Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclusion with vagotomy

The operative management and clinical course of 17 patients treated for severe pancreatico-duodenal injuries from 1983 to 1990 was reviewed. The etiology of these injuries was gunshot wound in 15 patients; stab wound in 1 patient; and a motor vehicle accident in 1 patient. Seven patients presented in shock with a systolic blood pressure of less than 80. At exploration, 57 associated injuries were found in the 17 patients including 16 major vascular injuries. All patients were treated with pyloric exclusion and drainage. Vagotomy was performed in eight patients. None of these 17 patients were felt to have extensive enough damage to require pancreatico-duodenectomy. Two patients died in the immediate postoperative period of severe coagulopathy and two patients died of sepsis. Seven patients had complications related to the pancreatico-duodenal injury. All seven developed pancreatic fistulas; three also had pancreatitis and two developed multiple enterocutaneous fistulas. Systemic complications included pulmonary complications in eight patients and sepsis in five patients, including two patients with abdominal abscesses. Six patients bled in the immediate postoperative period secondary to coagulopathy. Three patients had complications related to pyloric exclusion. One developed afferent loop syndrome necessitating reoperation. The other two had marginal ulcers, which either perforated or bled and required reoperation. Of interest, neither of these two patients had vagotomy initially. The results of this series confirm the effectiveness of pyloric exclusion with vagotomy for severe pancreatico-duodenal injury.