Pancreatic Trauma

: Surgical Management

dr. Erik Prabowo, M.Si.Med., SpB-KBD

Kariadi General Hospital / Diponegoro University
Semarang
Pancreatic trauma occurs in :

o 0.2% of patients with blunt trauma

o 1–12% of patients with penetrating trauma

Characterized by high morbidity and mortality

 which further increase with delayed

diagnoses
In the early 1900s, observation of pancreatic
injury was associated with a 100% mortality rate.

More recently, the medical literature supports

observation in select blunt injuries to the
pancreas.

The standard of care in penetrating injuries is

still operative exploration.
Ilahi et al found that CT was only moderately
sensitive in detecting the severity of
pancreatic injury while both missing and
underestimating injuries

Ilahi O, Bochicchio GV, Scalea TM. Efficacy of CT in the diagnosis of pancreatic injury in adult blunt trauma
patients: A single-institutional study. Am Surgeon Aug 2002
 Pancreatic injury was diagnosed by CT, U/S, ERCP,
intra-operative or post- mortem findings in 56 pts.

71% had increased admission amylase levels, but

these did not correlate with the severity of pancreatic
injury

Repeated amylase determinations for 48 hours might

therefore be helpful in diagnosing major duct injuries
Jobst MA, Canty TG, Lynch FP. Management of pancreatic injury in Pediatric Blunt abdominal trauma. J of Ped
Surg, May 1999
Blunt trauma patients with stable hemodynamics
and CT scans showing no evidence of pancreatic
injury may be observed

But should not be considered to be cleared for

pancreatic injury for at least 72 hours.

Continues abdominal pain or develops

symptoms of pancreatic injury should be
thoroughly reassessed for pancreatic injury
and operative intervention.
Surgery is by far the most common therapeutic modality for
patients with pancreatic trauma

Especially in those with penetrating trauma, in whom

exploratory laparotomy is both a diagnostic and therapeutic
measure.

Vasquez et al (2001) showed improved outcomes when

penetrating pancreatic injury therapy was based on injury
grade and location.

.
Preoperative Details

Adherence to ATLS standards in patients with

pancreatic injury reduces morbidity and mortality rates.

Early surgical intervention with identification of ductal

injuries has been shown to reduce the incidence of
early and late complications and death.
“For pancreatic trauma: treat the pancreas
like a crawfish, suck the head... eat the
tail.”(Timothy Fabian)
The state of the main pancreatic duct is a crucial
determinant of the operative strategy in the injured
pancreas.

Intraoperative pancreatography by means of a

cholecystectomy and cholangiogram with filling of the
pancreatic duct is occasionally informative.

In some settings, intraoperative endoscopic

pancreatography (ERCP) might be available.
In most cases of blunt injury, surgical resection is not necessary

Wide drainage with soft closed suction drains suffices in 80-90%

of patients with pancreatic injuries.

Pancreatic parenchymal transection against the vertebral bodies

may require resection of the body with oversewing of the distal
duct with a nonabsorbable suture and drainage of the
pancreatic bed

Ligation of the duct has traditionally been performed with a

nonabsorbable suture, but a few authors have had good results
with the newer, long-lasting monofilament absorbable
sutures.
Splenic preservation, although ideal, is frequently not
possible with a fracture of the pancreatic body.

The same anatomic orientation over the spinal column

that created the parenchymal fracture and ductal injury has
usually caused a splenic artery or venous injury, which
results in thrombosis or aneurysmal formation and
eventual splenic loss.

Resection of the pancreas at the vertebral column usually

leaves 40-50% of the glandular tissue, so permanent
diabetes and exocrine insufficiency are unusual after
resection.
Penetrating trauma to the head and neck of the pancreas
without ductal injury can be managed with simple drainage.

The appearance of bile from a penetrating injury should alert

the surgeon to the possibility of a ductal injury, and a
cholangiogram or ductogram is extremely.

Isolated minor ductal damage can occasionally be stented

operatively ,should always be accompanied by an exploratory
laparotomy with wide local drainage and close observation.

Roux-en-Y pancreaticojejunostomy, theoretically feasible, the

actual incidence of its use is rare (summarized in separate
reviews by Graham et al and Jones).
In the recovery room, direct attention toward
warming the patient; monitoring metabolic
acidosis, especially in prolonged operations

Maintaining normal hemodynamic parameters.

Adequate urine output, vigorous intravenous fluid

replacement with crystalloid solution and blood
products (as needed), and mechanical support of
ventilation are necessary.
The second greatest cause of death related to pancreatic
injury is noted in the ICU during the postoperative period.

As might be expected, death is most common with massive

injury of multiple organs and a history of significant
blood loss.

ARDS, multisystem organ failure, and infection are the

most common causes of delayed death in these situations.
Complications of pancreatic injury are from minor
pancreatitis prolonging the hospital stay to death.

Fistula formation is the most frequently reported

complication

Wide local drainage and good nutrition and supportive care,

fistulas usually resolve spontaneously within 2 weeks of
injury.

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.
The future will continue to bring better and faster
diagnostic modalities
(CT cholangiopancreatography)

The evolution of care of the pancreatic injury will

improve and morbidity rates will decrease.

Multidetector CT scanners and MRCP are

emerging as more sensitive diagnostic tools
The main benefits of laparoscopy are that it can
reduce the rate of nontherapeutic and negative
laparotomies

It can identify other organ injuries accurately, and

in some cases provide a therapeutic option.

The use as a diagnostic or therapeutic method

only for hemodynamically stable patients
The anterior aspect of the pancreas is exposed
through the lesser sac by division of the gastrocolic
omentum

The posterior aspect of the head is exposed by a

Kocher maneuver

The posterior aspect of the tail is achieved by splenic

mobilization.
Delayed diagnosis and delayed surgery while under
observation show a higher rate of pancreas-specific
morbidity and mortality.

The implications of delayed intervention in a pancreatic

duct injury must be weighed against the morbidity of a
non-therapeutic laparotomy as well.

Exploratory laparoscopy is the future?

THANK YOU