The document discusses pancreatic injuries, highlighting their incidence, mortality rates, and various causes such as road traffic accidents. It outlines diagnostic approaches including imaging techniques and various classification systems for treatment based on injury severity. Additionally, it provides insights into management algorithms, emphasizing non-operative and surgical treatment options along with potential complications.

1. Pancreatic injury
• Moderator Presentor
• Dr Aymen Ahmed Khan Dr Pooja Pandey
• Ass. Professor JR PG -1st yr
• Department of general surgery Department of general surgery
• Mayo institute of medical sciences Mayo institute of medical sciences
Barabanki, U.P Barabanki, U.P

2. Pancreatic injury
Learning objectives
• Introduction
• Mechanism of injury
• Clinical presentation
• Management
• Follow up
• References

3. Pancreatic injury
Introduction to injury
• Major public health problem world wide
• Every 5sec one individual dies in the world because of injury
• 10% of the world's deaths, 32% more than the number of fatalities that
result from malaria, tuberculosis, and HIV/AIDS combined.
• For people between the ages of 5 and 44 years, injuries are 1 of the top
3 causes of death
Agarwal, Harshit MS, MCh; Gupta, Amit MS, FRCS; Kumar, Subodh MS, FRCS∗ An overview of pancreatic trauma, Journal of Pancreatology: September 2020 - Volume 3 - Issue 3 - p 139-
146 doi: 10.1097/JP9.0000000000000044

4. Pancreatic injury
Incidence
• 7 to 10 % of abdominal truma in a polyrauma patient .
• Injuries to the pancreas occur in approximately
• 5% of patients with blunt abdominal trauma,
• 6% of patients with gunshot wounds to the abdomen,
• and 2% of patients with stab wounds to the abdomen.
• The reported incidence ranges from 0.4% to 12%.
Agarwal, Harshit MS, MCh; Gupta, Amit MS, FRCS; Kumar, Subodh MS, FRCS∗ An overview of pancreatic trauma, Journal of Pancreatology: September 2020 - Volume 3 - Issue 3 - p 139-146 doi:
10.1097/JP9.0000000000000044

5. Pancreatic injury
Incidence conrd..
• In India Pancreatic injuries were present in 1.18 % of all trauma
admissions(Indian scenario)
• Mortality for pancreatic injuries ranges from 9% to 34%; however, only
5% of the pancreatic injuries are directly related to the fatal outcome.
Uma Debi, Ravinder Kaur, Kaushal Kishor Prasad, Saroj Kant Sinha, Anindita Sinha, Kartar Singh World J Gastroenterol. 2013 Dec 21; 19(47): 9003–9011. Published online 2013 Dec
21. doi: 10.3748/wjg.v19.i47.9003

6. Pancreatic injury
Mortality
• Most of the mortality within 48hrs due to acute haemorrhage of
traumatized vasulature including-
• Splenic vein
• Portal vein
• Inferior vena cava
• Pt surviving the initial haemorrhage ,nearly half will have a
complication of their pancreatic wound such as abscess ,fistula
,pseudocyst , false aneurysm or anastomotic leak .
• Trauma for surgery

7. Pancreatic injury
• Isolated pancreatic injuries are not common.
• Up to 90% of patients present with associated hepatic, gastric, splenic,
renal, colonic, or vascular lesions.
• Pancreatic injuries commonly occur in association with injury to the
duodenum because of their proximity.
Relations
• Anteriorly: From right to left: the transverse colon and
• the attachment of the transverse mesocolon, the lesser
• sac, and the stomach

8. Pancreatic injury
Snell’s clinical anatomy pg no 159

9. Pancreatic injury
• Posteriorly:
• From right to left:
• the bile duct,
• the portal and splenic veins,
• the inferior vena cava,
• the aorta, the
• origin of the superior mesenteric artery,
• the left psoas
• muscle, the left suprarenal gland, the left kidney, and the
• hilum of the spleen (Figs. 5.4 and 5.27)

10. Pancreatic injury
 Causes of injury
• Road traffic accident
• Steering wheel injury(neck > body)
• Fall from height
• Penetrating injury.(head=body=tail)

11. Pancreatic injury
.
183
 Mechanism of injury
• Direct compression of the epigastrium against the vertebral column
• varies according to the age of the patient
• Infants and children – child abuse & bicycle handlebar injury
• Adult –Road traffic accident and penetrating injury.
• Most common in children and young adult because of decreased intra-
abdominal fat .

12. Pancreatic injury
Diagnosis
• The identification of pancreas injuries can be challenging, particularly
because available imaging modalities are not highly effective.
• Based on the technology employed, the ability to detect parenchymal
injury and pancreatic duct disruption remained below 60%.
• Peitzman and colleagues reported better performance by CT in a
prospective study in which the sensitivity of CT was approximately
80%.

13. Pancreatic injury
CT Scan
• The modality of choice
• Findings peripancreatic hematomas,
free fluid in the lesser sac, and abnormal
thickening of Gerota fascia

14. Pancreatic injury
FIGURE 16-26 Pancreatic injury on abdominal CT. The injury involves the pancreatic neck and appears as a 2-cm
segment of nonperfused pancreas tissue with surrounding edema as identified by the arrow.

15. Pancreatic injury
• DIAGNOSIS SERUM AMYLASE LEVEL
Suggest only pancreatic injury Cannot predict or correlate with the
degree of injury
• SERUM LIPASE LEVEL
nonspecific and a poor indication of injury elevated levels may
provide a clue to a severe injury requiring further investigation

16. Pancreatic injury
• Isolated pancreatic amylase measurement is not recommended because
up to 40% of patients with transected pancreatic duct have normal
serum amylase levels.
• When it is obtained more than 3 hours after injury occurrence, an
elevated serum amylase level may reflect pancreatic trauma.
• Used in this way, serum amylase levels are reasonably sensitive but
are lacking in specificity and therefore are of limited value.
• Serial quantification levels increase the sensitivity of the assay.

17. Pancreatic injury
MRCP
• High sensitivity and specificity
• Provides excellent visualization of the pancreatic duct, peripancreatic
fluid contiguous to fractured segments of the pancreas, and
hemorrhage after nonpenetrating trauma.
• Main limitations include high cost, availability, and amount of time
required to perform the study.

18. Pancreatic injury
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)
• sensitivity and specificity of 100%
• demonstrate clearly the site of duct disruption and the grade of duct injury
effective and safe non- operative treatment tool leakages of the pancreatic
duct, trans papillary stent insertion might seal the injury and stabilize it

19. Pancreatic injury
•ERCP
• The most reliable test to demonstrate pancreatic duct integrity.
• limited by the risk of inducing pancreatitis, availability, and severity of
the trauma

20. Pancreatic injury
 Lucas classification:
• Type I: Minor contusion (small hematoma) with minimal parenchymal
damage. Main Pancreatic duct intact.
• Type II: Major contusion, laceration or transection, confined to body
and tail of pancreas with or without ductal disruptiion.
• Type III: Major contusion, laceration or transection involving head of
pancreas with or without ductal disruption.
• Type IV: Combined pancreaticoduodenal injury.
• A- Duodenal injury with minor pancreatic injury.
• B-Duodenal injury with severe pancreatic injury with duct disruption

21. Pancreatic injury

22. Pancreatic injury
TREATMENT ALGORITHM
• NON OPERATIVE MANAGEMENT
• Absence of a ductal injury (Grade I and II)
 bowel arrest
total parental nutrition serial imaging with either CT scans or
ultrasound to follow injury resolution

23. Pancreatic Injury

24. Pancreatic injury
• TREATMENT
• PROXIMAL DUCT INJURY Incomplete / complete disruption of the
MPD without duct obstruction is the best candidate for the pancreatic
duct stent therapy.
• Transductal pancreatic stent allows internal drainage of the pancreatic
secretion and re- establishment of duct continuity

25. Pancreatic injury
• TREATMENT
• GRADE IV INJURIES WITH PDI In stable patients
pancreaticoduodenectomy is the best definite treatment .
• In unstable patients, exploration and placing of external drainage may be the
best choice for damage control surgery .

26. Pancreatic injury
• TREATMENT
• DISTAL PANCREATIC INJURY WITH DUCT INVOLVEMENT wounds in the
body or tail of the pancreas with an obvious duct injury or transection
of more than half the width of the pancreas these grade III injuries
are best treated by Distal pancreatectomy .
• Complete transection of the pancreatic body from the head, a distal
Pancreaticojejunostomy and closure of the proximal end of the
pancreas rupture

27. Pancreatic injury
Complications
• Fistula
• Pancreatic abscess
• Pseudocyst formation and
• Sepsis

28. Pancreatic injury
•Pancreatic fistula
• 25% of patients following external drainage for pancreatic injuries.
• Drainage between 100–300 ml should be allowed to continue with the
drain left in place and majority of these fistula closes in 6–12 weeks
time.
• The closure of the fistula may be hastened by a short course of
octreotide for 5 days.
• The drain is removed when the fistula discharge becomes less than 30
ml per day.

29. Pancreatic injury
Pancreatic fistula
• Premature removal of the drain may result in abscess formation.
• Drainage in excess of 300 ml per day is unlikely to close spontaneously.
This is usually
associated with major ductal disruption.
If the fistula persists due to ductal disruption, this should be treated by
internal drainage into a Roux-en-Y loop of jejunum.

30. Pancreatic injury

31. References
• Agarwal, Harshit MS, MCh; Gupta, Amit MS, FRCS; Kumar, Subodh MS, FRCS∗ An
overview of pancreatic trauma, Journal of Pancreatology: September 2020 - Volume
3 - Issue 3 - p 139-146 doi: 10.1097/JP9.0000000000000044
• Uma Debi, Ravinder Kaur, Kaushal Kishor Prasad, Saroj Kant Sinha, Anindita Sinha,
Kartar Singh World J Gastroenterol. 2013 Dec 21; 19(47): 9003–9011. Published
online 2013 Dec 21. doi: 10.3748/wjg.v19.i47.9003
• Sabiston text book of surgery vol II 4rth edition
• Bailey and love short practice of surgery 27th edition

32. Thank you