Management of pancreaticoduodenal injuries.

The nature of the pancreatic or duodenal injury itself influences mortality, and is co-dependent on the presence of multiple other injuries, which account for most of the early mortality. Intra-abdominal sepsis leading to multiple organ failure accounts for most of the late deaths, indicating the importance of early haemodynamic stabilization, adequate debridement of devitalized tissue and wide drainage. Most duodenal injuries can be adequately managed with primary repair or resection and anastomosis. The presence of a pancreatic injury certainly increases the likelihood of an anastomic leak from a duodenal repair. With a significant associated pancreatic injury a more conservative initial approach to the duodenal injury may be more appropriate. Pancreatic injuries should be treated by debridement and simple drainage unless there is clinically obvious duct involvement. For distal injuries with duct involvement, a distal pancreatectomy is indicated. In injuries to the pancreatic head with clinical duct involvement, complex procedures such as pancreaticoduodenectomy should not be performed in the unstable patient with multiple injuries. Debridement and wide external drainage may be implemented and the resulting fistula dealt with at a later operation, if necessary. Large, complex, combined pancreaticoduodenal injuries may require temporary duodenal ligation or a pancreaticoduodenectomy and subsequent reconstruction.