TY - JOUR
AU - Nicol, A
AB - Abstract Background Pancreatic injuries are uncommon but result in substantial morbidity and mortality. This study evaluated the factors associated with morbidity and mortality in civilian patients with pancreatic gunshot wounds. Methods This was a single-institution, retrospective review of patients with gunshot wounds of the pancreas treated from 1976 to 2009 in Cape Town, South Africa. Univariable and multivariable analyses were performed. Results A total of 219 patients (205 male, median age 27 years) had pancreatic American Association for the Surgery of Trauma grade I–II (111 patients) and grade III–V (108) gunshot injuries to the pancreatic head (72), neck (8), body (75) and tail (64). The patients underwent 239 laparotomies, including drainage of the pancreas (169), distal pancreatectomy (59) and pancreaticoduodenectomy (11). Some 218 patients had 642 associated intra-abdominal and 91 vascular injuries. Forty-three (19·6 per cent) required an initial damage control procedure. A total of 150 patients (68·5 per cent) had 407 postoperative complications (median 4, range 1–7). The 46 patients (21·0 per cent) who died had a median of 3 (range 1–7) complications. Median (range) intensive care unit and total hospital stay were 5 (1–153) and 11 (1–255) days respectively. Multivariable analyses identified age, high-grade pancreatic injury, associated vascular injuries and need for repeat laparotomy as predictors of morbidity. Age, shock on admission, need for damage control surgery, high-grade pancreatic injuries and associated vascular injuries were significant factors associated with mortality. Conclusion Morbidity and mortality rates were high after gunshot injuries to the pancreas. Initial shock and severe injury combined with need for damage control surgery were associated with the highest risk of death. Introduction Injuries to the pancreas are uncommon but may result in substantial morbidity and mortality, especially if pancreatic, vascular and adjacent organ injuries occur in combination1,2. Outcome is influenced by the cause and complexity of the pancreatic injury, amount of blood lost, duration of shock, speed of resuscitation, number of associated injuries, and the magnitude and quality of the surgical intervention3,4. The anatomical proximity of the major abdominal veins to the head and neck of the pancreas makes these structures susceptible to penetrating injuries involving the proximal pancreas. Early death results from uncontrolled venous bleeding or major adjacent organ injuries5–7. Late mortality is generally a consequence of infection or multiple organ failure. Neglect of a main pancreatic duct injury may lead to major complications, including pseudocyst, fistula, pancreatitis, sepsis and secondary haemorrhage3,4,8,9. Wide variations in morbidity and mortality rates have been reported after pancreatic injury3,8,9. Most studies have included all patients with blunt and penetrating pancreatic injuries, but some reports have not consistently divided complications into those involving the pancreas and those resulting from associated injuries. Several series on pancreatic injury have been published, including reports from the authors' institution10–12, but few substantial series have specifically assessed the outcome of gunshot wounds of the pancreas13–15. The aim of this study was to describe and examine factors associated with morbidity and mortality among civilians with pancreatic gunshot wounds. Methods This was a retrospective review of all adult patients with gunshot injuries of the pancreas treated at the level 1 trauma centre and hepatopancreatobiliary and surgical gastroenterology units in Groote Schuur Hospital, Cape Town, between January 1976 and December 2009. Data collection The medical records, including operative, intensive care, radiology, endoscopy and multidisciplinary clinic reports, were reviewed and the data recorded on a standard data form. The variables recorded for each patient included: demographic data, Revised Trauma Score (RTS), presence of shock on admission, anatomical location and grade of the pancreatic injury, associated intra- and extra-abdominal injuries, interval between injury and operation, surgical procedure, duration of hospital stay, presence and type of pancreas-related and other complications, and mortality. Definitions Shock was defined as a systolic blood pressure lower than 90 mmHg before or during surgery. The severity of the pancreatic injury was graded according to the American Association for the Surgery of Trauma (AAST) classification16 (Fig. 1). Fig. 1 Open in new tabDownload slide American Association for the Surgery of Trauma classification of pancreatic trauma: a normal anatomy, b grade I (mild contusion without duct injury, or superficial laceration without duct injury), c grade II (major contusion without duct injury, or major laceration without duct injury or tissue loss), d grade III (distal transection or parenchymal injury with duct injury), e grade IV (proximal transection or parenchymal injury involving the ampulla) and f grade V (massive disruption of the pancreatic head) Morbidity was considered as any postoperative complication, and included systemic, intra-abdominal and pancreatic complications. Bleeding was considered important if transfusion or intervention was required. Abscess was defined as a purulent fluid collection that required surgical or percutaneous ultrasound-guided catheter drainage. Peripancreatic fluid collections were diagnosed by computed tomography (CT), and pancreatic fistula was diagnosed if there was any amylase-rich drainage fluid that persisted for more than 1 week. Mortality was defined as any cause of death in hospital after a pancreatic injury. Operative management of pancreatic injury Initial resuscitation was according to Advanced Trauma Life Support (ATLS®) guidelines. Operative management of the pancreatic injury followed a specific operative strategy, as described previously13. In brief, the principles applied were urgent control of intra-abdominal bleeding, closure of visceral perforations to prevent contamination of the peritoneal cavity, and rapid volume replacement to correct acidosis, coagulopathy and hypothermia17. Since 1995, unstable patients who had pancreatic as well as major associated organ and visceral vascular injuries underwent an initial damage control procedure before definitive intervention. In order to assess the effect of damage control surgery (DCS) on outcome, the data were also assessed in two time cohorts, 1976–1994 (before DCS) and 1995–2009 (including DCS). Statistical analysis Pearson's χ2 test was used for analysis of categorical variables, and odds ratios (ORs) with 95 per cent confidence intervals were calculated. The Shapiro–Wilk test indicated that numerical variables were not normally distributed, so the non-parametric Wilcoxon rank sum test was applied. Variables that were statistically significant and considered as potential risk factors were included in the model for logistic regression analysis. P < 0·050 was considered statistically significant. The data were analysed using Stata® version 11 (StataCorp LP, College Station, Texas, USA). Results During the period under review, 408 patients were treated for pancreatic injuries, of whom 219 had gunshot injuries to the pancreas. Median age was 27 (range 14–69) years and most patients were male (205, 93·6 per cent). The median RTS was 11·25 (range 0–12). Ninety-six patients (43·8 per cent) were in shock on admission to hospital despite volume resuscitation by paramedical staff while in transit. Anatomical site and severity of injury Eighty patients had proximal pancreatic injuries (head or uncinate process 72, neck 8). Seventy-five patients had an injury to the body of the pancreas and 64 injuries involved the tail. One hundred and eleven patients had AAST grade I or II pancreatic injuries, and 108 patients grade III, IV or V pancreatic injuries (Table S1, supporting information). Surgical management All 219 patients had a laparotomy. Median time to surgery after admission to hospital was 4·3 (range 0·1–26) h. One hundred and thirty-eight patients (63·0 per cent) underwent emergency operation for an acute abdomen, intra-abdominal bleeding or shock not responding to fluid resuscitation. Eighty-one patients were haemodynamically stable after initial resuscitation. Fifty of these 81 patients also had extra-abdominal gunshot injuries, and had either a Statscan (Lodox Systems, Sandton, South Africa) (34) or contrast-enhanced CT (16) before laparotomy to delineate the extent of the extra-abdominal injuries. This allowed coordination of the proposed surgical strategy between vascular, thoracic, orthopaedic and neurosurgeons who were also involved in the treatment of the extra-abdominal injuries in individual patients. Associated injuries to other organs Only one patient had an isolated pancreatic injury. Two hundred and eighteen patients had a total of 733 associated intra-abdominal injuries, which included 91 vascular injuries. The stomach (126, 57·8 per cent), liver (125, 57·3 per cent), colon (73, 33·5 per cent), kidney (73, 33·5 per cent), diaphragm (67, 30·7 per cent), duodenum (56, 25·7 per cent) and spleen (55, 25·2 per cent) were the most commonly involved intra-abdominal organs. Duodenal injury was associated with increased morbidity (OR 2·61, 1·23 to 5·55; P = 0·011), but none of the injury locations was associated with increased mortality. One hundred and twenty patients (54·8 per cent) had three or more associated intra-abdominal injuries. One hundred and six patients (48·4 per cent) had 139 extra-abdominal bullet wounds involving the chest, limbs, spinal cord or head. Associated vascular injuries Fifty-nine patients (26·9 per cent) had 91 associated vascular injuries which included the inferior vena cava (30), renal artery and renal vein (16), superior mesenteric artery (7), aorta (6), portal vein (6), superior mesenteric vein (6), and splenic (3), hepatic (2), coeliac (1), middle colic (1) and femoral (1) arteries. The presence of an associated vascular injury correlated significantly with morbidity (P < 0·001) and mortality (P < 0·001) (Tables 1 and 2). Table 1 Univariable analysis of factors associated with overall morbidity . Total no. of patients (n = 219)* . Patients who developed complications (n = 150)* . Patients with no complications (n = 69)* . P¶ . Odds ratio‡ . Age (years)† 26 (14–64) 27 (14–64) 24 (14–69) 0·010# — Sex  M 205 140 (93·3) 65 (94) 0·807 0·86 (0·26, 2·85)  F 14 10 (6·7) 4 (6) Revised Trauma Score  0–11 57 46 (30·7) 11 (16) 0·021 2·33 (1·12, 4·85)  12 162 104 (69·3) 58 (84) Shock on admission  Yes 96 81 (54·0) 15 (22) < 0·001 4·23 (2·19, 8·14)  No 123 69 (46·0) 54 (78) Blood transfusion  Yes 167 125 (83·3) 42 (61) < 0·001 3·21 (1·68, 6·14)  No 52 25 (16·7) 27 (39) Amount transfused (units)† 6 (1–55) 8 (2–55) 4 (1–18) < 0·001# — Damage control surgery  Yes 43 41 (27·3) 2 (3) < 0·001 12·60 (2·95, 53·80)  No 176 109 (72·7) 67 (97) AAST grade  I–II 111 58 (38·7) 53 (77) < 0·001 0·19 (0·10, 0·36)  III–V 108 92 (61·3) 16 (23) Site of pancreatic injury  Head and neck 80 58 (38·7) 22 (32) 0·374 1·38 (0·68, 2·81)  Body 75 50 (33·3) 25 (36) 0·897 1·04 (0·52, 2·12)  Tail 64 42 (28·0) 22 (32) Required second pancreatic operation  Yes 20 19 (12·7) 1 (1) 0·007 9·86 (1·29, 75·25)  No 199 131 (87·3) 68 (99) Associated abdominal injuries  0–2 organs§ 99 63 (42·0) 36 (52) 0·160 0·66 (0·37, 1·18)  ≥ 3 organs 120 87 (58·0) 33 (48) Associated vascular injuries  Yes 59 53 (35·3) 6 (9) < 0·001 5·74 (2·33, 14·14)  No 160 97 (64·7) 63 (91) Required repeat laparotomies  Yes 74 71 (47·3) 3 (4) < 0·001 19·77 (5·95, 65·68)  No 145 79 (52·7) 66 (96) ICU admission  Yes 103 93 (62·0) 10 (14) < 0·001 9·63 (4·56, 20·32)  No 116 57 (38·0) 59 (86) Time in ICU (days)† 5 (1–153) 6 (1–153) 3 (1–7) 0·019# — . Total no. of patients (n = 219)* . Patients who developed complications (n = 150)* . Patients with no complications (n = 69)* . P¶ . Odds ratio‡ . Age (years)† 26 (14–64) 27 (14–64) 24 (14–69) 0·010# — Sex  M 205 140 (93·3) 65 (94) 0·807 0·86 (0·26, 2·85)  F 14 10 (6·7) 4 (6) Revised Trauma Score  0–11 57 46 (30·7) 11 (16) 0·021 2·33 (1·12, 4·85)  12 162 104 (69·3) 58 (84) Shock on admission  Yes 96 81 (54·0) 15 (22) < 0·001 4·23 (2·19, 8·14)  No 123 69 (46·0) 54 (78) Blood transfusion  Yes 167 125 (83·3) 42 (61) < 0·001 3·21 (1·68, 6·14)  No 52 25 (16·7) 27 (39) Amount transfused (units)† 6 (1–55) 8 (2–55) 4 (1–18) < 0·001# — Damage control surgery  Yes 43 41 (27·3) 2 (3) < 0·001 12·60 (2·95, 53·80)  No 176 109 (72·7) 67 (97) AAST grade  I–II 111 58 (38·7) 53 (77) < 0·001 0·19 (0·10, 0·36)  III–V 108 92 (61·3) 16 (23) Site of pancreatic injury  Head and neck 80 58 (38·7) 22 (32) 0·374 1·38 (0·68, 2·81)  Body 75 50 (33·3) 25 (36) 0·897 1·04 (0·52, 2·12)  Tail 64 42 (28·0) 22 (32) Required second pancreatic operation  Yes 20 19 (12·7) 1 (1) 0·007 9·86 (1·29, 75·25)  No 199 131 (87·3) 68 (99) Associated abdominal injuries  0–2 organs§ 99 63 (42·0) 36 (52) 0·160 0·66 (0·37, 1·18)  ≥ 3 organs 120 87 (58·0) 33 (48) Associated vascular injuries  Yes 59 53 (35·3) 6 (9) < 0·001 5·74 (2·33, 14·14)  No 160 97 (64·7) 63 (91) Required repeat laparotomies  Yes 74 71 (47·3) 3 (4) < 0·001 19·77 (5·95, 65·68)  No 145 79 (52·7) 66 (96) ICU admission  Yes 103 93 (62·0) 10 (14) < 0·001 9·63 (4·56, 20·32)  No 116 57 (38·0) 59 (86) Time in ICU (days)† 5 (1–153) 6 (1–153) 3 (1–7) 0·019# — * With percentages in parentheses unless indicated otherwise; † values are median (range). ‡ Values in parentheses are 95 per cent confidence intervals. § One patient had an isolated pancreatic injury. AAST, American Association for the Surgery of Trauma; ICU, intensive care unit. ¶ χ2 test, except # Wilcoxon rank sum test. Open in new tab Table 1 Univariable analysis of factors associated with overall morbidity . Total no. of patients (n = 219)* . Patients who developed complications (n = 150)* . Patients with no complications (n = 69)* . P¶ . Odds ratio‡ . Age (years)† 26 (14–64) 27 (14–64) 24 (14–69) 0·010# — Sex  M 205 140 (93·3) 65 (94) 0·807 0·86 (0·26, 2·85)  F 14 10 (6·7) 4 (6) Revised Trauma Score  0–11 57 46 (30·7) 11 (16) 0·021 2·33 (1·12, 4·85)  12 162 104 (69·3) 58 (84) Shock on admission  Yes 96 81 (54·0) 15 (22) < 0·001 4·23 (2·19, 8·14)  No 123 69 (46·0) 54 (78) Blood transfusion  Yes 167 125 (83·3) 42 (61) < 0·001 3·21 (1·68, 6·14)  No 52 25 (16·7) 27 (39) Amount transfused (units)† 6 (1–55) 8 (2–55) 4 (1–18) < 0·001# — Damage control surgery  Yes 43 41 (27·3) 2 (3) < 0·001 12·60 (2·95, 53·80)  No 176 109 (72·7) 67 (97) AAST grade  I–II 111 58 (38·7) 53 (77) < 0·001 0·19 (0·10, 0·36)  III–V 108 92 (61·3) 16 (23) Site of pancreatic injury  Head and neck 80 58 (38·7) 22 (32) 0·374 1·38 (0·68, 2·81)  Body 75 50 (33·3) 25 (36) 0·897 1·04 (0·52, 2·12)  Tail 64 42 (28·0) 22 (32) Required second pancreatic operation  Yes 20 19 (12·7) 1 (1) 0·007 9·86 (1·29, 75·25)  No 199 131 (87·3) 68 (99) Associated abdominal injuries  0–2 organs§ 99 63 (42·0) 36 (52) 0·160 0·66 (0·37, 1·18)  ≥ 3 organs 120 87 (58·0) 33 (48) Associated vascular injuries  Yes 59 53 (35·3) 6 (9) < 0·001 5·74 (2·33, 14·14)  No 160 97 (64·7) 63 (91) Required repeat laparotomies  Yes 74 71 (47·3) 3 (4) < 0·001 19·77 (5·95, 65·68)  No 145 79 (52·7) 66 (96) ICU admission  Yes 103 93 (62·0) 10 (14) < 0·001 9·63 (4·56, 20·32)  No 116 57 (38·0) 59 (86) Time in ICU (days)† 5 (1–153) 6 (1–153) 3 (1–7) 0·019# — . Total no. of patients (n = 219)* . Patients who developed complications (n = 150)* . Patients with no complications (n = 69)* . P¶ . Odds ratio‡ . Age (years)† 26 (14–64) 27 (14–64) 24 (14–69) 0·010# — Sex  M 205 140 (93·3) 65 (94) 0·807 0·86 (0·26, 2·85)  F 14 10 (6·7) 4 (6) Revised Trauma Score  0–11 57 46 (30·7) 11 (16) 0·021 2·33 (1·12, 4·85)  12 162 104 (69·3) 58 (84) Shock on admission  Yes 96 81 (54·0) 15 (22) < 0·001 4·23 (2·19, 8·14)  No 123 69 (46·0) 54 (78) Blood transfusion  Yes 167 125 (83·3) 42 (61) < 0·001 3·21 (1·68, 6·14)  No 52 25 (16·7) 27 (39) Amount transfused (units)† 6 (1–55) 8 (2–55) 4 (1–18) < 0·001# — Damage control surgery  Yes 43 41 (27·3) 2 (3) < 0·001 12·60 (2·95, 53·80)  No 176 109 (72·7) 67 (97) AAST grade  I–II 111 58 (38·7) 53 (77) < 0·001 0·19 (0·10, 0·36)  III–V 108 92 (61·3) 16 (23) Site of pancreatic injury  Head and neck 80 58 (38·7) 22 (32) 0·374 1·38 (0·68, 2·81)  Body 75 50 (33·3) 25 (36) 0·897 1·04 (0·52, 2·12)  Tail 64 42 (28·0) 22 (32) Required second pancreatic operation  Yes 20 19 (12·7) 1 (1) 0·007 9·86 (1·29, 75·25)  No 199 131 (87·3) 68 (99) Associated abdominal injuries  0–2 organs§ 99 63 (42·0) 36 (52) 0·160 0·66 (0·37, 1·18)  ≥ 3 organs 120 87 (58·0) 33 (48) Associated vascular injuries  Yes 59 53 (35·3) 6 (9) < 0·001 5·74 (2·33, 14·14)  No 160 97 (64·7) 63 (91) Required repeat laparotomies  Yes 74 71 (47·3) 3 (4) < 0·001 19·77 (5·95, 65·68)  No 145 79 (52·7) 66 (96) ICU admission  Yes 103 93 (62·0) 10 (14) < 0·001 9·63 (4·56, 20·32)  No 116 57 (38·0) 59 (86) Time in ICU (days)† 5 (1–153) 6 (1–153) 3 (1–7) 0·019# — * With percentages in parentheses unless indicated otherwise; † values are median (range). ‡ Values in parentheses are 95 per cent confidence intervals. § One patient had an isolated pancreatic injury. AAST, American Association for the Surgery of Trauma; ICU, intensive care unit. ¶ χ2 test, except # Wilcoxon rank sum test. Open in new tab Table 2 Univariable analysis of factors associated with overall mortality . Total no. of patients (n = 219)* . Patients who died (n = 46)* . Survivors (n = 173)* . P¶ . Odds ratio‡ . Age (years)† 26 (14–69) 28 (16–64) 25 (14–69) 0·005# — Sex  M 205 44 (96) 161 (93·1) 0·523 1·64 (0·35, 7·60)  F 14 2 (4) 12 (6·9) Revised Trauma Score  0–11 57 18 (39) 39 (22·5) 0·023 2·21 (1·11, 4·41)  12 162 28 (61) 134 (77·5) Shock on admission  Yes 96 37 (80) 59 (34·1) < 0·001 7·94 (3·59, 17·56)  No 123 9 (20) 114 (65·9) Blood transfusion  Yes 167 43 (93) 124 (71·7) 0·002 5·66 (1·68, 19·11)  No 53 3 (7) 49 (28·3) Amount transfused (units)† 6 (1–55) 16 (2–55) 4 (1–8) < 0·001# — Damage control surgery  Yes 43 24 (52) 19 (11·0) < 0·001 8·84 (4·18, 18·71)  No 176 22 (48) 154 (89·0) AAST grade  I–II 111 10 (22) 101 (58·4) < 0·001 0·20 (0·09, 0·42)  III–V 108 36 (78) 72 (41·6) Site of pancreatic injury  Head and neck 80 22 (48) 58 (33·5) 0·017 3·09 (1·22, 7·79)  Body 75 17 (37) 58 (33·5) 0·074 2·39 (0·92, 6·19)  Tail 64 7 (15) 57 (32·9) Required second pancreatic operation  Yes 20 6 (13) 14 (8·1) 0·300 1·70 (0·62, 4·71)  No 199 40 (87) 159 (91·9) Associated abdominal injuries  1–2 organs§ 99 17 (37) 82 (47·4) 0·206 0·65 (0·33, 1·27)  ≥ 3 organs 120 29 (63) 91 (52·6) Associated vascular injuries  Yes 59 28 (61) 31 (17·9) < 0·001  No 160 18 (39) 142 (82·1) 7·13 (3·51, 14·47) Required repeat laparotomies  Yes 74 19 (41) 55 (31·8) 0·225  No 145 27 (59) 118 (68·2) 1·51 (0·77, 2·95) ICU admission  Yes 103 29 (63) 74 (42·8) 0·014 2·28 (1·17, 4·46)  No 116 17 (37) 99 (57·2) Time in ICU (days)† 5 (1–153) 3 (1–150) 7 (1–53) 0·036# — Any complication  Yes 150 46 (100) 104 (60·1) < 0·001 —  No 69 0 (0) 69 (39·9) . Total no. of patients (n = 219)* . Patients who died (n = 46)* . Survivors (n = 173)* . P¶ . Odds ratio‡ . Age (years)† 26 (14–69) 28 (16–64) 25 (14–69) 0·005# — Sex  M 205 44 (96) 161 (93·1) 0·523 1·64 (0·35, 7·60)  F 14 2 (4) 12 (6·9) Revised Trauma Score  0–11 57 18 (39) 39 (22·5) 0·023 2·21 (1·11, 4·41)  12 162 28 (61) 134 (77·5) Shock on admission  Yes 96 37 (80) 59 (34·1) < 0·001 7·94 (3·59, 17·56)  No 123 9 (20) 114 (65·9) Blood transfusion  Yes 167 43 (93) 124 (71·7) 0·002 5·66 (1·68, 19·11)  No 53 3 (7) 49 (28·3) Amount transfused (units)† 6 (1–55) 16 (2–55) 4 (1–8) < 0·001# — Damage control surgery  Yes 43 24 (52) 19 (11·0) < 0·001 8·84 (4·18, 18·71)  No 176 22 (48) 154 (89·0) AAST grade  I–II 111 10 (22) 101 (58·4) < 0·001 0·20 (0·09, 0·42)  III–V 108 36 (78) 72 (41·6) Site of pancreatic injury  Head and neck 80 22 (48) 58 (33·5) 0·017 3·09 (1·22, 7·79)  Body 75 17 (37) 58 (33·5) 0·074 2·39 (0·92, 6·19)  Tail 64 7 (15) 57 (32·9) Required second pancreatic operation  Yes 20 6 (13) 14 (8·1) 0·300 1·70 (0·62, 4·71)  No 199 40 (87) 159 (91·9) Associated abdominal injuries  1–2 organs§ 99 17 (37) 82 (47·4) 0·206 0·65 (0·33, 1·27)  ≥ 3 organs 120 29 (63) 91 (52·6) Associated vascular injuries  Yes 59 28 (61) 31 (17·9) < 0·001  No 160 18 (39) 142 (82·1) 7·13 (3·51, 14·47) Required repeat laparotomies  Yes 74 19 (41) 55 (31·8) 0·225  No 145 27 (59) 118 (68·2) 1·51 (0·77, 2·95) ICU admission  Yes 103 29 (63) 74 (42·8) 0·014 2·28 (1·17, 4·46)  No 116 17 (37) 99 (57·2) Time in ICU (days)† 5 (1–153) 3 (1–150) 7 (1–53) 0·036# — Any complication  Yes 150 46 (100) 104 (60·1) < 0·001 —  No 69 0 (0) 69 (39·9) * With percentages in parentheses unless indicated otherwise; † values are median (range). ‡ Values in parentheses are 95 per cent confidence intervals. § One patient had an isolated pancreatic injury. AAST, American Association for the Surgery of Trauma; ICU, intensive care unit. ¶ χ2 test, except # Wilcoxon rank sum test. Open in new tab Table 2 Univariable analysis of factors associated with overall mortality . Total no. of patients (n = 219)* . Patients who died (n = 46)* . Survivors (n = 173)* . P¶ . Odds ratio‡ . Age (years)† 26 (14–69) 28 (16–64) 25 (14–69) 0·005# — Sex  M 205 44 (96) 161 (93·1) 0·523 1·64 (0·35, 7·60)  F 14 2 (4) 12 (6·9) Revised Trauma Score  0–11 57 18 (39) 39 (22·5) 0·023 2·21 (1·11, 4·41)  12 162 28 (61) 134 (77·5) Shock on admission  Yes 96 37 (80) 59 (34·1) < 0·001 7·94 (3·59, 17·56)  No 123 9 (20) 114 (65·9) Blood transfusion  Yes 167 43 (93) 124 (71·7) 0·002 5·66 (1·68, 19·11)  No 53 3 (7) 49 (28·3) Amount transfused (units)† 6 (1–55) 16 (2–55) 4 (1–8) < 0·001# — Damage control surgery  Yes 43 24 (52) 19 (11·0) < 0·001 8·84 (4·18, 18·71)  No 176 22 (48) 154 (89·0) AAST grade  I–II 111 10 (22) 101 (58·4) < 0·001 0·20 (0·09, 0·42)  III–V 108 36 (78) 72 (41·6) Site of pancreatic injury  Head and neck 80 22 (48) 58 (33·5) 0·017 3·09 (1·22, 7·79)  Body 75 17 (37) 58 (33·5) 0·074 2·39 (0·92, 6·19)  Tail 64 7 (15) 57 (32·9) Required second pancreatic operation  Yes 20 6 (13) 14 (8·1) 0·300 1·70 (0·62, 4·71)  No 199 40 (87) 159 (91·9) Associated abdominal injuries  1–2 organs§ 99 17 (37) 82 (47·4) 0·206 0·65 (0·33, 1·27)  ≥ 3 organs 120 29 (63) 91 (52·6) Associated vascular injuries  Yes 59 28 (61) 31 (17·9) < 0·001  No 160 18 (39) 142 (82·1) 7·13 (3·51, 14·47) Required repeat laparotomies  Yes 74 19 (41) 55 (31·8) 0·225  No 145 27 (59) 118 (68·2) 1·51 (0·77, 2·95) ICU admission  Yes 103 29 (63) 74 (42·8) 0·014 2·28 (1·17, 4·46)  No 116 17 (37) 99 (57·2) Time in ICU (days)† 5 (1–153) 3 (1–150) 7 (1–53) 0·036# — Any complication  Yes 150 46 (100) 104 (60·1) < 0·001 —  No 69 0 (0) 69 (39·9) . Total no. of patients (n = 219)* . Patients who died (n = 46)* . Survivors (n = 173)* . P¶ . Odds ratio‡ . Age (years)† 26 (14–69) 28 (16–64) 25 (14–69) 0·005# — Sex  M 205 44 (96) 161 (93·1) 0·523 1·64 (0·35, 7·60)  F 14 2 (4) 12 (6·9) Revised Trauma Score  0–11 57 18 (39) 39 (22·5) 0·023 2·21 (1·11, 4·41)  12 162 28 (61) 134 (77·5) Shock on admission  Yes 96 37 (80) 59 (34·1) < 0·001 7·94 (3·59, 17·56)  No 123 9 (20) 114 (65·9) Blood transfusion  Yes 167 43 (93) 124 (71·7) 0·002 5·66 (1·68, 19·11)  No 53 3 (7) 49 (28·3) Amount transfused (units)† 6 (1–55) 16 (2–55) 4 (1–8) < 0·001# — Damage control surgery  Yes 43 24 (52) 19 (11·0) < 0·001 8·84 (4·18, 18·71)  No 176 22 (48) 154 (89·0) AAST grade  I–II 111 10 (22) 101 (58·4) < 0·001 0·20 (0·09, 0·42)  III–V 108 36 (78) 72 (41·6) Site of pancreatic injury  Head and neck 80 22 (48) 58 (33·5) 0·017 3·09 (1·22, 7·79)  Body 75 17 (37) 58 (33·5) 0·074 2·39 (0·92, 6·19)  Tail 64 7 (15) 57 (32·9) Required second pancreatic operation  Yes 20 6 (13) 14 (8·1) 0·300 1·70 (0·62, 4·71)  No 199 40 (87) 159 (91·9) Associated abdominal injuries  1–2 organs§ 99 17 (37) 82 (47·4) 0·206 0·65 (0·33, 1·27)  ≥ 3 organs 120 29 (63) 91 (52·6) Associated vascular injuries  Yes 59 28 (61) 31 (17·9) < 0·001  No 160 18 (39) 142 (82·1) 7·13 (3·51, 14·47) Required repeat laparotomies  Yes 74 19 (41) 55 (31·8) 0·225  No 145 27 (59) 118 (68·2) 1·51 (0·77, 2·95) ICU admission  Yes 103 29 (63) 74 (42·8) 0·014 2·28 (1·17, 4·46)  No 116 17 (37) 99 (57·2) Time in ICU (days)† 5 (1–153) 3 (1–150) 7 (1–53) 0·036# — Any complication  Yes 150 46 (100) 104 (60·1) < 0·001 —  No 69 0 (0) 69 (39·9) * With percentages in parentheses unless indicated otherwise; † values are median (range). ‡ Values in parentheses are 95 per cent confidence intervals. § One patient had an isolated pancreatic injury. AAST, American Association for the Surgery of Trauma; ICU, intensive care unit. ¶ χ2 test, except # Wilcoxon rank sum test. Open in new tab Surgery The 219 patients underwent a total of 239 laparotomies for the treatment of pancreatic injuries. One hundred and sixty-nine patients (77·2 per cent) had drainage of the pancreas after haemostasis as a primary (157) or secondary (12) procedure. Fifty-nine patients (26·9 per cent) had a distal pancreatectomy and 11 (5·0 per cent) a pancreaticoduodenectomy (Table 3). Table 3 Pancreas-related surgical management Pancreas-related surgery . First intervention . Second intervention . Total . Drainage/packing 157 12 169 Distal resection and splenectomy 48 4 52 Distal resection with splenic preservation 5 2 7 Pancreaticoduodenectomy 9 2 11 Total 219 20 239 Pancreas-related surgery . First intervention . Second intervention . Total . Drainage/packing 157 12 169 Distal resection and splenectomy 48 4 52 Distal resection with splenic preservation 5 2 7 Pancreaticoduodenectomy 9 2 11 Total 219 20 239 Open in new tab Table 3 Pancreas-related surgical management Pancreas-related surgery . First intervention . Second intervention . Total . Drainage/packing 157 12 169 Distal resection and splenectomy 48 4 52 Distal resection with splenic preservation 5 2 7 Pancreaticoduodenectomy 9 2 11 Total 219 20 239 Pancreas-related surgery . First intervention . Second intervention . Total . Drainage/packing 157 12 169 Distal resection and splenectomy 48 4 52 Distal resection with splenic preservation 5 2 7 Pancreaticoduodenectomy 9 2 11 Total 219 20 239 Open in new tab Forty-three (19·6 per cent) of the 219 patients had initial DCS for complex pancreatic and associated injuries complicated by major blood loss, acidosis, coagulopathy and hypothermia, and received a median of 16 (range 2–55) units of blood. Thirty-two of the 43 patients were in shock on admission, 25 of whom had a RTS of 12. Twenty-one had associated vascular injuries and 33 had three or more associated adjacent organ injuries. Nine patients had a distal pancreatectomy and splenectomy as definitive management of the pancreatic injury during the initial damage control laparotomy, whereas the remaining 34 patients had haemostasis and drainage only. Four patients had definitive pancreatic procedures during subsequent laparotomies (pancreaticoduodenectomy 2, distal pancreatectomy and splenectomy 2). Twenty-four of the 43 patients who had DCS died (Table S2, supporting information). Eighteen patients, all with major vascular injuries, died soon after the DCS from intractable coagulopathy and bleeding after receiving a median of 20 (range 6–38) units of blood. Six patients died after multiple repeat laparotomies from multiple organ failure (3), sepsis (2) and ischaemic small bowel secondary to superior mesenteric artery thrombosis (1). The 19 survivors in the DCS group underwent between one and six repeat laparotomies and required a median of 18 (range 2–47) units of blood. Fifty-six patients (25·6 per cent) had combined pancreaticoduodenal injuries. Thirteen had AAST grade IV injuries and 14 had grade V injuries, 11 of whom had a pancreaticoduodenectomy. Nine pancreaticoduodenectomies were completed during the first laparotomy, six in patients with major associated vascular injuries (Table 3). Five patients underwent a pylorus-preserving pancreaticoduodenectomy, and six had a classic Whipple resection. Nine of the 11 patients had a stented pancreatojejunal anastomosis. In two patients gross oedema of the jejunum precluded a safe pancreatojejunal anastomosis and both had a pancreatogastrostomy. Three patients died, one from refractory coagulopathy and bleeding, and two from sepsis 5 and 41 days after the pancreaticoduodenectomy. Combined pancreatoduodenal injuries in the remaining 45 patients were amenable to primary duodenal repair and closed suction drainage of the pancreas. Those who had major duodenal injuries also had intraluminal duodenal tube drainage and a feeding jejunostomy. Morbidity Median (range) intensive care unit and total hospital stay were 5 (1–153) and 11 (1–255) days respectively. Sixty-nine patients (31·5 per cent) had no postoperative complications and had a median hospital stay of 10·7 (range 6–58) days. Twenty-three of the 69 patients, however, had a prolonged hospital stay for associated head and spinal injuries. The remaining 150 patients (68·5 per cent) had a total of 407 complications, including abdominal sepsis (39), disseminated intravascular coagulopathy (DIC) (34), bleeding (32), acute respiratory distress syndrome (30), pneumonia (27), renal failure (20), anastomotic leak (15), enterocutaneous fistula (14), bowel obstruction (6) and bile leak (6). The median number of complications per patient in this subgroup was 4 (range 1–7). Median hospital stay for patients with complications was 17 (1–255) days. The site of the pancreatic injury (proximal versus distal) was not significant with regard to development of general complications (P = 0·374). The grade of pancreatic injury, however, had a significant impact on the development of general complications (AAST grade I–II versus grade III–V injuries; P < 0·001) (Table 1). Pancreatic fistula Thirty-nine patients (17·8 per cent) developed a pancreatic fistula as a complication of the pancreatic injury. Twenty-five fistulas resolved on conservative management alone. Thirteen patients with persistent fistula underwent endoscopic retrograde cholangiopancreatography and sphincterotomy and pancreatic stenting (4) or pancreatic sphincterotomy alone (7). One patient had failed endoscopic pancreatic duct access and one patient had complete pancreatic duct disruption. Pancreatic fistulas resolved after a median of 6·4 (range 1–36) weeks. The majority of the pancreas-related complications occurred in patients with AAST grade III injuries (Table S1, supporting information). Factors associated with morbidity Univariable analysis showed that age, RTS, presence of shock, the need for transfusion and volume of blood transfused, DCS, grade of pancreatic injury, repeat laparotomy, second pancreatic surgery, associated duodenal or vascular injury, ICU admission and time in ICU were significant predictors of morbidity (Table 1). In the final multivariable logistic regression analysis model four variables were significant predictors of morbidity: age (OR 2·36, 1·09 to 5·11; P = 0·029), AAST grade of pancreatic injury (grades I–II versus III–V, OR 0·30, 0·13 to 0·69; P = 0·005), associated vascular injury (OR 3·59, 1·10 to 11·68; P = 0·033) and the need for repeat laparotomy (OR 7·01, 1·69 to 29·08; P = 0·007). Mortality Forty-six patients (21·0 per cent) with a median RTS of 10·7 (range 4–12) died from multiple organ failure (18), DIC and continued bleeding (17), sepsis (6), respiratory failure (3), mesenteric ischaemia (1) and hypoxic brain injury (1). The severity of the pancreatic injury significantly affected mortality (AAST grade I–II versus grade III–V injuries; P < 0·001) (Table 2). Patients who died had a median of 3 (range 1–7) complications, and 17 had four or more complications. Thirty-seven of the 46 patients who died were in shock on admission. Median transfusion requirement in this group was 16 (range 2–55) units of packed cells. Shock on admission to hospital was a significant predictor of mortality (P < 0·001). Twenty-eight of the patients who died had associated vascular injuries (P < 0·001). There were 22 deaths among 80 patients with proximal pancreatic injuries compared with 24 among 139 who had distal pancreatic injuries (P = 0·017) (Table 2). Only three patients who had pancreas-related complications died, all from sepsis. One patient had complicated gastric and duodenal repair leaks, one had a colonic anastomotic leak and another had a small bowel leak; all developed peripancreatic abscesses. All three had multiple relaparotomies, and eventually died from sepsis with multiple organ failure. Influence of damage control surgery Analysis of the data from two cohorts before the introduction of DCS (1976–1994) and including DCS (1995–2009) showed an increase in mortality from 9 to 23·0 per cent, with a mortality rate of 56 per cent in patients who had a damage control procedure (Table S2, supporting information). The 1995–2009 group had significantly more associated injuries than the earlier group (64·7 versus 41 per cent with at least three associated injuries); 39 of 43 patients undergoing DCS had three or more associated injuries. Predictors of mortality Univariable analysis showed that age, RTS, presence of shock, need for a major transfusion and volume transfused, need for DCS, severe grade of pancreatic injury and proximal pancreatic injuries, associated colonic, duodenal and vascular injuries, postoperative complications, ICU admission and time in ICU were significantly associated with death (Table 2). However, in the final stepwise multivariable logistic regression analysis model only five variables were significant predictors of death: age (OR 4·42, 1·60 to 12·20; P = 0·004), shock (OR 6·38, 2·07 to 19·60; P < 0·001), need for DCS (OR 3·19, 1·22 to 8·35; P = 0·018), severe AAST grade injuries (grades I–II versus III–V, OR 0·34, 0·13 to 0·88; P = 0·027) and associated vascular injuries (OR 8·17, 2·75 to 24·25; P < 0·001). Discussion Half of these patients with gunshot injuries to the pancreas had low-grade injuries that could be treated successfully by external drainage. The commonest major injury in this series involved the proximal body or neck of the pancreas, which required a distal pancreatectomy. With careful assessment of the injury by intraoperative evaluation, most pancreatic injuries could be managed by either drainage or distal resection without the need for complex enteric diversions or pancreaticoenteric anastomoses as a primary procedure during the acute injury in patients with multiple associated injuries. Overall reported morbidity rates following pancreatic injury range from 30 to 70 per cent, and are primarily related to associated vascular, hepatic and bowel injuries5–7. Penetrating pancreatic injuries result in substantial collateral damage owing to the close proximity of adjacent organs and critical vascular structures. All but one of 219 patients in this series (99·5 per cent) had associated intra-abdominal injuries, confirming that isolated penetrating pancreatic injuries are rare. The finding of 3·3 associated injured organs per patient is consistent with the 2·5–4·0 associated injured organs reported in other series5–7,13,14,18,19. Up to 70 per cent of pancreatic injuries in other series were reported as minor5–7. In the present study only 50·7 per cent of injuries were classified as minor (AAST I–II) and 49·3 per cent injuries as major (AAST III–V). In all injury grades, more than half of the patients had at least three associated intra-abdominal organ injuries. Increasing severity of pancreatic injury in this study significantly influenced overall morbidity and mortality. The incidence of pancreas-related complications was 17·8 per cent, which is less than the published range of 21·8–38·5 per cent5–7,19,20. The most common pancreatic complication in this and other series was pancreatic fistula5,6. Most fistulas can be managed conservatively and resolve spontaneously. For persistent fistulas, a pancreatic duct stent placed endoscopically has been reported as a successful measure21,22. When stenting fails, a distal pancreatectomy is recommended for a fistula originating in the body or tail, whereas a Roux-en- Y pancreatojejunostomy has been used for persistent fistulas involving the main pancreatic duct in the head or neck of the pancreas3,4. Reported mortality rates for pancreatic injuries range from 12 to 46 per cent5–7,13,14,18,19. The degree of preoperative shock, vascular injuries, number of associated injuries, and location and complexity of the pancreatic injury are factors reported to influence overall mortality1–4. In the present study shock at presentation was predictive of death. The overall mortality rate was 21·0 per cent, and more than half of deaths were among patients with major associated vascular injuries. Others have noted major bleeding from associated vascular injuries to be a significant factor in early deaths5–7,18. In this study one in four patients had vascular injuries, with the inferior vena cava and renal vessels most commonly involved, compared with one-third of patients with associated vascular trauma in other studies6,7,18–21. DCS is now an essential strategy in the management of complex trauma aggravated by coagulopathy, hypothermia and acidosis22. A surprising and counterintuitive finding was that the overall mortality rate increased in the more recent period when DCS was applied. Over half of the patients requiring an initial damage control procedure died, which is higher than the reported mortality rate of 17–31 per cent23,24 for DCS in penetrating trauma. A likely explanation for the increased mortality rate despite DCS is the increased incidence of associated major abdominal and visceral vascular injuries in penetrating pancreatic trauma22,25,26. Pancreaticoduodenectomy for combined pancreaticoduodenal injuries is seldom necessary, and is reserved for patients with severe injuries of the head of pancreas and duodenum in whom primary repair is not feasible1,27. The mortality rate for a Whipple resection in severely injured and unstable patients is prohibitive, with most series also showing a high rate of postoperative complications1,3,27. When faced with a devitalized head of the pancreas and duodenum, an avulsed ampulla or a near-complete traumatic resection, a surgeon may have little choice but to proceed and complete the resection provided that the patient is haemodynamically stable and the necessary surgical expertise available3,27. According to consensus, patients with major pancreatic injuries and haemodynamic instability due to bleeding, hypothermia, acidosis or coagulopathy should have an abbreviated laparotomy with a damage control procedure and subsequent re-exploration, resection and reconstruction when stable23–25. When a pancreatoduodenectomy is necessary, technical difficulties may arise in the reconstruction of the pancreatic and biliary anastomoses owing to the small size of the ducts and gross oedema of the jejunum3,27. Two patients in this series had a pancreatogastrostomy that overcame the technical problem. These technical difficulties illustrate the added complexity of a Whipple resection when required for trauma and the need for the assistance of an experienced pancreatic surgeon during the resection3,27. Acknowledgements The authors thank Rauf Sayed, Senior Biostatistician, School of Public Health and Family Medicine, University of Cape Town, for assistance with the statistical analysis. Disclosure: The authors declare no conflict of interest. References 1 Subramanian A , Dente CJ, Feliciano DV. The management of pancreatic trauma in the modern era . Surg Clin North Am 2007 ; 87 : 1515 – 1532 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Degiannis E , Glapa M, Loukogeorgakis SP, Smith MD. Management of pancreatic trauma . Injury 2008 ; 39 : 21 – 29 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Krige JE , Beningfield SJ, Nicol AJ, Navsaria P. The management of complex pancreatic injuries . S Afr J Surg 2005 ; 43 : 92 – 102 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 4 Chrysos E , Athanasakis E, Xynos E. Pancreatic trauma in the adult: current knowledge in diagnosis and management . Pancreatology 2002 ; 2 : 365 – 378 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Young PR Jr, Meredith JW, Baker CC, Thomason MH, Chang MC. Pancreatic injuries resulting from penetrating trauma: a multi-institution review . Am Surg 1998 ; 64 : 838 – 843 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 6 Vasquez JC , Coimbra R, Hoyt DB, Fortlage D. Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center . Injury 2001 ; 32 : 753 – 759 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Kao LS , Bulger EM, Parks DL, Byrd GF, Jurkovich GJ. Predictors of morbidity after traumatic pancreatic injury . J Trauma 2003 ; 55 : 898 – 905 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Krige JEJ , Bornman PC, Beningfield SJ, Funnell IC. Pancreatic trauma. In Hepatobiliary and Pancreatic Disease , Pitt H, Carr-Locke D, Ferrucci J (eds). Little, Brown : Philadelphia , 1995 ; 421 – 436 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 9 Krige JE , Beningfield SJ, Bornman PC. Management strategies in pancreatic trauma. In Recent Advances in Surgery (29th edn), Johnson C, Taylor I (eds). Royal Society of Medicine : London , 2006 ; 95 – 118 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 10 Farrell RJ , Krige JE, Bornman PC, Knottenbelt JD, Terblanche J. Operative strategies in pancreatic trauma . Br J Surg 1996 ; 83 : 934 – 937 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Lewis G , Krige JE, Bornman PC, Terblanche J. Traumatic pancreatic pseudocysts . Br J Surg 1993 ; 80 : 89 – 93 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Funnell IC , Bornman PC, Krige JE, Beningfield SJ, Terblanche J. Endoscopic drainage of traumatic pancreatic pseudocysts . Br J Surg 1994 ; 81 : 879 – 881 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Degiannis E , Levy RD, Velmahos GC, Potokar T, Florizoone MG, Saadia R. Gunshot injuries of the head of the pancreas: conservative approach . World J Surg 1996 ; 20 : 68 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Degiannis E , Levy RD, Potokar T, Lennox H, Rowse A, Saadia R. Distal pancreatectomy for gunshot injuries of the distal pancreas . Br J Surg 1995 ; 82 : 1240 – 1242 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Madiba TE , Mokoena TR. Favourable prognosis after surgical drainage of gunshot, stab or blunt trauma of the pancreas . Br J Surg 1995 ; 82 : 1236 – 1239 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Moore EE , Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA et al. Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum . J Trauma 1990 ; 30 : 1427 – 1429 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Thorsen K , Ringdal KG, Strand K, Søreide E, Hagemo J, Søreide K. Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury . Br J Surg 2011 ; 98 : 894 – 907 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Ivatury RR , Nallathambi M, Rao P, Stahl WM. Penetrating pancreatic injuries. Analysis of 103 consecutive cases . Am Surg 1990 ; 56 : 90 – 95 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 19 Hwang SY , Choi YC. Prognostic determinants in patients with traumatic pancreatic injuries . J Korean Med Sci 2008 ; 23 : 126 – 130 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Antonacci N , Di Saverio S, Ciaroni V, Biscardi A, Giugni A, Cancellieri F et al. Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome? J Hepatobiliary Pancreat Sci 2011 ; 18 : 195 – 201 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Lin BC , Liu NJ, Fang JF, Kao YC. Long-term results of endoscopic stent in the management of blunt major pancreatic duct injury . Surg Endosc 2006 ; 20 : 1551 – 1555 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Wang GF , Li YS, Li JS. Damage control surgery for severe pancreatic trauma . Hepatobiliary Pancreat Dis Int 2007 ; 6 : 569 – 571 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 23 Seamon MJ , Kim PK, Stawicki SP, Dabrowski GP, Goldberg AJ, Reilly PM et al. Pancreatic injury in damage control laparotomies: is pancreatic resection safe during the initial laparotomy? Injury 2009 ; 40 : 61 – 65 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Smith BP , Adams RC, Doraisway VA, Nagaraja V, Seamon MJ, Wisler J et al. Review of abdominal damage control and open abdomens: focus on gastrointestinal complications . J Gastrointest Liver Dis 2010 ; 19 : 425 – 435 . Google Scholar OpenURL Placeholder Text WorldCat 25 Brenner M , Bochicchio G, Bochicchio K, Ilahi O, Rodriguez E, Henry S et al. Long-term impact of damage control laparotomy: a prospective study . Arch Surg 2011 ; 146 : 395 – 399 . Google Scholar Crossref Search ADS PubMed WorldCat 26 Stawicki SP , Schwab CW. Pancreatic trauma: demographics, diagnosis, and management . Am Surg 2008 ; 74 : 1133 – 1145 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Krige JEJ , Bornman PC, Terblanche J. The role of pancreatoduodenectomy in the management of complex pancreatic trauma. In Pancreatoduodenectomy , Hanyu F, Takasaki K (eds). Springer : Tokyo , 1997 ; 49 – 62 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Surgical management and outcome of civilian gunshot injuries to the pancreas
JO - British Journal of Surgery
DO - 10.1002/bjs.7761
DA - 2011-12-22
UR - https://www.deepdyve.com/lp/oxford-university-press/surgical-management-and-outcome-of-civilian-gunshot-injuries-to-the-a6UO2hZZHk
SP - 140
EP - 148
VL - 99
IS - Supplement_1
DP - DeepDyve
ER -