Pancreatic Trauma Treatment & Management
- Author: H Scott Bjerke, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
In the early 1900s, observation of pancreatic injury was associated with a 100% mortality rate. However, 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.
Patients who have experienced blunt trauma and who have stable hemodynamics and CT scans showing no evidence of pancreatic parenchymal fracture, parenchymal hematoma, parenchymal edema, fluid in the lesser sac, or retroperitoneal hematoma may be observed but should not be considered to be cleared for pancreatic injury for at least 72 hours. Any patient with blunt trauma who continues to have abdominal pain or who develops symptoms of pancreatic injury should be thoroughly reassessed for pancreatic injury and operative intervention. Cuenca and Islam reported success with nonoperative treatment of low-grade injuries.
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.
In most cases of blunt injury, ductal damage can be visualized directly. Most commonly, the damage is minor and such findings as capsular tears, superficial lacerations, bullet wounds of the body or tail, small contusions, or hematomas should be visualized and documented; however, they should not be surgically explored unless ductal injury is suspected. Soft closed suction drains (eg, Jackson-Pratt, Blake) should be used. The author usually uses 2 drains, but a single drain may suffice in some situations. Continued drainage with high amylase levels persisting beyond 48-72 hours is highly suggestive of a missed ductal injury. These problems must be treated with workup of the ductal integrity with ERCP or another modality and may require another operation. Occasionally, a trial of total parenteral nutrition (TPN) or elemental diet through a feeding jejunostomy may result in decreased drainage and closure of the leak.
Significant blunt trauma to the pancreas with parenchymal fracture is easily visualized on exploration by noting the retroperitoneal hematoma around the pancreas at the spinal column. Patients with ductal injury usually require resection of the tail and body distal to the vertebral column, and patients with documented intact ductal systems may be drained and observed.
More details regarding pancreatic surgical technique can be found in the Intraoperative details section below. Combined pancreatic and duodenal injuries are not reviewed in this article.
Adherence to ATLS standards and adequate preparation for emergency surgery 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.
In most cases of blunt injury, surgical resection is not necessary. Small or superficial capsular tears, contusions, or hematomas are best managed without sutures. 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. If possible, the distal parenchyma should also be oversewed, but contused, edematous pancreatic parenchyma is notoriously difficult to sew, and drainage of the bed may be all that is possible in this situation. Some surgeons use linear surgical staplers, which create a staple line that is 1.5 mm in depth.
Make sure to assess and suture ligate the pancreatic duct in these cases. 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.
As with blunt trauma, examination and peripancreatic drainage is the most common intervention, but the range and severity of penetrating injuries to the pancreas are much more extreme. Resection of the tail or body is accomplished in a similar fashion and is technically simple, but injuries to the head and neck of the pancreas may require more creative and more difficult operative therapies.
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 valuable in helping the surgeon to plan the needed operative intervention. Isolated minor ductal damage can occasionally be stented operatively or by the interventional radiologist and should always be accompanied by an exploratory laparotomy with wide local drainage and close observation.
For patients in whom the duodenum is intact but injury to the pancreatic head and ductal system precludes repair, stenting, or local drainage, some authors suggest a Roux-en-Y pancreaticojejunostomy to preserve the pancreatic parenchyma. While theoretically feasible, the actual incidence of its use is rare (summarized in separate reviews by Graham et al and Jones). Asenio et al provide medical illustrations of many of the rarely used surgical options for trauma to the head and neck of the pancreas in the monograph on management of pancreatic injuries.
Fortunately, massive injury to the head of the pancreas, including the duodenum, rarely requires a trauma Whipple operation or pancreaticoduodenectomy. The mortality rate remains high in these cases, with even experienced centers reporting only a 50-64% survival rate. Unless the patient is actively exsanguinating, surgeons in smaller facilities with limited operating and intensive care unit (ICU) facilities should consider damage-control methods, stabilize injuries, staunch active hemorrhage, and then transfer the patient to the closest level 1 trauma center, where experience with this type of injury is more common.
The intimate anatomic position of the vena cava, portal vein, and mesenteric artery and vein with the pancreas also creates significant problems. Higher mortality rates in these cases are caused by uncontrolled hemorrhage rather than pancreatic injury; make every effort to repair these injuries first, directing attention to the pancreatic injury only after vascular integrity has been accomplished. Damage-control techniques may be necessary in these situations, addressing the pancreatic injury at a second operation, 12-48 hours later, when the patient has been warmed and stabilized.
In the recovery room, direct attention toward warming the patient; monitoring metabolic acidosis, especially in prolonged operations; and 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. Acute respiratory distress syndrome (ARDS), multisystem organ failure, and infection are the most common causes of delayed death in these situations. In cases of more isolated pancreatic injury, common early complications include fistula formation, pancreatitis, and abscess formation.
Delayed presentation of complications of pancreatic injury are rare but should be considered during the follow-up period. Chronic pancreatitis, traumatic pseudocysts, and splenic artery aneurysms have been reported and should be considered in all patients.
Exocrine or endocrine insufficiency is also rare and usually occurs only in patients with a pancreatic resection greater than 80-90%. Relative insufficiency may also occur and should be considered if symptoms of altered glucose hemostasis or gastrointestinal abnormalities manifest after injury.
Complications of pancreatic injury are myriad and run the gamut from minor pancreatitis prolonging the hospital stay to death.
Fistula formation is the most frequently reported complication, but with 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. Somatostatin analogues have been reported anecdotally in multiple prospective randomized clinical trials to decrease fistula output and to facilitate closure, but they have not been proven to be of absolute benefit. The commercially available analogue is expensive and, if used, should be closely monitored for its effects in individual patients.
Delayed diagnosis and delayed surgery while under observation show a higher rate of pancreas-specific morbidity and mortality. Early diagnosis and therapy are associated with better overall outcomes in these patients.
More recent papers in the trauma literature have reported an increase in infectious complications in patients when pancreatic wounds occur in conjunction with hollow viscus injury (ie, duodenum, small bowel, colon). While the pathophysiology of this finding has not been well elucidated yet, experimental data in rats with pancreatic ductal ligation protected from hemorrhagic shock induced lung injury and, to a lesser degree, gut injury. Pancreatic proteases may activate digestive enzymes in ischemic intestine, which then travel via lymphatics to cause lung injury.
Delayed complications of recurrent pancreatitis, pancreatic pseudocysts, splenic artery aneurysm, and endocrine or exocrine insufficiency have also been reported.
Outcome and Prognosis
Outcome from minor and isolated pancreatic injury is usually quite good. Complications are rare, and functional outcome is excellent.
Outcome from severe pancreatic injury is much poorer overall than with other organ injuries. This outcome is primarily due to the frequent presence of associated life-threatening injuries and the unforgiving nature of the pancreas, both for missed injury and after major emergency operative intervention.
Future and Controversies
The future will continue to bring better and faster diagnostic modalities (eg, faster and more precise CT technology, including CT cholangiopancreatography). As these new methods are examined and compared to current technology, 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, but further clinical trials will be necessary to prove their effectiveness in pancreatic injury.
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