Managing grade 5 pancreatic injuries—Think smart, act smart, and call in the pancreatic cavalry early

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To the Editor:
We congratulate Dr Ho and her colleagues on their excellent guidelines for the management of pancreatic trauma based on a literature review from 1995 to 2014.1 However, due to a lack of information, the authors provide no recommendation for grade 5 injuries, although these are the very injuries where guidance is most needed. Understandably, the rarity and complexity of these injuries have provided scant robust data. The authors do indicate that both surgical and resuscitation strategies have evolved significantly and include damage control procedures and early balanced resuscitations and stress that the intraoperative and immediate postoperative rate of death is high. Since 2014, several publications have suggested innovative additions and modifications to management and emphasized established principles of care. Three sequential components of care for grade 5 pancreatic head injuries are crucial; the initial assessment and accurate staging, the need and timing of primary or secondary resection, and the technique of reconstruction.2 Fundamental to the management of a complex pancreatic head injury after stabilization and control of collateral damage is the detailed damage assessment by intraoperative evaluation after mobilization, aided by either direct or transpapillary or endoscopic pancreatography, or intraoperative ultrasound when appropriate. After detailed assessment, in a substantial proportion of injuries resection can be avoided. Specific criteria mandate the need for a trauma pancreatoduodenectomy which should be reserved for a select group of hemodynamically stable patients who have complex injuries with a devitalized duodenum or a de facto traumatic avulsion of the ampulla or head of pancreas in whom lesser procedures repair are not feasible or are bound to fail.3 In the cohort of patients who require initial damage control, both the pancreatoduodenectomy and the reconstruction should be delayed until the subsequent definitive operation.4 It is sensible to involve a pancreatic surgeon at an early stage as the technical intricacies both for resection and reconstruction of complex pancreatic injuries require special organ-specific surgical skills and expertise.2
We note that the largest prospective single center series of patients undergoing a pancreatoduodenectomy for complex pancreatic injuries from our trauma center published in 2014 has not been cited.3 More recent data support the increasing use of initial damage-control laparotomy and pancreatoduodenectomy for complex combined pancreaticoduodenal injuries.2,4,5 Factors complicating surgery are well known and include shock on admission, number of associated injuries, coagulopathy, hypothermia, gross bowel edema, and traumatic pancreatitis. Sixteen of the 19 patients in our series survived and, as anticipated, outcome and mortality were related to associated major visceral venous and the number of other organs injured.2,3 Each resection was performed or supervised by an experienced pancreatic surgeon working with the trauma team. These data demonstrated a paradigm shift in the overall management of complex pancreatic injuries and emphasizes that no single operation is appropriate for all pancreatoduodenal injuries.2–5 Operative intervention in each patient should ideally be individualized and surgeons need to have a flexible strategy and should be familiar with the full range of surgical techniques required for repair. Our data strongly support the close collaboration between trauma and pancreatic surgeons in managing complex pancreatic injuries. In our study, all of the pancreatic head resections were done by pancreatic surgeons working in conjunction with trauma surgeons, a team approach which we believe should be the model applied in modern trauma surgery.
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