Pancreatic Injury

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