Pancreatic injuries are uncommon due to the pancreas being protected deep in the retroperitoneum. They can be difficult to diagnose due to delayed presentation. Most injuries are caused by penetrating trauma and are often associated with injuries to other abdominal organs. Surgical management depends on the grade of injury and may involve drainage, resection, or reconstruction of the pancreatic duct. Complications include fistula, abscess, pancreatitis, and sepsis, with sepsis being a major cause of mortality. Close attention to detail is needed to identify and treat pancreatic injuries and prevent complications.

1. Pancreatic Injuries
Mamoun Nabri
Trauma Fellow
11/24/2009

2. Pancreas
– The pancreas was first identified by Herophilus
(335-280 BC), a Greek anatomist and surgeon
– Hundred years later, , another Greek anatomist,
Ruphos, gave the pancreas its name.
– The term "pancreas" is derived from the Greek
pan, "all", and kreas, "flesh",

3. History
• 1827:an autopsy report,
St Thomas Hospital,
London, document the
first pancreatic injury,
PHBW of Sage coach,
complete body
transection.

4. History
• Laborderie in 1856 reported the first penetrating
pancreatic injury in the literature.
• Kulenkampff in 1882 reported a patient that
survived blunt injury to the pancreas with the
development of a pseudocyst.
• Kocher, in 1903 described the surgical approach
to the mobilization of the duodenum and head of
the pancreas
• 1903: only 45 cases, 21 penetrating, 24 blunt
• 1905: Korte, pancreatic transection with fistula

5. Introduction
• Injuries are uncommon, protected deep in
retroperitoneal
• diagnostic dilemma and delay
• When identified early, treatment is
straightforward.
• Accounts for 10% to 12% of all abdominal
injuries.
• Mortality rates 9%-34%; Morbidity 30%-60%
• Approximately 50% of the overall mortality due
to associated major abdominal vascular injuries.

6. Introduction
• Major abdominal vascular injuries are present, 75% of
cases of penetrating pancreatic trauma
• Sepsis and multiple organ failure account for most of
the late deaths.
• The incidence of pancreatic-related mortality ranges
from 2% to 5% in large urban trauma series.
• WW I, and in WWII only 62 cases of pancreatic trauma
were reported (2% of abdominal injuries) with a 56%
mortality
• Only nine cases of pancreatic injury were reported
from the Korean War (22% mortality)

7. Pancreas
• It is a combined endocrine and exocrine gland
• Divided into head, neck, body and tail
• Head lies within the curve of the duodenum
• Uncinate process projects from the head
• Superior mesenteric vessels separate the head
from the body

11. Embryology

18. Pancreas
• 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

20. Histology/Physiology
• 80 – 90 % of the mass is composed of acinar cells
• These form the exocrine portion of the gland
• Secret alkaline juice, amylase, lipase.(1-1.2 L/day)
• Islets of Langerhans are dispersed within the
gland
• They form islands of endocrine tissue
• The islets consist of Types A (20%), B (70%) and D
(10%) cells
– Type A cells produce glucagons
– Type B produce insulin
– Type D produce somatostatin

25. Posterior view of duodenum/pancreas

27. Associated Injuries
90-95% other injuries
• Liver 42-32%
• Spleen 25-40%
• Stomach 20-40%
• Major vessel 25-35%
• Thorax 22-31%
• Bowel 10-29%
• CNS 25%
• Duodenum 18%

28. Etiology
• The great majority of such injuries are caused
by penetrating mechanisms and are often
associated with significant injuries involving
other intra-abdominal organs.
• Blunt trauma to the abdomen caused by a
direct blow or seat belt injury may compress
the pancreas over the vertebral column and
result in pancreatic disruption

29. Diagnosis
• Ductal injury, determine outcome
• High index of suspicion
• H & PE
• Mechanism of injury
• Pancreatic injury can be diagnosed at laparotomy
• Serum amylase, NPV 95%
• CT, sensitivity and specifity more than 80%
• ERCP, eval. duct, plan surgery, stents
• MR, MRCP, evaluate the duct injury
• Intraoperative pancreatography

30. Classification of Injury

32. Surgical Management
• The primary operative goal of abdominal trauma
to control the hemorrhage and gastrointestinal
contamination.
• Proper exposure.
• Evaluation of pancreas require complete
exposure of the gland.
• Intra-operative pancreatography.
• Normal endocrine and exocrine function has
been reported after 90% pancreatectomy, leave
at least 20%.

33. Transection of gastrocoloic ligament, body and tail

34. Kocher maneuver; head and uncinate process

35. Divide peritoneum lateral to spleen and colon;
posterior ( Aird’s maneuver)

36. 60% of pancreatic injuries, minor contusion, hematoma
and capsular laceration, Grade I

37. 20% of injuries, parenchyma laceration without ductal
disruption, Grade II

38. Surgical Management
• These injuries, grade I & II, require only
hemostasis and external drainage
• Resist temptation to repair capsular laceration
• External close drainage, for 10 days
• Nutritional support, elemental diets

40. Distal pancreatic transection, with duct injury, treated
with distal pancreatectomy, Grade III

41. Surgical Management
• Distal pancreatectomy: Grade III
– Transected duct, closed U, figure of 8, non-
absorbable
– Full thickness interlocking U-stitch
– TA, stapler
– Omental patch
– Close suction drainage
– Feeding jejunostomy
– With or without splenctomy

43. TA Stapler, distal pancreatectomy, ligate splenic vessels

44. Spleen preservation distal pancreatectmy

45. Surgical Management
• Pancreatic head injury: Grade IV
– Define ducal anatomy
– Intraoperative pancreatography
– Wide external drainage with postoperative ERCP
• Ductal anatomy not clear
• Hemodynamically unstability
– Patton and colleague, reported, effectiveness of
drainage alone for proximal injuries, with 37
patients, only 13.5%, fistula or abscess

46. For injuries of the pancreatic head that involve the pancreatic
duct but spare the common bile duct, central pancreatic
resection with Roux-en-Y pancreaticojejunostomy

47. Surgical Management
• Combined pancreatic head and duodenal: G V
– Rare, caused by penetrating injuries
– Determine distal CBD and ampulla integrity, IOC
– Associated vascular injuries
– Whipple resection remains, the preferred option
– Harborview MC, Seattle, 6 years, 10 of 117,
underwent Whipple, 4 abscess, 2 pancreatitis, 1
fistula, all 10 patients survived.

50. pancreas duodenum

51. pancreas duodenum

53. Complications
• Most complications are self-limiting and/or
treatable
• Sepsis, MOF: nearly result in 30% of deaths
• Fistula: most common, incidence 7-20%
– < 200ml/d, resolve with adequate drainage
– > 700ml/d, external drainage, nutrition
– Somatostatin, few data support its use in post-
traumatic fistulae

54. Complications
• Abscess:
– 10-25%
– Subfascial or peripancreatic
– Require drainage, percutaneous or open
– The mortality is 25%
• Pancreatitis:
– 8-18%
– Usually treated conservatively
– Hemorrhagic pancreatitis, occurring in less than 2%

57. Complications
• Secondary hemorrhage:
– 5-10%
– Require re-exploration or angioembolization
• Pseudocyst:
– Unrecognized pancreatic injury
– Intra-duct, percutaneous drainage
– Injured duct, definitive therapy
– ERCP before drainage
• Exocrine, endocrine insufficiency,
– uncommon,
– only 10-20% of normal pancreatic tissue is needed for
normal function

60. Conclusion
• Traumatic pancreatic injuries are uncommon
• They are easily missed
• Attention to details that is required to identify
and treat complications
• Diagnosis require high index of suspicion,
pre/intraoperativily, and tests performed in a
timely fashion.

61. Whatever happens, don’t loose your head

62. References
• Current Therapy of Trauma and Surgical Critical Care, Juan
A. Asensio, Donald D. Trunkey
• Trauma, David V. Feliciano, Kenneth L. Mattox, Ernest E.
Moore
• Poole H: Wounds of the pancreas. In Coates JJ, DeBakey M,
eds. Surgery in World War II: General Surgery. vol II.
Washington DC: Office of Surgeon General, 1955.
• Culotta R, Howard J, Jordan GJ: Traumatic injuries to the
pancreas. Surgery 40:320, 1956. [PubMed: 13352116]
• PANCREATIC AND DUODENAL INJURIES COMPLEX AND
LETHAL, J. A. Asensio, P. Petrone, G. Roldán, R. Pak-art,
A. Salim, Scandinavian Journal of Surgery 91: 81–86

63. False Positive