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Pancreatic injury in damage control

laparotomies: Is pancreatic resection safe
during the initial laparotomy?
ARTICLE in INJURY JANUARY 2009
Impact Factor: 2.14 DOI: 10.1016/j.injury.2008.08.010 Source: PubMed

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Injury, Int. J. Care Injured 40 (2009) 6165

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Pancreatic injury in damage control laparotomies: Is pancreatic resection safe

during the initial laparotomy?
Mark J. Seamon a,*, Patrick K. Kim b, S. Peter Stawicki c, G. Paul Dabrowski d, Amy J. Goldberg a,
Patrick M. Reilly b, C. William Schwab b
a

Division of Trauma and Surgical Critical Care, Department of Surgery, Temple University School of Medicine, Philadelphia, PA, United States
Division of Traumatology and Surgical Critical Care, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
Division of Critical Care, Trauma, and Burn, Department of Surgery, The Ohio State University Medical Center, Columbus, OH, United States
d
Trauma Program, Reading Hospital and Medical Center, Reading, PA, United States
b
c

A R T I C L E I N F O

A B S T R A C T

Article history:
Accepted 19 August 2008

Objectives: While damage control (DC) techniques such as the rapid control of exsanguinating
haemorrhage and gastrointestinal contamination have improved survival in severely injured patients,
the optimal pancreatic injury management strategy in these critically injured patients requiring DC is
uncertain. We sought to characterise pancreatic injury patterns and outcomes to better determine
optimal initial operative management in the DC population.
Materials and methods: A two-centre, retrospective review of all patients who sustained pancreatic injury
requiring DC in two urban trauma centres during 19972004 revealed 42 patients. Demographics and
clinical characteristics were analysed. Study groups based on operative management (pack  drain vs.
resection) were compared with respect to clinical characteristics and hospital outcomes.
Results: The 42 patients analysed were primarily young (32.8  16.2 years) males (38/42, 90.5%) who
suffered penetrating (30/42, 71.5%) injuries of the pancreas and other abdominal organs (41/42, 97.6%). Of the
12 patients who underwent an initial pancreatic resection (11 distal pancreatectomies, 1 pancreaticoduodenectomy), all distal pancreatectomies were performed in entirety during the initial laparotomy while
pancreaticoduodenectomy reconstruction was delayed until subsequent laparotomy. Comparing the
pack  drain and resection groups, no difference in mechanism, vascular injury, shock, ISS, or complications
was revealed. Mortality was substantial (packing only, 70%; packing with drainage, 25%, distal
pancreatectomy, 55%, pancreaticoduodenectomy, 0%) in the study population.
Conclusions: The presence of shock or major vascular injury dictates the extent of pancreatic operative
intervention. While pancreatic resection may be required in selected damage control patients, packing
with pancreatic drainage effectively controls both haemorrhage and abdominal contamination in
patients with life-threatening physiological parameters and may lead to improved survival. Increased
mortality rates in patients who were packed without drainage suggest that packing without drainage is
ineffective and should be abandoned.
2008 Elsevier Ltd. All rights reserved.

Keywords:
Damage control
Pancreatic injury
Pancreatic resection

Introduction
Damage control techniques have improved the survival of
severely injured patients. Underscoring the relative rarity of

* Corresponding author at: Department of Surgery, Temple University Hospital,

3401 North Broad Street, Philadelphia, PA 19104, United States.
Tel.: +1 215 707 8225; fax: +1 215 707 3945.
E-mail addresses: mark.seamon@tuhs.temple.edu (M.J. Seamon),
patrick.kim@uphs.upenn.edu (P.K. Kim), stawicki_ace@yahoo.com (S.P. Stawicki),
dabrowskip@readinghospital.org (G.P. Dabrowski),
amy.goldberg@tuhs.temple.edu (A.J. Goldberg), patrick.reilly@uphs.upenn.edu
(P.M. Reilly), charles.schwab@uphs.upenn.edu (C.W. Schwab).
00201383/$ see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2008.08.010

pancreatic injuries, the optimal management of these injuries in

critically injured patients requiring damage control (DC) remains
unclear. To date, numerous reports have described the application
of damage control techniques for abdominal, thoracic, vascular,
orthopaedic, and neurosurgical injuries, but none have described
these techniques in relation to pancreatic injury.19,10,20,4,2,7 We
hypothesised that, in selected patients, pancreatic resection may
be required during an abbreviated initial DC laparotomy to prevent
further haemorrhage or contamination of the abdominal cavity
with pancreatic juices, and may be safely performed at either
initial or subsequent laparotomy depending on physiological
derangement. The purpose of this study was to characterise
pancreatic injury patterns and outcomes to better determine

62

M.J. Seamon et al. / Injury, Int. J. Care Injured 40 (2009) 6165

optimal initial operative management in this unique, critically

injured population.

Table 1
Overall demographics and clinical characteristics for the entire group of 42 study
patients.
n

Materials and methods

Age

This study is a two-centre, retrospective review of patients who

sustained pancreatic injury and required DC between 1997 and
2004. The study centres were the Hospital of the University of
Pennsylvania and Temple University Hospital, both urban Level I
trauma centres in Philadelphia, PA. Pancreatic injuries were
diagnosed and graded during laparotomy. The operating attending
trauma surgeon made all intraoperative management decisions,
including the need for damage control techniques. Damage control
laparotomy patients were dened by the need for temporary
abdominal closure or open abdomen and planned re-exploration. Shock was dened as systolic blood pressure less than
100 mmHg for two consecutive measurements.
Study groups were based on initial laparotomy operative
management (packing only, packing with drainage, distal pancreatectomy, or pancreaticoduodenectomy) and compared with
respect to clinical characteristics and outcomes. Variables included
age, sex, injury mechanism, pancreatic injury location (head, neck/
body, tail), pancreatic injury grade according to AAST criteria,15 the
presence of either admission or intraoperative shock, the presence
of major vascular injury (dened by injury to named abdominal
vessels) and/or associated abdominal injury, and Injury Severity
Score. Analysed outcomes included pancreatic complications,
hospital length of stay (LOS [days]), early mortality (<24 h), and
in-hospital mortality.
Descriptive statistics were calculated for all continuous and
categorical variables. Post hoc analysis included Pearsons Chi
Square, Fishers Exact Test, and Students T tests. A p-value less
than or equal to 0.05 was considered statistically signicant.
Institutional Review Boards of both participating institutions
approved the study.
Results
The study group comprised of 42 patients with pancreatic
injuries who required DC techniques. The mean age of the study
population was 32.8  16.2 (mean  S.D.) years (Table 1). Patients
were primarily males (90.5%) injured by penetrating mechanisms
(71.5%). Twenty-eight of 42 patients suffered gunshot wounds (GSW)
and 2 patients were stabbed (SW), while blunt pancreatic injury
accounted for 12 of 42 patients. Blunt injuries were caused by a
variety of different mechanisms, including motor vehicle collisions
(14.3%), falls (4.8%), motorcycle collision (2.4%), assault (2.4%), and
pedestrian struck (4.8%). The pancreatic head was the most
commonly injured anatomic segment (50%), while the neck or body
(16.7%) and pancreatic tail (33.3%) were injured less often. Pancreatic
injuries were moderate to severe (mean grade, 2.6  1.2), and
haemorrhagic shock (71.4%) from vascular injury (59.5%) was
common. Forty-one of 42 patients had associated abdominal injuries
(Fig. 1). Overall, the study group of 42 patients was severely injured
(Injury Severity Score [ISS], 29.1  16.7).
Patients managed with (n = 12) and without (n = 30) pancreatic
resection during the initial laparotomy were compared (Table 2).
No signicant difference between resection and non-resection
groups was detected with respect to age, sex, and injury
mechanism. Both groups consisted primarily of gun shot victims
(resection, 75.0% vs. no resection, 63.3%; p = 0.37). While no
signicant difference was seen between resection and nonresection groups with respect to injuries to the pancreatic neck
or body, patients who underwent pancreatic resection less
commonly had injuries of the pancreatic head (resection, 16.7%

%
a

32.8  16.2

Sex
Male
Female

38
4

90.5
9.5

Injury mechanism
GSW
SW
MVC
Fall
Pedestrian struck
MCC
Assault

28
2
6
2
2
1
1

66.7
4.8
14.3
4.8
4.8
2.4
2.4

Injury location
Head
Neck/body
Tail

21
7
14

50
16.7
33.3

Pancreatic injury grade

Shock
Vascular injury
Associated abdominal injury
ISS

2.6  1.2a
30
25
41

71.4
59.5
97.6
29.1  16.7a

GSW (gun shot wound), SW (stab wound), MVC (motor vehicle collision), MCC
(motorcycle collision), ISS (injury severity score).
a
Mean  S.D.

vs. no resection, 63.3%; p = 0.007) but more commonly suffered

pancreatic tail injuries (resection, 66.7% vs. no resection, 20.0%;
p = 0.006) with no signicant difference in pancreatic injury grade
(resection, 2.83  0.72 vs. no resection, 2.43  1.33; p = 0.33)
compared to those who did not undergo pancreatic resection. No
signicant difference in the presence of major vascular injury
(resection, 50.0% vs. no resection, 63.3%; p = 0.20), and ISS (resection,
35.9  21.4 vs. no resection, 26.2  13.6; p = 0.09) was seen between
resection and non-resection groups.
Outcome in patients managed with and without resection was
compared (Table 2). No signicant difference in outcome was seen
between resection and non-resection groups with respect to
pancreatic complications (resection, 33.3% vs. no resection, 20.0%;
p = 0.30), hospital length of stay (resection, 20.6  15.1 vs. no
resection, 25.7  23.6; p = 0.49), early mortality within 24 h (resection, 8.3% vs. no resection, 20.0%; p = 0.34), and in-hospital mortality
(resection, 50.0% vs. no resection, 40.0%; p = 0.27).
Study patients were compared on the basis of initial operative
intervention (packing only, packing with drainage, distal pancreatectomy, pancreaticoduodenectomy) with respect to clinical
characteristics and outcome (Table 3). Patients were critically

Figure 1. Forty-one of 42 (98%) patients had associated abdominal injuries. IVC:

inferior vena cava.

M.J. Seamon et al. / Injury, Int. J. Care Injured 40 (2009) 6165

Table 2
Patients who underwent pancreatic resection during initial laparotomy were
compared to those that were treated without resection.

injuries in the packing only group, early mortality within 24 h of

injury was common (4 of 10) and in-hospital mortality was the rule (7
of 10) in these most severely injured patients. The majority of patients
who underwent packing with pancreatic drainage as their initial
pancreatic operative intervention also suffered penetrating injuries.
Twelve of 20 suffered penetrating pancreatic injuries, although most
(17 of 20) were grade I or II. Associated vascular injuries were
common (11 of 20) but early mortality within 24 h was infrequent (2
of 10%). Five of 20 patients who underwent packing with drainage
died before hospital discharge.
Twelve patients underwent pancreatic resection during their
initial laparotomy. Of 11 patients who underwent distal pancreatectomy during their initial laparotomy, 9 (81.8%) had penetrating
injuries, most commonly causing grade II or III pancreatic injuries
(10 of 11, 90.9%). Six of 11 (54.6%) suffered abdominal vascular
injuries and 6 (54.6%) died before hospital discharge. All distal
pancreatectomies were performed during the initial laparotomy as
were 1 of 3 pancreaticoduodenectomies. This single patient who
underwent pancreaticoduodenectomy suffered a grade IV pancreatic head injury due to gunshot. He had no major abdominal
vascular injury or evidence of shock. Although the resection was
performed during the initial laparotomy, reconstruction was
delayed until a subsequent laparotomy following complete
resuscitation. The other 2 patients underwent both pancreaticoduodenectomy and reconstruction during a subsequent laparotomy.
All
3
patients
who
eventually
underwent
pancreaticoduodenectomy had penetrating injuries causing severe
(grade IV or V) pancreatic injuries. Hospital stay was extended after
pancreaticoduodenectomy (47.3  17.8 days), but all 3 patients
survived hospitalisation. Overall, 14 patients eventually underwent a
formal pancreatic resection during their hospitalisation.
Shock was highly prevalent in patients who expired during
hospitalisation, regardless of operative management during the
initial laparotomy. Six of 7 who died after packing had evidence of
shock, as did all 5 patients who died after packing with abdominal
drainage, and 5 of 6 who underwent distal pancreatectomy and
expired during hospitalisation.

Demographics, clinical characteristics, and

outcomes
Resection
(n = 12)

No resection
(n = 30)

Age

37.3  21.3a

31.0  13.6

0.25

Sex
Male

11

27

0.68

Injury mechanism
GSW
SW
MVC
Fall
Pedstruck
MCC
Assault

9
1
1
1
0
0
0

19
1
5
1
2
1
1

0.37
0.42
0.44
0.42
0.51
0.71
0.71

Injury location
Head
Neck/body
Tail

2
2
8

19
5
6

0.007
0.66
0.006
0.33
0.15
0.20
0.09

Pancreatic injury grade

Shock
Vascular injury
ISS

2.83  0.72
7
6
35.9  21.4

2.43  1.33
23
19
26.2  13.6

Operative management
Packing
Packing and drainage
Distal pancreatectomy
Pancreaticoduodenectomy

0
0
11
1

10
20
0
0

Pancreatic complications
LOS
Mortality <24 h
In-hospital mortality

4
20.6  15.1
1
6

6
25.7  23.6
6
12

63

p-Value

0.02
<0.001
<0.001
0.29
0.30
0.49
0.34
0.27

GSW (gun shot wound), SW (stab wound), MVC (motor vehicle collision), MCC
(motorcycle collision), ISS (injury severity score), LOS (length of hospital stay).
a
Mean  S.D.

injured (ISS; 29.8  16.4, 24.5  12.0, 36.0  22.5, 35, respectively)
in all intervention groups. Eight of 10 (80%) in the packing only group
suffered penetrating pancreatic injuries, of which 6 of 10 were grade
IV or V. With 8 of 10 patients having concomitant abdominal vascular

Discussion
While it is well established that DC improves survival of
severely injured patients, the management of pancreatic injury

Table 3
Patients were compared on the basis of initial operative intervention.
Clinical characteristics and outcome by initial operative management
Packing (n = 10)

Packing and drainage (n = 20)

Distal pancreatectomy (n = 11)

Pancreaticoduodenectomy (n = 1)

Total (n = 42)

Mechanism
Penetrating
Blunt

8
2

12
8

9
2

1
0

30
12

Grade
1
2
3
4
5

2
2
0
2
4

5
12
2
1
0

0
4
6
1
0

0
0
0
1
0

7
18
8
5
4

0
35
1
55
0
0

25

Vascular injury
ISS
Complications
LOS (days)
Mortality <24 h
Hospital mortality

8
29.8  16.4a
2
18.6  28.4a
4
7

11
24.5  12.0a
4
29.2  20.7a
2
5

6
36.0  22.5a
3
17.5  11.1a
1
6

10
7
18

Patients with signicant injuries and clinical parameters allowing packing as the only operative intervention were largely (7 of 10, 70%) fatal. Complications were limited to
those of pancreatic origin. ISS (injury severity score), LOS (length of hospital stay).
a
Mean  S.D.

64

M.J. Seamon et al. / Injury, Int. J. Care Injured 40 (2009) 6165

during DC laparotomy is less certain.19,10,20,4,2,7 Here, we present

42 DC laparotomy patients with pancreatic injuries managed with
a variety of operative techniques revealing three key ndings. First,
pancreatic resection may not only be in accordance with
fundamental DC principles, pancreatic resection may be necessary
in properly selected patients to control further haemorrhage or
abdominal contamination. Second, in patients without suitable
physiological parameters, packing and drainage of the injured
pancreas may be more appropriate. Lastly, abdominal packing
without pancreatic drainage should be avoided. Regardless of
intervention, mortality in this critically injured population remains
substantial.
The DC approach involves rapid control of exsanguinating
haemorrhage and abdominal contamination. The classic triggers
for initiation of DC surgery include acidosis (pH <7.30),
hypothermia (temperature <35 8C), and coagulopathy (presence
of non-mechanical bleeding).19,10,20,4,2,7 The DC laparotomy
consists of a four-phase approach, beginning with recognition of
the DC patient, an abbreviated laparotomy to rapidly control
haemorrhage and contamination, resuscitation in the intensive
care unit (ICU), and a series of subsequent operations to provide
denitive repair of injuries and to further restore the physiological
milieu.10 While initial operations are abbreviated, resection may
still play a role in haemorrhage or contamination control before
complete resuscitation is achieved. In the present report, we
analysed the impact of mechanism of injury, pancreatic injury
location, injury grade, physiological derangement, pancreatic
complications, and mortality on DC patients with respect to 4
different pancreatic operative interventions.
With regards to the anatomic distribution of pancreatic injuries,
the most common site of injury was the pancreatic head, followed
by injuries to the pancreatic tail and pancreatic neck/body. The
location of injury was important in selection of surgical therapy,
with distal injuries associated with surgical resection more
commonly than pancreatic head injuries (75% vs. 20%, respectively). Pancreatic packing was used in severe pancreatic injuries.
Six of 10 of the pancreatic packing only group suffered grade IV or V
pancreatic injuries. Packing with peripancreatic drainage was used
in patients with less severe pancreatic injuries. Seventeen of 20
who underwent packing with peripancreatic drainage suffered
grade I or II injuries. Most distal pancreatectomies were due to
intermediate injury grade (grade II or III) penetrating injuries
(81.8%) to the pancreatic tail. Pancreaticoduodenectomy was
required only once during the initial laparotomy in this series. This
reluctance to perform this complex, time-consuming procedure
during an initial laparotomy has been corroborated in previous
series.17,18,21,3,6,14,8,9,23,1,13
Early mortality usually resulted from massive bleeding from
concomitant vascular or adjacent organ injuries. Haemorrhagic
shock was common in the present series. Our results corroborated
previous reports.12,11 Patients in haemorrhagic shock and major
abdominal vascular injury were more likely to die early in their
hospital course than patients without these poor prognosticators.
Although shock was present in one patient who eventually
underwent pancreaticoduodenectomy, the procedure was performed during a subsequent laparotomy after complete resuscitation. Surprisingly, no difference between resection and no
resection groups was seen with regards to the presence of shock,
major vascular injury, or ISS.
Protected by its deep retroperitoneal location, pancreatic injury
is relatively uncommon.22 This modest injury occurrence has led to
a paucity of reports describing pancreatic injury in patients
undergoing DC, or pancreatic DC (PDC).18 Moreover, the vast
majority of existing literature regarding pancreatic injuries
pertains to blunt trauma.22,16,5 Our study population differed in

that it consisted of predominantly young males injured by gunshot

wounds with blunt injury comprising only 29% of PDC cases. In the
PDC group with the most severe injuries, the overall mortality was
over 87%, with 50% mortality within the rst 24 h of hospital
arrival. Others also report over 50% of patients with pancreatic
injury presenting with documented shock, which was associated
with signicantly increased mortality.21 The experience of Olah
et al.,16 although limited to blunt pancreatic injuries, corroborates
the high mortality (30% in their series) of pancreatic injuries with
concomitant vascular injury.
Our observed PDC patient mortality appears to be higher than
that of other DC series.19,10,20,4,2,7 Mortality in the present series is
also higher than that previously reported for pancreatic injury,
regardless of whether pancreatic resection was performed (50.0%)
or not (40.0%) during the initial laparotomy. Rickard et al.18
reported mortality of 23.2% for gunshot wounds and 22.7% for
blunt trauma involving the pancreas. However, their gure
included all patients who sustained pancreatic injury, and did
not select the most critically injured patients who underwent DC
surgery. It has been previously noted that mortality varies
depending on the reason to apply DC techniques, with pancreatitis
being associated with the highest observed mortality (43%)
and trauma patients having the lowest mortality rates
(1327%).19,10,20,4,2,7 We may speculate that the high mortality
associated with DC in severe pancreatitis also relates to the high
mortality associated with PDC in this series. Additionally, we may
postulate that packing without pancreatic drainage controls
haemorrhage but not abdominal contamination and may, therefore contribute to a dysregulated inammatory response and
eventual clinical embarrassment in these patients. In our study
population, 70% of patients who were packed without drainage
ultimately died, 43% of whom died after 24 h of hospitalisation.
While we recognise that many factors contributed to the demise of
these critically injured patients, adequate drainage is technically
straightforward and may offer a rapid method to increase survival
by controlling abdominal contamination.
One third of patients who underwent pancreatic resection and
20% of those who did not undergo resection developed pancreaticrelated complications. This is generally in agreement with
complication rates in other studies of major pancreatic trauma
(1262%).17,18,21,3,6,14,8,9,23,1,13,11,22 Increased complication rates
may be associated with delay in treatment of greater than 24 h,
with morbidity rate up to 30% without delay in treatment,
and over 60% when treatment is delayed more than
24 h.17,18,21,3,6,14,8,9,23,1,13,11,22,16 Although the specic nature of
pancreatic complications in this study was not analysed, others
reported the most common post-traumatic pancreatic complications to be intra-abdominal abscess (39%), necrotising pancreatitis
(715%), pseudocyst formation (59%), abscess (632%) and stula
formation (423%).17,18,21,3,6,14,8,9,23,1,13,11,22,16
Resource consumption was substantial in the study group.
Patients required an extended hospital length of stay (mean, 24
days), regardless of operative management. Others have corroborated these ndings. While Vasquez et al.21 reported a 20-day
mean hospital stay in their series, patients in the Lee et al.13 series
were hospitalised an average of 50 days. Additionally, the
performance of numerous surgical, endoscopic, and interventional
procedures in pancreatic injury and pancreatic DC patients quickly
contribute to hospital costs.21,16 All three patients who ultimately
underwent pancreaticoduodenectomy survived until hospital
discharge although hospital stay was prolonged (mean, 47 days).
Limitations of this study are inherent to its retrospective, nonrandomised nature. Underscoring the scarcity of this injury
complex, our modest sample size, despite the inclusion of two
busy urban trauma centres, limits the statistical power of this

M.J. Seamon et al. / Injury, Int. J. Care Injured 40 (2009) 6165

study. Only through a large multi-centre study can one operative

management strategy be validly compared to another. Furthermore, the decision to employ damage control techniques and
choice of operative intervention were both based on the discretion
of the operating trauma surgeon, not formalised study protocols.
Conclusions
In conclusion, a variety of operative interventions for pancreatic
damage control are available to the operating surgeon but
mortality is substantial. Our results suggest that haemodynamics,
concomitant injury, and the anatomic pancreatic injury complex
should dictate the extent of pancreatic operative intervention
during an initial damage control laparotomy. While patients
without evidence of acidosis, coagulopathy, or hypothermia may
undergo distal pancreatic resection, packing combined with
adequate pancreatic drainage effectively controls both haemorrhage and abdominal contamination in patients with either lifethreatening physiologic parameters or proximal pancreatic injuries. Increased mortality rates in patients who were packed
without drainage suggest that packing without drainage is an
ineffective DC option and should be abandoned.
Conict of interest
We have no nancial or personal conict of interest that could
potentially bias our work.
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