THE TRAUMA WHIPPLE: A RARE BUT SURVIVABLE PROCEDURE

Objectives: In trauma, pancreaticodoudenectomy (PD), a Whipple procedure, is rare and strictly reserved for destructive pancreaticoduodenal injuries not amenable to conservative operative management. The objective of this study is to review our institutional experience with PD in trauma.

Methods: This was a retrospective review over eleven years (January 2010 to December 2021) at a busy urban Level I Trauma Center. All trauma patients identified with AAST-OIS Grades IV-V pancreatic and duodenal injuries in the operating room were included. Patient demographics, injury characteristics, and outcome measures were studied.

Results: Nineteen patients met study criteria. The median age was 31±12 years (range, 15 – 58 years), 84% were male, and 46% black. The mean ISS was 27±8.49 and AIS-abdomen was 5. Most injuries resulted from penetrating mechanisms (95%); all of which were gunshot wounds. Mean admission systolic blood pressure was 94.1±43 mmHg, pulse rate 97.6±42 bpm, and base deficit -8.7±7.8. There were 4 grade IV pancreatic injuries, 13 grade V pancreatic injuries and 2 grade IV-V duodenal injuries. There were 7 intra-operative deaths, 3 of which arrived to the trauma center pulseless necessitating resuscitative thoracotomy. The most common concomitant injuries included: a major vascular injury (79%), high-grade liver injury (79%), and colon injury (74%). Nine patients required damage-control surgery (75%) with staged PD reconstruction at a mean of 44.8 hours. Utilization of massive transfusion (84%) for resuscitation required a mean of 24 units packed red blood cells, 17 units fresh frozen plasma, 1 pack of platelets and cryoprecipitate. The estimated mean blood loss of 3734±1781 ml. The mean ICU LOS was 28±16.5 days with 14.8±13.3 ventilator days and a total hospital LOS of 38.7±28.3 days. Overall survival was 63%.

Conclusion: Complex pancreaticoduodenal injuries requiring PD are rare. In such patients, hemorrhage was the leading cause of death in the first 24 hours. The majority of survivors underwent damage control surgery and staged PD.