PANCREATIC TRAUMA

Presented by

Manojit Mandal

Overview

General points
Pancreas & Duodenum are difficult structures for Surgical exposure. They are retroperitoneal structures; so, isolated pancreatic injuries dont usually present with peritonitis. Also, the injuries present late. They have intimate anatomical relations with large vessels like SMA & vein, IVC, Pancreaticoduodenal, hepatic & splenic vessels.

General points
Prognosis is influenced by : Cause & complexity of injury. Amount of blood loss. Duration of shock. Speed of resuscitation. Type of surgical intervention.

Delay in diagnosis is M/C cause of morbidity/ mortality.

Mechanism of injury
Blunt trauma : neck or body is compressed against
lumbar spine usu. in steering wheel injury (M<20%)

Penetrating trauma : roughly 2/3rd of cases

Stab injury (M<5%) Single fragment missile injury (M<20%) Shotgun injury (M>50%) Stab-injury damages along its tract, whereas, in gunshot injures tissues in missile-tract and surrounding pressure wave area are damaged. Pancr. ductal injury is mostly d/t penetrating injury.

Associated Injuries
50-90% of patients have associated injuries.
A mean of 3.5 other organs are injured.

Most morbidity/mortality depend upon the associated injuries; not the Pancreatic injury itself.
M/c injured organs are :Liver, Stomach, major vessels, Thoracic viscera, Colon & small-bowel, spinal-cord vertebra & Duodenum.

Grading of injury : Organ injury scale (Modified Lucas classification)

(vis a vis AAST scale)

Class-1 : Superficial contusion/laceration Without major ductal-injury Any part of pancreas (AAST -1 :American association for the Surgery of Trauma scale )

(Modified Lucas classification)

Class- 2 & 3 : Deep laceration/transection With/without ductal injury Neck/body/tail (cl-2), head (cl-3) (AAST-2 without duct injury, AAST-3 distal & AAST-4 proximal pancreatic injury alongwith duct injury ) Class- 4 : Combined pancreatico-duodenal injury (involving ampulla, AAST-5)

Organ injury scale

Diagnosis

Diagnosis
Injury is clinically not much evident d/t central retroperitoneal position and abundance of associated injuries. Usually diagnosed at laparotomy. Serum biochemistry : level of serum amylase poorly correlate with pancreatic injury. It has both high false +ve: high amylase in intact pancreas (10-90%) & high false ve :normal amylase with injury (25-97%). Amylase measured after 3 hrs & serially rising amylase have a little better prognostic value.

Diagnostic Radiology : CECT

Inv. Of choice in haemodynamically stable pt.& Late complication of trauma. Overall 90% sensitive. For major ductal injuries low sensitivity(43%) Low before 12 hrs d/t overlying blood or obscure laceration planes.

Diagnostic Radiology : CECT

Features : for any injury : focal/diffiuse pancreatic enlargement/oedema; infiltration of peripancreatic soft tissue. Laceration: linear, irregular, low attenuation areas (fluid/ haematoma) within normal-looking parenchyma. Subtle changes are found in early cases; cases with minimal retroperitoneal fat

Diagnostic Radiology : others

ERCP :problems : There may be distorted recognisable mucosal landmarks incl. papilla d/t haematoma or pacreatic- oedema. Pancreatography is problematic d/t failure to cannulate ampulla (10%) Helpful in late compl. Of pancreatic injury : in Fistula for stenting; in pseudocyst for transgastric drainage

Diagnostic Radiology : others

non-invasive ; No need for dye, since fluid-filled duct shows high signal density. Duct anatomy upstream of injury is also visualised (cf.ERCP). Rapid MR takes <10 min.

MRCP :

Plain X-ray : retroperitoneal gas-bubble; groundglass appearance etc.nonspecific. USG (FAST) & DPL for free intraperitoneal fluid are
nonspecific, so rarely helpful.

Intra-OP diagnosis
Clues to Pancreatic injury: Central retroperitoneal hematoma, & intra abdominal bile-staining. Intra operative pancreatography is done if Pre-OP duct delineation not sufficient. Methods are; Trans-duodenal pancreatic duct cathetarisation, Distal cannulation of duct in tail, Needle cholecysto-cholangiogram.

Management

Management
CONTUSION & LACERATIONS WITHOUT DUCT INJURY

70% of injuries. Control of bleeding, closed external drainage, without repair of capsular laceration is all that is required.

Management
DISTAL INJURY WITH DUCT DISRUPTION
Treated best with distal pancreatectomy with splenectomy. Visible duct at cut end is ligated with transfixing suture, pancreas is oversewed. Spleen sparing surg. Requires ligation of 7-10 splenic art. Branches, & 13-22 splenic vein branches ; so rarely done. Roux en Y pancreatojejunostomy involving the resection margin has high risk of anastomotic leak.

Management
PROXIMAL INJURY WITH PROBABLE DUCT DISRUPTION
Best managed by simple external drainage Provided there is no devitalisation & ampulla is intact. A controlled fistula is formed ; either settle spontaneously, or may later require elective internal drainage after definition of exact site of duct leakage.

Management
COMBINED MAJOR PANCREATICODUODENAL INJURIES

Involves head of pancreas, adjacent duodenum &/or papilla, likely to include major vascular structures. They occur in 10% of cases.
For unstable pts.,initial goal is: hemostasis (may even req. pancreatoduodenectomy as initial Opn ), minimising contamination, repairing torn bowel, then associatd injuries (damage control ). Followed by aggressive resuscitation > Definitive surgery.

Management
COMBINED MAJOR PANCREATICODUODENAL INJURIES

More definitive operations to divert gastric, pancreatic & biliary secretions away from duodenum should be considered when pt. is stable. Occur in <10 % cases. Choices are: Duodenal diverticularization Pyloric exclusion/gastrojejunostomy Triple tube decompression 10% of patients require pancreaticoduodenectomy , but Whipples reconstruction is not feasible, only damage control is possible.

Management
COMBINED MAJOR PANCREATICODUODENAL INJURIES

Duodenal diverticulization :
Aim is to convert a potentially uncontrolled lateral duodenal fistula into a controlled end fistula. suture repair of duodenal injury Extensive periduodenal & peripancreatic drainage

Antrectomy & gastrojejunostomy (gastric diversion) Choledochotomy & Ttube drain (biliary diversion) Tube duodenostomy( for decompression)

Management
COMBINED MAJOR PANCREATICODUODENAL INJURIES

Pyloric exclusion/gastrojejunostomy
Through a gastrostomy, the pylorus is closed with a purse-string suture & antecolic gastrojejunostomy performed at gastrostomy site. Duodenal injuries repaired & area extensively debrided. Use of slowly absorbable (2-3 wks) suture in pyloric closure results in a patent & functional pylorus in 90% pts after 3 wks.

Management
COMBINED MAJOR PANCREATICODUODENAL INJURIES

Triple tube decompression

Placement of gastrostomy tube (gastric decompression) Drainage of duodenum via a tube passed retrogradely through a jejunostomy Antegrade jejunostomy tube for enteral nutrition Rapid method, problem is inadequate diversion & tube dislodgement.

Management
ADJUNCTS
Nutritional support :
Feeding jejunostomy is recommended in all patients with major injuries precipitating prolonged gastric ileus. TPN is required if enteral accss not possible.

Somatostatin & analogues

They are recommended in post-OP pancreatic fistulas.

Complications

Complications
Post OP complication rate is 42%, even more with combined & associated injuries. Most morbidities are treatable. Complications are early or late. Early :Pancreatic fistula Fluid collection/abscess Secondary Hge Pancreatitis Late:Pseudocyst Endocrine & exocrine deficit

Complications
Pancreatitis : may vary from transient biochemical leak to fulminant Haemorrhageic pancreatitis. Around 7% of traumas. Most respond to conservative Tm.

m/c specific compl. after injury . Resolve within 1-2 wk if adequately drained. High output (>700 ml/d) persisting >10d; usu. associated with major duct-injury. Supplimentary nutrition & octreotide , Sinogram to define ductal injury site, Endoscopic papillary stenting, distal resection for tail injury,

Pancreatic fistula:

Complications
Usually Peripancreatic, subhepatic, subphrenic. True pancreatic abscess is uncommon. Inf. Suggested by increased temp, leucocytosis, prolonged ileus. Guided FNAC for C/S & amylase, therapeutic aspiration if possible + antibiotic are required.

Fluid collection/abscess:

From pancreatic bed, & surrounding vessels. d/t infected devitalised tissue, & retroperitoneal autodigestion. Try angiographic embolisation> operative ligation.

Secondary Haemorrhage :

Complications
Pseudocyst :
D/t. Undetected duct disruption with contd. Leakage. For symptomatic/enlarging cyst: ERCP/MRCP for duct delineation > intervention. Distal duct leak/ minor leak: P/cut. guided aspiration. Proximal leak : endoscopic drainage, if failed, Cystoenterostomy.

Complications
Exocrine & endocrine deficit :resection distal to SMA leaving head (20% of pancr. mass) is functionally enough. For more resection replacement therapy required. Mortality: early death d/t vascular & associated injury Late death is d/t sepsis & MOF.

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