Pancreatic trauma

Abstract

INTRODUCTION Pancreatic trauma occurs in approximately 4% of all patients sustaining abdominal injuries. The pancreas has an intimate relationship with the major upper abdominal vessels, and there is significant morbidity and mortality associated with severe pancreatic injury. Immediate resuscitation and investigations are essential to delineate the nature of the injury, and to plan further management. If main pancreatic duct injuries are identified, specialised input from a tertiary hepatopancreaticobiliary (HPB) team is advised. METHODS A comprehensive online literature search was performed using PubMed. Relevant articles from international journals were selected. The search terms used were: 'pancreatic trauma', 'pancreatic duct injury', 'radiology AND pancreas injury', 'diagnosis of pancreatic trauma', and 'management AND surgery'. Articles that were not published in English were excluded. All articles used were selected on relevance to this review and read by both authors. RESULTS Pancreatic trauma is rare and associated with injury to other upper abdominal viscera. Patients present with nonspecific abdominal findings and serum amylase is of little use in diagnosis. Computed tomography is effective in diagnosing pancreatic injury but not duct disruption, which is most easily seen on endoscopic retrograde cholangiopancreaticography or operative pancreatography. If pancreatic injury is suspected, inspection of the entire pancreas and duodenum is required to ensure full evaluation at laparotomy. The operative management of pancreatic injury depends on the grade of injury found at laparotomy. The most important prognostic factor is main duct disruption and, if found, reconstructive options should be determined by an experienced HPB surgeon. CONCLUSIONS The diagnosis of pancreatic trauma requires a high index of suspicion and detailed imaging studies. Grading pancreatic injury is important to guide operative management. The most important prognostic factor is pancreatic duct disruption and in these cases, experienced HPB surgeons should be involved. Complications following pancreatic trauma are common and the majority can be managed without further surgery.

The Epidemiology of and Outcome from Pancreatoduodenal Trauma in the UK, 1989–2013

“…Most series report only those patients managed exclusively by operative means or, less commonly, non-operative means but most authors agree that determining duct integrity is crucial to the management of pancreatic injuries. 2,3,[6][7][8]10,[13][14][15][16]22 Mortality associated with PD trauma is high. For blunt trauma, the mortality rate for PD trauma was 17.6% and for penetrating trauma, it was 12.2%.…”

Diagnosis and Management of High-Grade Pancreatic Trauma: Report of 14 Cases

“…However, ultrasound is valuable in the follow-up of complications. In patients with low-grade (I-II) blunt pancreatic injuries without disruption of the main pancreatic duct, conservative management or simple peripancreatic drainage is usually sufficient [1][2][3]. Although there are reports of successful treatment of pediatric pancreas fracture with conservative management [17,18], operative management is recommended for patients with high-grade (III-IV) blunt pancreatic injuries with involvement of the main pancreatic duct [1][2][3].…”

“…Preservation of the spleen is recommended for patients that are hemodynamically stable. However, the inclusion of a splenectomy can reduce the surgical trauma in unstable patients with multiple injuries [1][2][3]. Although an overwhelming post-splenectomy infection is a possible complication, the risk in adults is quite low.…”

“…Central pancreatectomy is therefore recommended due to the risk for diabetes mellitus from the reduced volume of the remaining pancreas [1][2][3]. However, distal pancreatectomy should be considered for hemodynamically unstable patients.…”

“…Traumatic injury to the pancreas after blunt abdominal trauma is rare due to its retroperitoneal location, with rates of 1-5 % [1][2][3]. In addition, there are no specific physical signs or indicators [4], and therefore, diagnosis is delayed.…”