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SURGERY

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  • PANCREATIC TRAUMAPresented by

    Manojit Mandal

  • Overview

  • General pointsPancreas & Duodenum are difficult structures for Surgical exposure.

    They are retroperitoneal structures; so, isolated pancreatic injuries dont usually present with peritonitis. Also, the injuries present late.

    They have intimate anatomical relations with large vessels like SMA & vein, IVC, Pancreaticoduodenal, hepatic & splenic vessels.

  • General points Prognosis is influenced by : Cause & complexity of injury.Amount of blood loss.Duration of shock.Speed of resuscitation.Type of surgical intervention.

    Delay in diagnosis is M/C cause of morbidity/ mortality.

  • Mechanism of injuryBlunt trauma : neck or body is compressed against lumbar spine usu. in steering wheel injury (M
  • Associated Injuries50-90% of patients have associated injuries.

    A mean of 3.5 other organs are injured.

    Most morbidity/mortality depend upon the associated injuries; not the Pancreatic injury itself.

    M/c injured organs are :Liver, Stomach, major vessels, Thoracic viscera, Colon & small-bowel, spinal-cord vertebra & Duodenum.

  • Grading of injury : Organ injury scale(Modified Lucas classification)(vis a vis AAST scale)

    Class-1 : Superficial contusion/lacerationWithout major ductal-injury Any part of pancreas

    (AAST -1 :American association for the Surgery of Trauma scale )

  • Organ injury scale(Modified Lucas classification)

    Class- 2 & 3 : Deep laceration/transectionWith/without ductal injury Neck/body/tail (cl-2), head (cl-3)(AAST-2 without duct injury, AAST-3 distal & AAST-4 proximal pancreatic injury alongwith duct injury )

    Class- 4 : Combined pancreatico-duodenal injury (involving ampulla, AAST-5)

  • Diagnosis

  • DiagnosisInjury is clinically not much evident d/t central retroperitoneal position and abundance of associated injuries. Usually diagnosed at laparotomy.

    Serum biochemistry : level of serum amylase poorly correlate with pancreatic injury. It has both high false +ve: high amylase in intact pancreas (10-90%) & high false ve :normal amylase with injury (25-97%).

    Amylase measured after 3 hrs & serially rising amylase have a little better prognostic value.

  • Diagnostic Radiology : CECTInv. Of choice in haemodynamically stable pt.& Late complication of trauma.

    Overall 90% sensitive.

    For major ductal injuries low sensitivity(43%)Low before 12 hrs d/t overlying blood or obscure laceration planes.

  • Diagnostic Radiology : CECTFeatures : for any injury : focal/diffiuse pancreatic enlargement/oedema; infiltration of peripancreatic soft tissue. Laceration: linear, irregular, low attenuation areas (fluid/ haematoma) within normal-looking parenchyma.

    Subtle changes are found in early cases; cases with minimal retroperitoneal fat

  • Diagnostic Radiology : others

    ERCP :problems : There may be distorted recognisable mucosal landmarks incl. papilla d/t haematoma or pacreatic- oedema. Pancreatography is problematic d/t failure to cannulate ampulla (10%)

    Helpful in late compl. Of pancreatic injury : in Fistula for stenting;in pseudocyst for transgastric drainage

  • Diagnostic Radiology : othersMRCP : non-invasive ; No need for dye, since fluid-filled duct shows high signal density.Duct anatomy upstream of injury is also visualised (cf.ERCP).Rapid MR takes
  • Intra-OP diagnosisClues to Pancreatic injury: Central retroperitoneal hematoma, & intra abdominal bile-staining.

    Intra operative pancreatography is done if Pre-OP duct delineation not sufficient. Methods are;Trans-duodenal pancreatic duct cathetarisation,Distal cannulation of duct in tail,Needle cholecysto-cholangiogram.

  • Management

  • ManagementCONTUSION & LACERATIONS WITHOUT DUCT INJURY

    70% of injuries.Control of bleeding, closed external drainage, without repair of capsular laceration is all that is required.

  • ManagementDISTAL INJURY WITH DUCT DISRUPTION

    Treated best with distal pancreatectomy with splenectomy.Visible duct at cut end is ligated with transfixing suture, pancreas is oversewed.

    Spleen sparing surg. Requires ligation of 7-10 splenic art. Branches, & 13-22 splenic vein branches ; so rarely done.Roux en Y pancreatojejunostomy involving the resection margin has high risk of anastomotic leak.

  • ManagementPROXIMAL INJURY WITH PROBABLE DUCT DISRUPTION

    Best managed by simple external drainageProvided there is no devitalisation & ampulla is intact.

    A controlled fistula is formed ; either settle spontaneously, or may later require elective internal drainage after definition of exact site of duct leakage.

  • ManagementCOMBINED MAJOR PANCREATICODUODENAL INJURIES

    Involves head of pancreas, adjacent duodenum &/or papilla, likely to include major vascular structures. They occur in 10% of cases. For unstable pts.,initial goal is: hemostasis (may even req. pancreatoduodenectomy as initial Opn ), minimising contamination, repairing torn bowel, then associatd injuries (damage control ). Followed by aggressive resuscitation > Definitive surgery.

  • ManagementCOMBINED MAJOR PANCREATICODUODENAL INJURIES

    More definitive operations to divert gastric, pancreatic & biliary secretions away from duodenum should be considered when pt. is stable. Occur in

  • ManagementCOMBINED MAJOR PANCREATICODUODENAL INJURIES

    Duodenal diverticulization : Aim is to convert a potentially uncontrolled lateral duodenal fistula into a controlled end fistula.

    suture repair of duodenal injuryExtensive periduodenal & peripancreatic drainage

    Antrectomy & gastrojejunostomy (gastric diversion)Choledochotomy & Ttube drain (biliary diversion)Tube duodenostomy( for decompression)

  • ManagementCOMBINED MAJOR PANCREATICODUODENAL INJURIESPyloric exclusion/gastrojejunostomy

    Through a gastrostomy, the pylorus is closed with a purse-string suture & antecolic gastrojejunostomy performed at gastrostomy site. Duodenal injuries repaired & area extensively debrided.

    Use of slowly absorbable (2-3 wks) suture in pyloric closure results in a patent & functional pylorus in 90% pts after 3 wks.

  • ManagementCOMBINED MAJOR PANCREATICODUODENAL INJURIESTriple tube decompression

    Placement of gastrostomy tube (gastric decompression)Drainage of duodenum via a tube passed retrogradely through a jejunostomyAntegrade jejunostomy tube for enteral nutrition

    Rapid method, problem is inadequate diversion & tube dislodgement.

  • ManagementADJUNCTSNutritional support : Feeding jejunostomy is recommended in all patients with major injuries precipitating prolonged gastric ileus. TPN is required if enteral accss not possible.

    Somatostatin & analoguesThey are recommended in post-OP pancreatic fistulas.

  • Complications

  • ComplicationsPost OP complication rate is 42%, even more with combined & associated injuries. Most morbidities are treatable.

    Complications are early or late.Early :Pancreatic fistulaFluid collection/abscessSecondary HgePancreatitis

    Late:PseudocystEndocrine & exocrine deficit

  • ComplicationsPancreatitis : may vary from transient biochemical leak to fulminant Haemorrhageic pancreatitis. Around 7% of traumas. Most respond to conservative Tm.

    Pancreatic fistula:m/c specific compl. after injury . Resolve within 1-2 wk if adequately drained.

    High output (>700 ml/d) persisting >10d; usu. associated with major duct-injury.Supplimentary nutrition & octreotide , Sinogram to define ductal injury site, Endoscopic papillary stenting, distal resection for tail injury,

  • ComplicationsFluid collection/abscess: Usually Peripancreatic, subhepatic, subphrenic. True pancreatic abscess is uncommon.Inf. Suggested by increased temp, leucocytosis, prolonged ileus.Guided FNAC for C/S & amylase, therapeutic aspiration if possible + antibiotic are required.

    Secondary Haemorrhage :From pancreatic bed, & surrounding vessels.d/t infected devitalised tissue, & retroperitoneal autodigestion.Try angiographic embolisation> operative ligation.

  • ComplicationsPseudocyst :D/t. Undetected duct disruption with contd. Leakage.For symptomatic/enlarging cyst: ERCP/MRCP for duct delineation > intervention.Distal duct leak/ minor leak: P/cut. guided aspiration.Proximal leak : endoscopic drainage, if failed, Cystoenterostomy.

  • Complications

    Exocrine & endocrine deficit :resection distal to SMA leaving head (20% of pancr. mass) is functionally enough. For more resection replacement therapy required.

    Mortality: early death d/t vascular & associated injuryLate death is d/t sepsis & MOF.

  • THANK YOU