Pancreatic Trauma

Muhammad Haris Aslam Janjua

Resident, Surgical unit I

SIMS/Services Hospital, Lahore

Outline

• Introduction• Relevant anatomy• Epidemiology• Etiology• Presentation• Indicators of injury• Workup• Staging• Treatment

Introduction

• Pancreas lies in a relatively protected position high in the retroperitoneum

– infrequently injured in typical blunt injuries (eg, from motor vehicle crashes) compared with its splenic and hepatic counterparts.

• Conversely, penetrating abdominal trauma

– more frequently includes pancreatic injury.

Relevant Anatomy

• Posteriorly protected by– Rib cage

– Thick dorsal muscle groups (paraspinous)

• Anteriorly protected by– adult rectus and abdominal muscles,

– combined with the energy-absorbing characteristics of the liver, colon, duodenum, stomach, and small bowel• provide physiologic padding that protects the pancreas

from blunt injury.

Relevant Anatomy

• Proximity of vascular structures to the head of the pancreas has a marked effect on the morbidity and mortality.

– Subhepatic IVC and the aorta sit just posterior to the pancreatic head to the patient's right side

– Superior mesenteric vein coalesces into the portal vein immediately behind the pancreas

– Splenic artery (off the celiac trunk) and vein (draining into the portal vein) run superior and posterior to the body and tail of the pancreas and are relatively easier to expose and control compared to the IVC and portal vein

Epidemiology

• The pancreas is estimated to be the 10th most injured organ

– Gunshot wounds,

– shotgun injuries,

– stabbings

• to the back, flank, and abdomen frequently include pancreatic injury,

• occurring in ~ 20-30% of all patients with penetrating traumas.

Etiology

• Isolated Pancreatic injury may result from Penetrating trauma to the mid back .

• In a blunt trauma–induced isolated pancreatic injury,– fracture over the spinal column is usually observed in

smaller children– caused by direct abdominal blows from malpositioned seat

belts .

• Penetrating trauma caused by firearms results in the highest frequency of pancreatic injury– associated with concurrent injury to other intra-abdominal

organs

Presentation

• A high degree of clinical awareness is necessary to ensure that pancreatic injuries are not overlooked or missed

• The type of injury (ie, blunt vs penetrating) and information about the injuring agent (eg, GSW, knife) help focus the clinician on the possibility of pancreatic injury.

• Physical examination.• Seat belt marks • flank ecchymoses, or penetrating injuries.• Dull epigastric pain or back pain

– due to contained fracture of the spleen with retroperitoneal hematoma or leak.

• severe peritoneal irritation

Indicators of injury

• In Blunt trauma– Retroperitoneal hematoma,

– retroperitoneal fluid,

– free abdominal fluid,

– pancreatic edema

• In patients with penetrating trauma– visualization of perforation,

– hemorrhage or fluid leak (eg, bile, pancreatic fluid),

– Retroperitoneal hematoma around the pancreas

American association for surgery of trauma StagingPancreas Injury Scale

Grade* Type of Injury Description of Injury AIS-90

I Hematoma Minor contusion without

duct injury

2

Laceration Superficial laceration

without duct injury

2

II Hematoma Major contusion without

duct injury or tissue loss

2

Laceration Major laceration without

duct injury or tissue loss

3

III Laceration Distal transection or

parenchymal injury with

duct injury

3

IV Laceration Proximal? transection or

parenchymal injury

involving ampulla

4

V Laceration Massive disruption of

pancreatic head

5

*Advance one grade for multiple injuries up to grade III. *863.51,863.91 - head; 863.99,862.92-body;863.83,863.93-

tail. aProximal pancreas is to the patients’ right of the superior mesenteric vein.From Moore et al. [6]: with

permission.

Abbreviated injury Score

AIS-Code InjuryAIS % prob. of

death

1 Minor 0

2 Moderate 1 – 2

3 Serious 8 – 10

4 Severe 5 – 50

5 Critical 5 - 50

6 Maximum 100

9

Not further

specified

(NFS)

WorkUp

Laboratory studies

• Elevation in amylase levels is suggestive of pancreatic injury or inflammation but is not diagnostic

• Elevated amylase levels in trauma may be from– salivary glands,

– small bowel injury,

– ovarian injury

– Perforated ulcer

– Ruptured Tubal pregnancy .

Workup

• Amylase detected in diagnostic peritoneal lavage(DPL) fluid is much more sensitive and specific for

pancreatic injury than blood or serum amylase determinations if diagnosis is in doubt.

Workup

Imaging Studies

• Plain Xray Abdomen may detect foreign bodies such as bullet fragments and projectile-induced bony injury

CT scan• A CT scan of the abdomen provides the simplest and

least invasive method to diagnose pancreatic injury.• Sensitivity is 40-68 %• Contraindicated in patients

– who are hemodynamically unstable– who have a penetrating trauma in which the decision for

operative intervention has been made

A CT scan performed after abdominal trauma showing diffuse pancreatic enlargement and was interpreted as suspicious for pancreatic injury. (Grade

1 injury)

Grade II pancreatic injury: Superficial pancreatic laceration without ductInjury.

Contrast CT scan showing transection of distal pancreas

Intra-operative photograph of transected distal body of pancreas (arrow).

Grade III injury

Grade 4 pancreatic transection

Grade V pancreatic injury: Pancreatic fracture with disruption of the pancreatic duct in a 27-year-old man after a motor vehicle collision. Axial contrast-enhanced CT

scan obtained at presentation shows a fracture of the pancreatic neck (arrow) with multiple expanding fluid collections (star). Intraoperative image confirmed the

findings, cystogastrostomy was performed.

Workup

• A CT scan of the pancreas is also useful in the follow-up care of patients with – pancreatic injury and trauma. – Traumatic pancreatic cysts,– pseudocysts, – delayed ductal injury,– pancreatic transection, – pancreatitis, – abscess, – pancreatic necrosis,– splenic artery aneurysms may be noted after surgery or

after the patient is released from the hospital.

Workup

• Magnetic resonance cholangiopancreatography(MRCP)

– is being used to assess injury to the ductal components but not frequently used.

• In the patient who is unstable, operative exploration provides the optimal diagnostic

tool for pancreatic injury

Workup

• ERCP is Gold standard for detection of pancreatic ductal injuries.

• Some authors suggest early ERCP

– i.e. within 6-12 h of injury

– to minimize delayed complications

– Can be done on operating table

Grade and location of injury Injury description

Pancreas

Class I (P1) Capsular damage, minor parenchymal damage

Class II (P2) Partial/complete duct transection in the body/tail

Class III (P3) Major duct injury involving the head of pancreas or the intrapancreatic common bile duct

Duodenum

Class I (D1) Contusion, haematoma or partial thickness injury

Class II (D2) Full thickness duodenal injury

Class III (D3) Full thickness injury with > 75% circumference injury or injury to the extrahepatic common bile duct

Combined

Type I P1D1, P2D1, D2P1

Type II D2P2

Type III D3P1–2, P3D1–2

Type IV D3P3

Frey and Wardell classification of pancreatic trauma.

• Takishima et al. have used ERCP to describe a three class classification of pancreatic ductalinjuries

Class interpretation

Class 1 Normal duct

Class 2a contrast from branch injuries does not leak outside the pancreatic parenchyma

Class 2b Contrast from branch injuries leaks into the retroperitoneal space

Class 3 Main duct injuries

• Takishima correlated the classification scheme with subsequent surgical management .

Injury treatment

class 1 and class 2a conservative

Class 2b and class 3 Laprotomy / drainage

Treatment

• Indication of conservative management– Blunt trauma with Hemodynamically stable patient.

– Negative Fast scan

– CT scans showing no evidence of • pancreatic parenchymal fracture,

• parenchymal hematoma,

• parenchymal edema,

• fluid in the lesser sac, or retroperitoneal hematoma.

• Patients having suspicion of pancreatic injury should be observed for at least 72 hours .

• Indications of exploratory laprotomy include

– Penetrating injury in region of pancreas

– Peritonitis based on physical examination

– Hypotension in combination with a positive focussed assessment with sonography (ultrasound) for trauma (FAST);

– Pancreatic duct disruption based on the results of CT scan or ERCP.

– Positive abdominal lavage following blunt trauma

Surgical treatment• Minor injuries that should not be explored unless ductal injury is suspected

are

– capsular tears,

– superficial lacerations,

– bullet wounds of the body or tail,

– small contusions,

• Soft closed suction drains (eg, Jackson-Pratt, Blake) should be used

• Continued drainage with high amylase levels persisting beyond 48-72 hours is highly suggestive of a missed ductal injury.

• In this case options include

– ERCP

– Trial of TPN .

– Re-exploration

• Optimal management of pancreatic trauma is determined by– where the parenchymal damage is located

– Whether the intrapancreatic common bile duct and main pancreatic duct remains intact.

• To determine the integrity of the pancreatic duct, several options exist– Direct exploration of the parenchymal laceration

– Operative pancreatography can be performed through a duodenotomy by cannulating the duct using a 5F pediatric feeding tube

• An alternative to pancreatography is to pass a 1.5- to 2.0-mm coronary artery dilator into the main duct via the papilla and observe the depth of the pancreatic wound. – If the dilator is seen in the wound, a ductal injury is

confirmed.

• A third method for identifying pancreatic ductal injuries is endoscopic retrograde pancreatography peroperatively

• Options for treating injuries of the pancreatic body and tail when the pancreatic duct is transected include

– In stable patients, spleen-preserving distal pancreatectomy should be performed.

– An alternative, which preserves both the spleen and distal transected end of the pancreas, is either a Roux-en-Y pancreaticojejunostomy or pancreaticogastrostomy

• If the patient is physiologically compromised, distal pancreatectomy with splenectomy is the preferred approach

• Regardless of the choice of definitive procedure, the pancreatic duct in the proximal edge of transected pancreas should be individually ligated

• Injuries to the pancreatic head add an additional element of complication because the intrapancreatic portion of the common bile duct traverses this area and often converges with the pancreatic duct.

• Identification of intrapancreatic common bile duct disruption– First method is to squeeze the gallbladder and look for

bile leaking from the pancreatic wound.

– Cholangiography, optimally via the cystic duct, is diagnostic

• Definitive treatment of this injury entails division of the common bile duct superior to the first portion of the duodenum, with ligation of the distal duct and reconstruction with a Roux-en-Y choledochojejunostomy.

• For injuries to the head of the pancreas that involve the main pancreatic duct but not the intrapancreatic bile duct,

– Distal pancreatectomy alone is rarely indicated due to the extended resection of normal gland and the resultant risk of pancreatic insufficiency

• Central pancreatectomy preserves the common bile duct, and mobilization of the pancreatic body permits drainage into a Roux-en-Y pancreaticojejunostomy.

• Pancreaticoduodenectomy is more appropriate in patients with multiple injuries.

• If closed suction drains have been inserted for major pancreatic trauma, these should remain in place until the patient is tolerating an oral diet or enteral nutrition.

Spleen preserving distal pancreatectomy

Central pancreatectomy

For injuries of the pancreatic head that involve the pancreatic duct but spare the common bile duct, central pancreatic resection with Roux-en-Y pancreaticojejunostomyprevents pancreatic insufficiency.

Pancreatoduedenectomy

Complications

• Pancreatic Fistula

• Peripancreatic abscess

• Pancreatic pseudocyst

• Delayed complications include– recurrent pancreatitis,

– splenic artery aneurysm,

– and endocrine or exocrine insufficiency.

Complications

• Pancreatic fistula is most common (20 %)

• Pancreatic fistula is diagnosed after postoperative day 5 in patients with drain output of >30 mL/d and a drain amylase level three times the serum value.

• Wide local drainage and good nutrition and supportive care, fistulas usually resolve spontaneously within 2 weeks of injury.

• Prolonged output of greater than 250 mL/d for more than 2 weeks or outputs of 750 mL/d or more should prompt ERCP or other diagnostic evaluation of the ductal system.

• Octreotide may be used to decrease fistula output.

Peripancreatic Abscess

• The best treatment modality involves antibiotics and CT-guided external drainage.

• Failure of the external drainage to resolve the abscess mandates operative drainage.

Pancreatic pseudocyst• If the patient is symptomatic or the size of the pseudocyst is enlarging,

MRCP or ERCP should be done to identify any ductal injury.

• If no communication of the main pancreatic duct to the pseudocyst, percutaneous drainage should be performed under CT or ultrasound guidance.

• If the pseudocyst is in communication with the main proximal pancreatic duct, endoscopic drainage should be attempted.

• If the pseudocyst is adherent to the stomach or duodenum and a bulge is identified during endoscopy, drainage can be attempted via endoscopic ultrasound guidance.

• If endoscopic drainage is not possible, operative drainage is required

Take home message

• Grade I injuries are managed conservativley

• Grade II injuries require simple drainage / debridement

• Grade III. Pancreatic injury with ductal disruption at the body or neck left of the superior mesenteric vein can be managed by performing a distal pancreatectomy. – Splenic salvage can be attempted but may not be

feasible in hemodynamically unstable patients.

Take home message

• Grade IV. Management of the pancreatic transaction to the right of the superior mesenteric vessels poses a great challenge

• A distal pancreatectomy requires almost 80% of the pancreas to be removed – will lead to hyperglycemia in a majority of patients.

• The appropriate procedure to be performed is central debridement or resection with distal pancreatojejunostomy.

• Grade V. Severe injury to the head of the pancreas may need ERCP evaluation and possible stenting of the severed proximal duct.

• Occasionally external drainage is the only modality required, thereby creating a controlled fistula.

• Pancreaticoduodenectomy is indicated only if the pancreatic head injury involves the major pancreatic duct and ampulla

• The basic principle in managing a combined pancreaticoduodenal injury is control of hemorrhage and intestinal spillage.

Take home message

References

• Bailey and Love

• Schwartz's Principles of Surgery

• Medscape

• ASST official site

• NCBI

“Eat when you can, Sleep when you can and Dont MESS with the PANCREAS”