Management of Pancreatic Injuries
Grade V. Fortunately rarely encountered, these injuries may require pancreaticoduodenectomy. Indications for this procedure generally include massive unreconstructable injury to the head of the pancreas, including the intrapancreatic bile duct and proximal main pancreatic duct, and avulsion of the ampulla of Vater from the duodenum with destruction of the second portion of the duodenum. Although it has been suggested that pancreaticoduodenectomy can be performed with reasonably good outcomes,26 these injuries are usually encounteredwith the patient in poor physiologic condition, so the principles of damage control initially apply.27 Indeed, Seamons et al.28 recently reinforced the concept that pancreatic resection during damage control is ill advised.Once the patient condition improves, the reconstruction is performed. In addition to improved physiologic status, there are tissue changes that facilitate reconstruction. Pancreatogastrostomy reconstruction may be preferable to pancreaticojejunostomy in these circumstances, for physiologic and anatomic reasons.29 One must also be mindful of the potential for complications if stents are used.30
Grade IV and V pancreatic injuries are often combinedwith duodenal injuries. The pyloric exclusion procedure as described by Vaughan et al.31 is preferred. The duodenal injury is repaired and is ‘‘protected’’ by gastric diversion. To accomplish this, a gastrotomy is created along the greater curve of the stomach adjacent to the pylorus, the pylorus is oversewn from the inside with nonabsorbable monofilament suture, and a gastrojejunostomy is created with a loop of jejunum. A long jejunal limb should be used to prevent reflux of enteric contents to the duodenum. If a fistula develops, it is a functional end duodenal fistula, which is usually easier to manage than a higher output lateral fistula. A jejunostomy is used in this setting to ensure a route for enteral nutrition. Even in the setting of an end fistula, the patient will often tolerate an oral diet after 10 days to 14 days. The pylorus usually opens within 6 weeks to 12 weeks; therefore vagotomy is not usually performed.