Surgical Management of Modern Combat-Related Pancreatic Injuries: Traditional Management and Unique Strategies

Transcription

1 MILITARY MEDICINE, 179, 3:315, 2014 Surgical Management of Modern Combat-Related Pancreatic Injuries: Traditional Management and Unique Strategies MAJ Amy Vertrees, MC USA* ; CAPT Eric Elster, MC USN ; Rahul Jindal, MD, PhD, MBA ; Camillo Ricordi, MD ; COL Craig Shriver, MC USA* ABSTRACT Background: Management of war-related pancreatic injuries is challenging with potential for associated concomitant injuries and complications. Methods: Retrospective record review of patients treated at Walter Reed Army Medical Center sustaining pancreatic injury during the conflicts in Iraq and Afghanistan from 2003 to 2009 was carried out. Results: Pancreatic injuries occurred in 31 of 522 (7%) patients, with the average age of 28 (range 19 54). Mechanism of injury included gunshot (68%), blast injuries (23%), and blunt injuries (10%). Distal pancreatic injuries were treated with distal pancreatectomy (55%) or drainage (45%). Head of the pancreas injuries were treated with drainage (86%). Four patients with unspecified anatomic location underwent drainage only. One patient underwent emergent pancreaticoduodenectomy (Whipple procedure) followed by completion pancreatectomy and islet cell autotransplantation. Conclusion: Management of war-related pancreatic injuries varied based on the anatomic location. Head of the pancreas injuries were primarily managed with drainage. Distal injuries were treated with resection or drainage. Autologous islet cell transplantation is a feasible option. INTRODUCTION Management of pancreatic injury is complicated because of the proximity of the pancreas to major structures and the significant damage that can be done with uncontrolled leakage of pancreatic enzymes. The high rate of initial mortality is due to associated vascular injuries including the aorta, superior mesenteric vein, inferior vena cava, and portal vein. 1,2 Late complications and mortality are common because of the autodigestive properties of the pancreas, especially if leakage is not controlled with drainage. 2 Colon anastomotic failure can be a devastating complication associated with pancreatic injury, especially in combat-related injuries. 3,4 Abscess, fistula formation, pseudocysts, pancreatitis, and insufficiency of exocrine and endocrine functions are commonly described late complications. 1,2,5,6 Despite many advances in trauma and critical care, mortality from pancreatic injuries has not changed over time, with pancreas-specific mortality at 6 to 20%. 7,8 Recent literature describing pancreatic management has been exclusively from civilian trauma with management focused on treatment of associated injuries, control of pancreatic leakage, and identification and treatment of any pancreatic ductal injury The pancreaticoduodenectomy or trauma Whipple is rarely required, reported as 3% of pancreatic injuries Warrelated injuries have rarely been reported, with the most recent *General Surgery Service and Transplant Surgery Service, Department of Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD Cell Transplant Center and Diabetes Research Institute, University of Miami, Coral Gables, FL doi: /MILMED-D studies mentioning pancreatic trauma from World Wars I and II without providing management details. 15,16 Current recommendations for war-related pancreatic injury in Emergency War Surgery and Combat Casualty Care: Lessons Learned From OEF and OIF have limited guidance, focusing on the far-forward strategies for management. Hemorrhage control, modest debridement of devitalized tissue, and wide closedsuction drainage were the predominate recommendation for pancreatic injuries. 17,18 A strategy of islet cell transplant was described in a recent war-injured patient where the pancreas was harvested at our institution, processed remotely, and transplanted into the patient to return endocrine function. 19 This study will investigate the modern management of pancreatic injuries in combat-injured patients, including the details of the first known successful islet cell autotransplant after completion pancreatectomy for traumatic injury of the pancreas. PATIENTS AND METHODS Patients The Walter Reed Army Medical Center (WRAMC) Institutional Review Board approved this retrospective study of 31 male patients sustaining pancreatic injuries from January 2003 to November 2009 (Work unit ). The patients were active duty American service members injured in Operation Enduring Freedom or Operation Iraqi Freedom. After initial stabilization in the theater of operations in Iraq and Afghanistan (Role II levels of care), they were evacuated to local military medical facilities (Role III). Patients were then transferred to Landstuhl Regional Medical Center (Role IV) in Germany before their final transfer to WRAMC in Washington, DC (Role V). WRAMC merged with National Naval Medical Center in 2011 to form Walter Reed National Military Medical Center. MILITARY MEDICINE, Vol. 179, March

2 Materials and Methods Inpatient and outpatient records of the study subjects were reviewed retrospectively. The age, gender, mechanism of injury, days from injury to admission at WRAMC, and associated injuries were recorded. The anatomic location of pancreatic injury (distal or proximal) was noted during exploratory laparotomy. Although there are five parts of the pancreas, to include the head, uncinate process, neck, body, and tail, the groupings were combined to note proximal and distal pancreas given the small number of patients and lack of clear anatomic location of the injury noted in the records. Proximal injuries involved the head of the pancreas or uncinate process. Distal injuries involved the neck, body, or tail. Operative records were searched for details of the pancreatic injury and drain placement. Complications in the patients were recorded; specifically persistent pancreatic leaks were determined by elevated amylase and lipase values from previously placed drains. There was no protocol in place for the management of pancreatic injuries, and injury management was at the discretion of the operating surgeon. Follow-up information was obtained from the inpatient and outpatient electronic records for the patients who were treated at WRAMC after their initial injury. Islet Cell Transplant Islet cell autotransplant was performed by harvesting the pancreas and spleen. All vessels and ligaments surrounding the pancreas and spleen were ligated with the splenic artery and vein ligated last to minimize ischemic time. The splenic artery and vein were used to immediately infuse chilled University of Wisconsin solution for organ preservation. The pancreas and spleen were packaged on ice per transplant protocols and sent to the University of Miami via courier and transported on the next available flight. The islet cells were harvested as described previously 17 and were then suspended in a ready-to-infuse solution. These cells arrived approximately 18 hours from harvest, with a total of 9 hours ischemic time. The temporary abdominal dressing was removed, and the portal vein was exposed. The previously obvious anatomy was significantly obscured as granulation tissue progressed even after the short time from the last operation. The portal vein was positively identified by both ultrasound and contrast injection into the portal vein. Once the portal vein was identified, a 16-gauge angiocatheter was inserted and connected to a pressure transducer. Portal pressure measurements were obtained at baseline, during, and after the infusion of islet cells as elevation of portal pressure could indicate compromise of portal vein flow or thrombosis. Glucose measurements were also obtained at baseline, during, and after the infusion as precipitous declines in glucose measurements may occur. C-peptide levels were measured as a baseline before and after the infusion of islet cells. Over the ensuing weeks, glucose, insulin, and C- peptide levels were obtained to document the progress of the islet cell uptake and resumption of function. Insulin requirement was also documented. RESULTS Patients Pancreatic injuries occurred in 31 of 431 (7%) patients undergoing exploratory laparotomy from January 2003 through November 2009 from the conflicts in Iraq and Afghanistan who returned to WRAMC for treatment. All patients were male with the average age of 28 (range 19 54). The majority of injuries included penetrating injuries inflicted by gunshot (n = 21; 68%) and secondary blast injuries (n = 7; 23%). Secondary blast injuries often have a combination of blunt and penetrating components. Blunt injuries occurred in 10% of patients, including injuries from a fall, crushing injury, and motor vehicle accident. Patients arrived a median of 4 days from injury (range 2 56 days). Hospital stay was an average of 44 ± 42 days (median 37 days). Grade of the pancreatic injury was rarely noted in the operative record. Operative Management Including Completion Pancreatectomy and Islet Cell Autotransplant Operative management of pancreatic injuries varied with anatomic location (Table I). Distal pancreatic injuries were nearly equally treated with distal pancreatectomy or drainage (55 and 45%, respectively). If the injury was drained, it was always with at least one closed-suction drain. Penrose drain or other passive open drainage was never used. Staplers were used for resection. Proximal injuries were nearly always treated with drainage (86%; Table I) with only one patient undergoing a traumatic pancreaticoduodenectomy (Whipple procedure) and ultimately a completion pancreatectomy (n = 1; 14%). This patient underwent islet cell transplantation, described earlier. Anatomic location was not documented in four patients, and all underwent drainage only without pancreatic resection. Damage control surgery was noted if more than one abdominal surgery was planned, with temporary closure of the abdomen placed between surgeries. Most patients (n = 24; 77%) underwent damage control surgery. Patients had an average of three operations before arrival at WRAMC. Of those patients, most arrived at WRAMC with temporary abdominal closure requiring further abdominal operations before abdominal fascial closure (18 of 24; 75%). Of the seven patients who did not undergo damage control laparotomy, two had persistent TABLE I. Operative Intervention According to Anatomic Location Anatomic Location n (%) n (%) Operative Intervention Distal 20 (65%) 11 (55%) Distal Pancreatectomy 9 (45%) Drained Head of the Pancreas 7 (23%) 6 (86%) Drained 1 (14%) Whipple, Completion Pancreatectomy Unspecified Location 4 (13%) 4 (100%) Drained 316 MILITARY MEDICINE, Vol. 179, March 2014

3 pancreatic leak controlled with previously placed drains. None of the seven patients required further operation. One patient had a completion pancreatectomy after pancreaticoduodenectomy. He was initially managed with resection of the head of the pancreas and duodenum as part of a damage control laparotomy. Small closed-suction drains were placed. He arrived at WRAMC 4 days after his initial injury with a temporary abdominal closure and inadequate drainage of his pancreatic injury, as significant saponification was present throughout his abdomen signifying ongoing pancreatic leakage beyond the drains placed. Significant saponification was concerning for potential life-threatening hemorrhage if pancreatic drainage continued. To prevent a life-threatening hemorrhage from further leakage of pancreatic enzymes, completion pancreatectomy was performed. He then underwent pancreatic islet cell autotransplant as outlined in the Patients and Methods section. His C-peptide level before transplant was <0.01. Over the ensuing weeks, this value increased to near-normal levels in response to corresponding glucose measurements. His insulin requirement was a maximum of 85 units per day while on total parenteral nutrition, but stabilized several weeks after injury as the islet cell function increased. His near normal oral glucose tolerance test at 1 and 2 months revealed insulin independence. 20 Concomitant Injuries Concomitant injuries were common in patients with pancreatic injuries (Table II). Predictably, splenic injuries were more common with distal pancreatic injuries (18 of 19 patients) and duodenal injuries were more common with head of the pancreas injuries (4 of 6 patients). Major vessel injuries included any named vessel and also the inferior vena cava (n = 2), TABLE II. Concomitant Injuries Location of Injury n (%) Head 6 (19) Neck 1 (3) Chest 20 (65) Diaphragm 14 (45) Esophagus 2 (6) Stomach 10 (32) Duodenum 6 (19) Liver 13 (42) Biliary 4 (13) Spleen 19 (61) Kidney 12 (39) Ureter 2 (6) Adrenal 3 (10) Small Intestine 12 (39) Colon 16 (52) Ostomy 12 (39) Rectal, Bladder Injuries 0 Pelvic Fracture 5 (16) Major Vessel Injury 7 (22) Extremity Injury 7 (22) TABLE III. Colon Injury, n Colon Anastomotic Leak Associated With Pancreatic Injury Colon Anastomosis, n Anastomotic Failure, n (%) Distal Injury DP (67) Drain Proximal Injury Whipple 1 Drain (50) DP, distal pancreatectomy. middle colic vein (n = 1), right renal vein (n = 1), left hepatic vein (n = 1), superior mesenteric vein (n = 1), and splenic artery (n = 1). Complications Several patients (n = 19; 61%) underwent anastomosis of small intestine or colon injuries. The anastomosis in five (26%) of these patients failed in the setting of a concomitant pancreatic injury, three were colon and two were small bowel anastomoses. All of these patients underwent damage control laparotomy. Colon anastomotic failure occurred after distal pancreas injury and resection (67%; Table III), and head of the pancreas injury with drainage (50%; Table III). Two small bowel anastomoses failed; one after distal pancreatic injury and resection and another after head of the pancreas injury treated with drainage. Both patients had multiple organs injured. A traumatic pseudocyst was identified on computed tomography scan in one patient after distal pancreatic injury and drainage, and did not required intervention. Pulmonary embolus (n = 2; 6%), deep venous thrombus (n = 4; 13%), intra-abdominal abscess (n = 8; 26%), pneumonia (n = 13; 42%), and necrotizing fasciitis of the abdominal fascia (n = 1; 3%) were other noted complications associated with pancreatic injuries. No patients developed fascial dehiscence. Persistent pancreatic leaks were identified in 10 (38%) patients. All patients survived to discharge. The patient who had islet cell transplant underwent a successful colostomy takedown a year after injury, but died nearly 2 years after his initial injury from complications not related to the transplant or operations. Another patient died of a motorcycle accident unrelated to his initial injury. DISCUSSION Pancreatic injury is relatively uncommon, likely because of its retroperitoneal location and the many surrounding structures. Initial mortality is high with pancreatic injury as several of the surrounding structures are major vessels. Although there are clinical guidelines available for the management of pancreatic injury, there is little consensus over treatment because of the lack of large clinical studies. Current civilian management recommendations in the Eastern Association for the Surgery of Trauma guidelines include resection of severely MILITARY MEDICINE, Vol. 179, March

4 damaged pancreatic injuries (grade III or greater) and drainage likely sufficient for grade I/II injuries. 21 The mechanism of war-injured patients, however, is significantly different than civilian trauma where most of the injuries to the pancreas are related to motor vehicle accidents. 12 Penetrating injury from gunshot or secondary blast injury was more common in the war-injured population, and specific injury management has not been noted in the conflicts in Iraq and Afghanistan. Details of pancreatic management in war-injured soldiers in recent conflicts are particularly scarce. Military-specific recommendations for pancreatic injury management found in Emergency War Surgery and Combat Casualty Care focus on the farforward management of pancreatic injury. 17,18 This study notes specific details on pancreatic injury management of the warinjured patient in the recent conflicts in Iraq and Afghanistan. In this study, the anatomic location of the injury was a major factor for the operative management. The location of the injury was noted as either proximal (head or uncinate process) or distal (neck, body, and tail). Distal pancreatic injuries were equally managed with resection and drainage or drainage alone. The decision regarding resection over drainage alone was not clear, although drainage alone was likely used with a lower grade of injury. Head of the pancreas injuries were nearly all managed with drainage alone. This is likely because of the precarious location of the head of the pancreas, as well as the shared blood supply with the duodenum. Resection of the head of the pancreas requires pancreaticoduodenectomy (Whipple procedure). The procedure is extensive, involving resection of the pancreas, duodenum, and bowel anastomoses. It should not be undertaken in an unstable patient, and even in the stable patient the procedure carries a high risk of morbidity and mortality, estimated at approximately 67%. 22 A majority of civilian and military literature agree that the Whipple procedure is recommended only when the dissection has already been done for you. The incidence of pancreaticoduodenectomy is fortunately rarely required, estimated at 3 to 5%, which was consistent with our findings (1 of 31; 3%). 9,22 A recent single institution study has challenged the high mortality associated with pancreaticoduodenectomy for trauma, with an unprecedented 33% mortality. 23 Thompson et al 23 noted that damage control laparotomy and staged reconstruction should occur, and this may have contributed to their significantly lower mortality rate. The presence of ductal injury is a significant factor in pancreatic injury management. Sharpe et al 11 described an algorithm based on ductal injury. Endoscopic retrograde cholangiopancreatography can identify head of the pancreas ductal injury, but is not available in Role II or III levels of care. Sharpe et al noted physical exam findings of ductal injury: direct visualization of the injury, complete transection of the gland, laceration of greater than one half of the gland, central perforation, and severe maceration. These findings do not require specific equipment such as endoscopic retrograde cholangiopancreatography, but lower levels of care may not have an ideal operative environment. Suboptimum lighting, presence of a mass casualty situation, lack of assistance providing optimal retraction, and active surrounding combat such as indirect fire are all potential scenarios in the war environment. Current military recommendations, supported in our study, include adequate closed-suction drainage and damage control operations if the situation involves an unstable patient or an unstable environment. 17,18 We have previously cautioned against colon anastomosis in the setting of war-related pancreas injuries with a 16% overall failure rate and 25% failure rate in patients whose anastomosis was performed at the initial operation. 4 Two thirds (67%) of the patients whose anastomosis failed had concomitant pancreatic injuries. Failure of the anastomosis had far-reaching consequences with multiple abdominal surgeries required and increased complications associated with eventual ostomy closure. 4 This study identified a high rate of colon anastomotic failure after damage control laparotomy with distal pancreatectomy (67%) or proximal pancreas injury (50%). Small bowel anastomosis is also at risk for failure, although the 2 patients in the study had a significant number of other organs injured in addition to the pancreas. Other reported complications associated with pancreatic injury include a higher rate of nosocomial infections and late septic complications in up to 40%. 5 In this study, complications including abscess, thromboembolic events, and pseudocysts were comparable to other studies. 5,6,12 Delayed mortality in undrained or incompletely drained pancreatic injuries occurs from progressive damage to surrounding vessels resulting in hemorrhage as well as septic complications. 2 Completion pancreatectomy was undertaken in a patient who arrived at WRAMC whose surrounding portal vein, inferior vena cava, and superior mesenteric vein already had evidence of digestion, underscoring the severity of inadequate initial and continuous drainage. Possibilities for treatment in this scenario of delayed inadequate pancreatic drainage included pancreaticojejunal anastomosis, drainage only with likely progression of saponification, and completion pancreatectomy with significant endocrine and exocrine consequences. All choices had severe consequences, and ultimately completion pancreatectomy and islet cell transplantation were chosen as the least life-threatening alternative. Although two cases of islet cell transplantation have been reported after trauma, these two patients underwent distal pancreatectomy with presumed function of the remaining islet cells. 24 Their islet cell transplantations were performed where the processing of the islet cells occurred, not remotely as in this study. Ichii et al 25 previously described successful shipment of human islet cells for transplantation, although the transplantation was for type 1 diabetic patients rather than trauma patients. This study noted the feasibility of implanting islet cells that were processed at a remote site; therefore, it can be done at any medical center without specialized equipment in the very specific and rare scenario. Islet cell autotransplant should be a very uncommon method of treatment. Endocrine consequence of pancreatic resection in the normal patient can be surprisingly benign, with 318 MILITARY MEDICINE, Vol. 179, March 2014

5 only 10 to 20% of normal pancreas needed to avoid critical diabetes; therefore, islet cell transplant should only be undertaken in extreme circumstances. The most recent assessment of islet cell outcomes indicates islet graft function should continue without deterioration beyond 5 years. 26,27 Sutherland et al 28 noted 30% insulin independence and 33% partial function of islet cells at 3 years in 409 adults and children with chronic pancreatitis from various etiologies, including idiopathic, genetic, alcohol, and other causes. Autotransplant of islet cells has shown improved function compared to islet cell allographs, with one study noting 85% function of islet cells in autotransplant patient compared to 66% of allographs. 28 Critical diabetes and insulin requirements could be avoided after islet cell function has reached normal levels, but supplementation with exogenous pancreatic enzymes is expensive and cumbersome as each meal and snack requires supplementation. There is still a significant burden to the patient, even if critical diabetes is prevented. Limitations of this study include the retrospective nature of review. Although most war-injured patients returned to Walter Reed, those patients who immediately died or were not stable to travel did not arrive soon after their injury. Specific data including grade of injury, specific anatomic location, specific operative details, and presence of duct injury were not well documented in all patients. Although the mechanism of injury is different than civilian trauma, management of pancreatic injuries in the Iraq and Afghanistan conflicts has not been appreciably different from civilian studies. Drainage is the primary component of any aspect of pancreatic injury management with resection in significantly damaged pancreas. Bowel anastomotic failure is a significant source of persistent mortality, and ostomy creation should be strongly considered in the setting of a pancreatic injury to avoid long-term consequences of anastomotic failure, specifically proximal injuries or distal injuries requiring resection. Trauma Whipple is rare (3% of injuries). Islet cell autotransplantation is a feasible option if ongoing pancreatic leakage risks life-threatening hemorrhage. No specialized center is necessary for this procedure, although cooperation of local transplant surgeons is essential. REFERENCES 1. Campbell R, Kennedy T: The management of pancreatic and pancreaticoduodenal injuries. Br J Surg 1980; 67: Akhrass R, Yaffe M, Brandt C, Reigle M, Fallon WF Jr, Malangoni MA: Pancreatic trauma: a ten-year multi-institutional experience. Am Surg 1997; 63: Kao LS, Bulger EM, Parks DL, Byrd GF, Jurkovich GJ: Predictors of morbidity after traumatic pancreatic injury. 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