Simple presentation on pancreatic injury.

1. PANCREATIC INJURY

3. RELEATIONS
• Posteriorly protected by
• Rib cage
• Thick dorsal muscle groups (paraspinous)
• Anteriorly protected by
• Rectus and abdominal muscles,
• The energy-absorbing characteristics of the liver, colon, duodenum, stomach, and small
bowel provide physiologic padding that protects the pancreas from blunt injury.

4. RELEATIONS
• Tail extends into the lienorenal ligament along with the splenic artery
• Anterior relations include transverse mesocolon and stomach
• Posterior relations include inferior vena cava, aorta, portal vein,
common bile duct and left kidney
• Superior relations include first part of duodenum and splenic artery

6. BLOOD SUPPLY
• Two different sources;
• Proximal to the 2nd part of the duodenum (forgut), gastroduodenal artery ,
superior pancreatoduodenal artery.
• Distal to this point (the midgut) the arterial supply is from the superior
mesenteric artery, inferior pancreatoduodenal artery supplies the 3rd and 4th
sections.
• The superior and inferior pancreatoduodenal form an anastomotic loop
between the celiac trunk and the SMA
• Venous drainage is into the portal and superior mesenteric vein

9. DUCTS
• Pancreatic ducts has two ducts
– Main pancreatic duct
– Accessory pancreatic duct
• The main pancreatic duct begins in the tail
• Drains into the second part of the duodenum together with the common bile
duct
• The main duct is also known as the Duct of Wirsung
• Accessory duct begins in the head
• The accessory duct is also known as the Duct of Santorini
• It usually drains into the main duct but can open separately into the duodenum

11. RELATIONS:
• Proximity of vascular structures to the head of the pancreas has a
marked effect on the morbidity and mortality.
• Subhepatic IVC and the aorta sit just posterior to the pancreatic head
to the patient's right side
• Superior mesenteric vein coalesces into the portal vein immediately
behind the pancreas
• Splenic artery (off the celiac trunk) and vein (draining into the portal
vein) run superior and posterior to the body and tail of the pancreas
and are relatively easier to expose and control compared to the IVC
and portal vein

12. • A high degree of clinical awareness is necessary to ensure that pancreatic
injuries are not overlooked or missed
• The type of injury (ie, blunt vs penetrating) and information about the
injuring agent (eg, GSW, knife) help focus the clinician on the possibility of
pancreatic injury.
• Physical examination.
Seat belt marks
Flank ecchymoses, or penetrating injuries.
• Dull to severe epigastric pain or back pain( severe peritoneal irritation)

13. INDICATORS OF INJURY
 Blunt trauma
• Retroperitoneal hematoma,
• Retroperitoneal fluid,
• Free abdominal fluid,
• Pancreatic edema
 Penetrating trauma
• Visualization of perforation,
• Haemorrhage or fluid leak (eg, bile, pancreatic fluid),
• Retroperitoneal hematoma around the pancreas

14. WORK UP:
• Serum amylase levels
• Amylase & lipase levels in peritoneal aspirate.
• CECT/HRCT
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Dynamic secretin-stimulated magnetic resonance
cholangiopancreatography (DSS-MRCP)
• Exploratory laparotomy

15. Classification of Injury

17. Diffuse pancreatic enlargement.
(Grade1 injury)

18. Superficial pancreatic laceration without duct
Injury.(Grade II)

19. Transection of distal
Pancreas (GRADE III)

20. Grade 4 pancreatic transection
Proximal pancreatic transection (GRADE IV)

21. Pancreatic fracture with disruption of the
pancreatic duct (Grade V )

23. AAST Treatment options
1 Observation
2 Simple external drainage
Omental pancreatorrhaphy and drainage
3 Distal pancreatectomy ± splenectomy
Roux-en-Y distal pancreatojejunostomy
4 Pancreatoduodenectomy
Roux-en-Y distal pancreatojejunostomy
Anterior Roux-en-Y pancreatojejunostomy
Endoscopically placed stent
Simple drainage in damage control situations
5 Pancreatoduodenectomy

24. • External closed drainage.(Jackson-Pratt, Blake’s)

25. • Roux-en-Y distal pancreatojejunostomy

26. • Anterior Roux-en-Y
pancreatojejunostomy

28. IND. FOR LAPAROTOMY:
• Peritonitis on physical examination
• Hypotension and a positive (anechoic fluid present in the abdomen)
focused ultrasound examination of the abdomen
• Evidence of disruption of the pancreatic duct on CECT or on ERCP
• Worsening of patient condition/ increasing enzyme levels.

29. COMPLICATIONS
• Secondary hemorrhage:
• 5-10%
• Require re-exploration or angioembolization
• Pancreatic Fistula
• Peripancreatic abscess
• Pancreatic pseudocyst
• Delayed complications include
• Recurrent pancreatitis,
• Splenic artery aneurysm,
• Endocrine or exocrine insufficiency.