 17,5 años, rango 16-21) con trauma duodenal pancreático grave se sometieron a un procedimiento de pancreatoduodenectomía y control de daños (disparo n = 4). En un segundo procedimiento quirúrgico, los pacientes fueron sometidos a reconstrucción del tracto gastrointestinal. Se informaron 75% de incidencia de infección del sitio quirúrgico, 25% de neumonía asociada a la atención médica y 50% de fístula pancreática postoperatoria. Con una estadía promedio en la unidad de cuidados intensivos de 12.25 días, y una estadía hospitalaria promedio de 29.5 días y sin mortalidad. Conclusione: Una pancreatoduodenectomía de emergencia puede ser un procedimiento que salva vidas en pacientes con lesiones duodenopancreáticas no reconstruibles. La cirugía de control de daños en el traumatismo duodenal pancreático es una alternativa para el tratamiento, aunque con un alto riesgo de morbilidad. Palabras clave: Atención de Apoyo Vital Avanzado en Trauma, Duodebi, Índices de Gravedad del Trauma, Páncreas, Trauma abdominal, Trauma múltiple. Panamerican Journal of Trauma, Critical Care & Emergency Surgery (2020): 10.5005/jp-journals-10030-1266 NTRODUCTION I 1Department of Surgery, Hospital Universitario Fundación Santa Severe trauma to the head of the pancreas and duodenum in Fe de Bogotá, Bogotá, Colombia; Department of General Surgery, a hemodynamically unstable patient with associated injuries Universidad El Bosque, Bogotá, Colombia; School of Medicine, is a complex situation to manage and is associated with a poor Universidad de los Andes, Bogotá, Colombia; Department of Surgery, prognosis. In this entity, morbidity and mortality have resisted the Los Cobos Medical Center, Bogotá, Colombia improvements achieved with many other life-threatening injuries, 2,4Department of General Surgery, Universidad El Bosque, Bogotá, with the largest series reporting mortalities 38–75%.1–9 Colombia Usually, these pancreaticoduodenal trauma grades IV and 3Department of General Surgery, Pontificia Universidad Javeriana, V require an emergency pancreatoduodenectomy, an unusual Bogotá, Colombia © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons. org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Complex Management of Severe Pancreaticoduodenal Injuries procedure with great technical difficulty.10–12 There are many technical 5Department of General Surgery, Universidad El Bosque, Bogotá, challenges for resecting and reconstructing complex pancreatic Colombia; Department of Surgery, Los Cobos Medical Center, Bogotá, injuries frequently requiring special surgical skills and expertise. Colombia This surgery is indicated in pancreatic and duodenal injuries with 6School of Medicine, Universidad El Bosque, Bogotá, Colombia a degree greater than III on the scale of the American Association 7,8Department of Surgery, Hospital Simón Bolivar, Bogotá, Colombia 1,8 for the Surgery of Trauma (AAST). Further complicating the care 9Department of Surgery, Hospital Cardiovascular del Niño de is that these patients typically present with significant additional Cundinamarca, Bogotá, Colombia injuries. Operative intervention is frequently complicated by active 10Department of Surgery, Universidad Militar, Bogotá, Colombia intraperitoneal or retroperitoneal hemorrhage, and concomitant 11Department of Surgery, Hospital Universitario Fundación Santa Fe hollow viscus injuries may lead to gross contamination of the de Bogotá, Bogotá, Colombia; School of Medicine, Universidad de los 13 abdominal cavity. Andes, Bogotá, Colombia The outcomes of pancreaticduodenal trauma is determined by Corresponding Author: Mauricio Pedraza, Department of General the grade of injury, extent, and magnitude of the associated hollow Surgery, Universidad El Bosque, Bogotá, Colombia, Phone: +57 and solid organs injuries, presence and type of vascular injuries, 3013709557, e-mail: [email protected] degree of intra-abdominal contamination, develop of coagulopathy, How to cite this article: Cabrera LF, Pedraza M, Sanchez S, et al. Damage presence of hypothermia, amount of blood loss and shock duration, Control Pancreatoduodenectomy for Severe Pancreaticoduodenal time of resuscitation, pancreatic postoperative fistula, type of surgical Trauma: A Multicentric Case Series in Colombia. Panam J Trauma Crit intervention, that could be in one or two stages.14 Care Emerg Surg 2020;9(1):38–44. Early mortality is due to major adjacent organ injuries or Source of support: Nil uncontrolled vascular bleeding from large splanchnic veins and Conflict of interest: None vena cava. Late mortality is generally a consequence of infection or multiple organ failure.10 Several issues regarding the role of a pancreatoduodenectomy time of stay in the ICU, length of hospital stay, re-intervention, and for major pancreatic injuries are unresolved. Therefore, we mortality. want to present our experience in the approach of emergency All patients who had a PD had grade V pancreatic injuries 15 pancreatoduodenectomy in two hospitals in Bogota, Colombia, according to the Organ Injury Scaling of the AAST, postoperative with a review of the literature. complications were classified according to the Clavien–Dindo grading system.16 MATERiaLS AND METHODS Definitions Study Population Shock was defined as a systolic blood pressure less than 90 mm Hg This study design was a multicenter retrospective cohort analysis of measured pre- or intraoperatively. Pancreatic fistula was graded four patients who underwent emergency pancreatoduodenectomy, according to the International Study Group of Pancreatic Fistula 17 and damage control for trauma between January 2012 and January classification scheme. Postoperative pancreatic fistula is defined 2018 in Bogota, Colombia. The study protocol was approved by the as drain output of any measurable volume of fluid on or after ethics committee. postoperative day 3 with an amylase content greater than three 17 The protocol was implemented in accordance with ethical times the serum amylase activity. Infectious complications were guidelines of the “World Medical Association Declaration of defined as a clinical or culture positive for nosocomial infections in 18 Helsinki—Ethical Principles for Medical Research Involving Human accordance with the Society of Critical Care Medicine guidelines. Subjects” adopted by the 18th WMA General Assembly, Helsinki, Postoperative complications recorded as Clavien–Dindo grade III 16 Finland, June 1964, and revised in Tokyo 2004. or greater were regarded as severe. Mortality was defined as any cause of death occurring in hospital
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