pancreatic injury

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    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


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


    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.


    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.


    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.


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


    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.


    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.