This presentation gives general overview of Pancreatic trauma

1. Pancreatic Trauma
Muhammad Haris Aslam Janjua
Resident, Surgical unit I
SIMS/Services Hospital, Lahore

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

3. 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.

4. 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.

5. 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

7. 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.

8. 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

9. 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

10. 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

11. American association for surgery of trauma Staging
Pancreas 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.

12. Abbreviated injury Score
AIS-Code Injury
AIS % 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)

13. 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 .

14. 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.

15. 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

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

17. Grade II pancreatic injury: Superficial pancreatic laceration without duct
Injury.

18. Contrast CT scan showing
transection of distal
pancreas
Intra-operative photograph
of transected distal body of
pancreas (arrow).
Grade III injury

19. Grade 4 pancreatic transection

20. 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.

21. 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.

22. Workup
• Magnetic resonance cholangiopancreatography(MRCP)
– is being used to assess injury to the ductal
components but not frequently used.

23. • In the patient who is unstable, operative
exploration provides the optimal diagnostic
tool for pancreatic injury

24. 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

25. Frey and Wardell classification of pancreatic trauma.
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

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

27. • Takishima correlated the classification scheme
with subsequent surgical management .
Injury treatment
class 1 and class 2a conservative
Class 2b and class 3 Laprotomy / drainage

28. 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 .

29. • 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

30. 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

31. • 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

32. • 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

33. • 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

34. • 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

35. • 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

36. • 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.

38. • 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.

39. • 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.

40. Spleen preserving distal pancreatectomy

41. Central pancreatectomy

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

43. Pancreatoduedenectomy

44. Complications
• Pancreatic Fistula
• Peripancreatic abscess
• Pancreatic pseudocyst
• Delayed complications include
– recurrent pancreatitis,
– splenic artery aneurysm,
– and endocrine or exocrine insufficiency.

45. 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.

46. • 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.

47. 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.

48. 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

49. 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.

50. 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.

51. Take home message
• 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.

52. References
• Bailey and Love
• Schwartz's Principles of Surgery
• Medscape
• ASST official site
• NCBI

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