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Pancreatic Trauma Treatment & Management

  • Author: H Scott Bjerke, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Jan 27, 2015
 

Medical Therapy

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.[7]

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Surgical Therapy

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.

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Preoperative Details

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.

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Intraoperative Details

Blunt injury

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.

Penetrating trauma

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.

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Postoperative Details

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.

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Follow-up

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.

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Complications

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.

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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.

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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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Contributor Information and Disclosures
Author

H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Professor, Department of Surgery, Kansas City University of Medicine and Biosciences

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Midwest Surgical Association, Royal Society of Medicine, Eastern Association for the Surgery of Trauma, Association for Academic Surgery, National Association of EMS Physicians, Pan-Pacific Surgical Association, Southwestern Surgical Congress, Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons

Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc<br/>Received income in an amount equal to or greater than $250 from: SimQuest Inc -- consultant on burn mapping softwear ($1,500).

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Ernest Dunn, MD Program Director, Surgery Residency, Department of Surgery, Methodist Health System, Dallas

Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

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