Newsletters - February 2010
Management of Traumatic Pancreatic Injuries
by Panna A. Codner, MD, Assistant Professor of Surgery
Injuries to the pancreas are uncommon, since the pancreas lies deep in the middle of the upper abdomen behind the stomach and other larger organs. The retroperitoneal location and character of the pancreas present a number of challenges to the trauma surgeon faced with a pancreatic injury. Recently, I cared for an 18 year-old man who sustained an isolated pancreatic injury after a garage door fell on his abdomen. Upon transfer to our facility, a computed tomography (CT) scan of the abdomen showed a Grade III pancreatic injury. He eventually made a full recovery. I will outline important points regarding pancreatic injury and discuss principles of treatment.
The first report of a blunt pancreatic injury was by Travers in England in 1827.2 Today, the most common cause of a pancreatic injury involves high-speed automobile crashes.2,3 However, any strong blow to the mid-abdomen can injure the pancreas. Other causes include gunshot wounds, stab wounds and explosive blasts. The result of these forces on the pancreas can range from a bruise to complete transection.
There are several classification systems for pancreatic injury (Table 1).4 Classification is useful, because surgical management varies with the type of injury. Diagnosing pancreatic injury can be difficult. Abdominal examination is unreliable, since the pancreas is located closer to the back than to the front of the abdomen. Back pain may be present, but most patients have minimal pain and tenderness immediately after injury. Our patient did not have significant abdominal pain. The absence of clear signs of pancreatic injury on physical examination frequently leads to diagnostic delay. Plain abdominal X-rays are not usually helpful. Serum amylase measurement is generally unreliable as a diagnostic test, but may be beneficial post-operatively as an indication of complications. For example, serum amylase levels may be normal in 30 percent to 35 percent of complete pancreatic transections.5 Diagnostic peritoneal lavage is a useful diagnostic tool in blunt abdominal trauma. However, false negative results are common with pancreatic injuries due to its retroperitoneal location, although a positive result from injury to an associated organ may lead to identification of the pancreatic injury during laparotomy. CT is useful for evaluating the stable bluntly injured patient. Associated injuries are more commonly identified by CT evaluation. However, CT imaging soon after presentation may miss major pancreatic injuries; CT appears normal in approximately 40 percent of patients with significant pancreatic injuries.
The gold standard for identification of pancreatic injuries is intra-operative evaluation at the time of laparotomy. A high index of suspicion is mandatory for detecting pancreatic injury. Signs that should raise suspicion include upper abdominal location for the injury, bruising or blood staining around the stomach or gastrocolic omentum between the stomach and transverse colon.
The operative management scheme for pancreatic injury follows the same principles as any trauma operation. First, hemorrhage is controlled and then, further gastrointestinal contamination is avoided. Several techniques for dealing with pancreatic injuries have been described. Simple drainage is employed for lesser injuries and when the main duct is intact. Damage to the pancreatic duct in the body or tail to the left of the mesenteric vessels should not be repaired, but rather a distal pancreatectomy and drainage should be undertaken. Creation of Roux-en-Y limb of jejunum is a versatile option for injury to the head of the pancreas, tail, or both. Pancreaticoduodenectomy should be reserved for extensive damage to the head of the pancreas or duodenum.
Distal pancreatectomy and splenectomy is the preferred management for many injuries to the body of the pancreas. In some cases, the spleen is uninjured and a splenectomy is performed to expedite pancreatic resection. This is reasonable in a hemodynamically unstable patient or a patient with multiple injuries. However, splenectomy in a stable patient for the sake of expediency is not justified due to the importance of the spleen
in preventing overwhelming post-splenectomy sepsis and current techniques available for splenic preservation.7,8 One technique utilized in our patient involved first mobilizing the spleen by carefully incising its retroperitoneal attachments, allowing the spleen to be delivered into the midline wound. The pancreas was then transected just proximal to the injury and dissected off the splenic vessels in a retrograde fashion. Peri-pancreatic drains were placed and the spleen was preserved.
Mortality and morbidity rates for pancreatic injuries remain high at 20 percent and 36 percent respectively.6,9 The rate of associated injury is also high and contributes to morbidity and mortality. Complications include fistula formation, abscess, pancreatitis, pseudocyst formation, hemorrhage, wound sepsis, exocrine and endocrine insufficiency and death. Our patient developed a superficial surgical site infection that was drained and managed by local wound care at the bedside; he has recovered well. If the management described herein is not part of a standardized approach to injured patients, such uncommon injuries may pose a therapeutic challenge.
Table 1. Pancreas Injury Grading Scale
Dr. Codner can be reached at 414-805-8624 or firstname.lastname@example.org.
Townsend, C.M. Jr., Beauchamp, R.D., Evers, B.M., et al. Sabiston Textbook of Surgery. 18th ed. Elsevier: 2008: 976-79, 1589-92.
Jones, R. C.,G.T. Shires. Pancreatic Trauma. Archives of Surgery. 1971; 102:424-30.
Jone, R.C. Management of Pancreatic Trauma. Southern Surgical Association. 1978; 187(5):555-64.
Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling. Surg Clin N A 1995; 75:293-303.
Wilson, R. H. and R. J. Moorehead. Current Management of Trauma to the Pancreas. Br. J. Surg. 1991; 78:1196-1202.
Jordan Jr, G. L. Pancreatic Trauma. Contemporary Surgery. 1985; 26:11-17.
Pachter, L.H.,Hofstetter, S.R., Liang,H.G., et al. Traumatic Injuries to the Pancreas: The Role of Distal Pancreatectomy with Splenic Preservation. J Trauma. 1989; 29(10):1352-55.
Dawson, D.L., Scott-Conner, C.E.H. Distal Pancreatectomy with Splenic Preservation: The Anatomic Basis for a Meticulous Operation. J Trauma. 1986; 26(12):1142-45.
Heitsch, R.C., Knutson, MD, Fulton, R.L., et al. Delineation of Critical Factors in the Treatment of Pancreatic Trauma. Surgery. 1976; 80(4):523-29.