Wounded surgical soul: persistent challenges in the management of pancreaticoduodenal injuries with major vascular injuries

Background: The "surgical soul" indicates a small spherical area at the head of pancreas with adjacent major vessels. Traumatic injuries to this area are known for the extreme complexity to manage. The aim of this study was to describe the characteristics and outcomes of patients with wounded surgical soul using a nationwide dataset. Methods: We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database (2013-2018). We included patients (age ≥16 years) with Abbreviated Injury Scale (AIS) ≥4 pancreatic and/or duodenal injuries with associated injuries to any of the following vessels: inferior vena cava (IVC), superior mesenteric artery/vein injury (SMA/SMV), portal vein (PV), renal vein (RV), and splenic vein (SV). Multivariate logistic regression was performed to identify factors associated with in-hospital mortality. Results: A total of 219 patients were identified. Of those, 178 (81.3%) sustained penetrating trauma. Pancreatic injury accounted for 73.5% of all patients, 39.8% with duodenal injury, 45.2% with IVC injury, 11.0% with SMA injury, and 56.6% with PV/SMV/RV/SV injury. Liver (56.2%), colon (47.0%), and stomach (37.9%) were common associated injuries. The overall in-hospital mortality rate was 58% with most deaths occurring 10 units within 24 hours were factors associated with mortality. Conclusions: Injuries to the surgical soul are rare but associated with a significant mortality risk. The surgical strategy should focus on early hemorrhage control to improve the likelihood of patient survival. Level of evidence: Prognostic/epidemiological, level IV.