Pancreatic Trauma Revisited*

Abstract

Pancreatic trauma is rare with an incidence between one and two percent in patients with abdominal trauma. Morbidity and mortality, however, are significant with rates approaching 40-45% in some reports. The majority of patients with injuries to the pancreas have associated trauma to other organs which are primarily responsible for the high mortality rate. The continuity of the main pancreatic duct is the most important determinant of outcome after injury to the pancreas. If there is no evidence of ductal injury on fine-cut CT or on ERCP, nonoperative management is chosen. The indications for operative management are as follows: (1) peritonitis on physical examination; (2) hypotension and a positive FAST; and (3) evidence of disruption of the pancreatic duct on fine-cut CT or on ERCP. After exposure and evaluation of the extent of injuries to the pancreas and duodenum, a decision must be made on the procedure. For pancreatic contusions, hematomas, or small lacerations, simple external drainage or pancreatorrhaphy with drainage can be performed. For ductal transection at the neck, body, or tail, the procedure of choice is a distal pancreatectomy or Roux-en-Y distal pancreatojejunostomy. If the patient has suffered a ductal transection at the head of the pancreas without injury to the duodenum, a Roux-en-Y distal pancreatojejunostomy or anterior Roux-en-Y pancreatojejunostomy is the operation of choice. For combined pancreatoduodenal injuries, the options are repair and drainage, diversion via a pyloric exclusion procedure, or pancreatoduodenectomy. Complications of pancreatic injuries include fistulas and intra-abdominal abscesses, and an occasional pancreatic pseudocyst. Key Words.

The current management of pancreatic trauma

“…Subramanian and Feliciano concur with the aforementioned findings and claim that if there is no evidence of pancreatic duct disruption on fine-cut C/T or ERCP, NOM is favoured [16].…”

“…Most authors agree that a distal pancreatectomy is indicated for grade III pancreatic injuries with transection of the pancreas to the left of the mesenteric vessels [16,21]. In the case of a stable child under 10 years of age or a stable adult with an isolated pancreatic injury, splenic salvage should be considered.…”

“…During laparotomy, choosing the appropriate surgical technique depends upon the patient's haemodynamic status, pancreatic duct continuity and the presence or absence of concomitant duodenal injury [16]. Intraoperative radiological methods for the evaluation of the pancreatic duct integrity include: i) intraoperative cholangiogram by the cystic duct or the common bile duct.…”

“…In the case of a stable child under 10 years of age or a stable adult with an isolated pancreatic injury, splenic salvage should be considered. If the patient is haemodynamically unstable, distal pancreatectomy with splenectomy is the procedure of choice [16]. Distal pancreatectomies comprise 29% of operations for pancreatic trauma and the fistula rate is 14%, which explains why suction drains should be left in place [10].…”

Focus on Emergency Surgery of the Pancreas

“…The indications for decompressive surgery, and the techniques and management of the ensuing open abdomen are challenging issues explored in this Focus on-issue that hopefully stimulates the discussion for future options and trends, and helps the readers in updating their knowledge in trauma and emergency surgery of the pancreas. I wish to express my gratitude to Dr. Subramanian [6], Dr. Feliciano [6], and Dr. De Waele [7] for their excellent contributions and thank for their support over the years.…”