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Blunt pancreatic transection: management by distal pancreatectomy with splenic salvage

R. L. SheridanlP2 and J. Mitchell’ ‘Surgical Service Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, and ‘Shriners Bums Institute, Boston, MA, USA

Injury, 1994, Vol. 25, 677-678, December

Introduction

Pancreatic transection is most commonly seen with blunt anteroposterior compressive abdominal injury and is usu- ally managed by distal pancreatectomy with splenectomy. Distal pancreatectomy with skeletonization of the splenic vein and splenic salvage has been described (Pachter et al., 1989) and is a useful spleen preserving option for the management of pancreatic transection.

Case report

A 23-year-old woman was the unrestrained driver in a high

speed, head-on motor vehicle accident and was brought to the hospital hypotensive and complaining of abdominal pain. Her only other injuries were a contusion of the face and minor concussion. Computed axial tomographic scanning of the head was normal. Computed axial scanning of the abdomen revealed a major laceration of the left lobe of the liver, a transection of the body of the pancreas, and a haemoperitonium.

After resuscitation her abdomen was explored through a midline incision. Intraperitoneal blood was evacuated and bleeding from the liver injury was controlled with packing. The only finding, other than a large isolated liver laceration, was a transection of the pancreas just to the left of the superior mesenteric vessels. The lesser sack was widely opened through the gastrocolic omentum and the gland exposed. The spleen was not injured but was fully mobilized to facilitate exposure of the distal pancreas. The spleen was elevated by packs placed into the splenic fossa further elevating the distal pancreas. The posterior peritoneal folds on the inferior and superior borders of the pancreas were incised, and the distal gland was elevated from the site of transection laterally, separating the gland from the splenic vein, while ligating multiple venous tributaries between fine silk ligatures. When the distal gland was free of the splenic vein, it was removed and the transected end of the main pancreatic duct was identified and ligated with a fine silk suture ligature. The remaining stump of the pancreas was then oversewn with a series of horizontal mattress sutures of silk.

The packs were removed from the liver laceration and residual bleeding was controlled with chromic ligatures. A closed suction drain was placed into the lesser sack, and the abdomen closed in layers. The patient had a smooth post-operative convalescence;

0 1994 Butterworth-Heinemann Ltd 0020-1383/94/100677-02

her drain was removed on the 10th postoperative day and she was discharged. She has subsequently done well. She has required no insulin or enteral pancreatic enzyme supple- mentation.

Discussion

Blunt pancreatic injuries can be a source of major morbidity and mortality and frequently present late. The best preoperative diagnostic tool is computed axial tomo- graphic scanning which will diagnose the majority of such injuries. Endoscopic retrograde cholangiopancreatography is another option but requires the timely availability of endoscopic resources and is consequently rarely used.

Given the potential risk of post-splenectomy sepsis, splenic salvage is desirable if it can be done without unduly prolonging the operative procedure. When reported, such efforts have been successful in as many as 50 per cent of patients with pancreatic injury without splenic injury (Cogbill et al., 1991; Robey et al., 1982).

Points of technique that facilitate the separation of the distal pancreas from the splenic vein include mobilization of the spleen with elevation of the distal pancreas and spleen with packs in the left upper quadrant, and the use of fine silk sutures to ligate doubly the splenic venous tributaries. An alternative technique of distal pancreatec- tomy with splenic salvage has been described (Warshaw, 1988), and involves resection of the portion of the splenic vein in intimate contact with the pancreas, with careful preservation of the short gastric vessels upon whom splenic viability then depends. However, one must not ligate splenic arterial branches in the hilum, as such a manoeuvre may be followed by splenic necrosis (Schein et al., 1991). We feel it is important to identify and ligate accurately the stump of the pancreatic duct to prevent pancreaticocutaneous fistula. The importance of adequate closed suction drainage cannot be overemphasized. Our practice in draining pancreatic injuries is to leave drains in place 7 to 10 days, measure the amylase level of any effluent, and remove drains only if the drainage is less than 24 ml per 24 h, and the amylase level of the drainage is not greater than that of the serum.

Although inappropriate in the unstable injured patient, and although the dissection is somewhat tedious, distal pancreatecomy without splenectomy can be successfully performed in the acutely injured patient.

678 Injury: International Journal of the Care of the Injured (1994) Vol. 25/No. 10

Acknowledgement

This work was supported by the Shriners Hospital for Crippled Children.

References

Cogbill T. H., Moore E. E., Morris J. A. Jr et al. (1991) Distal

pancreatectomy for trauma: a multicenter experience. 1. Trauma 31, 1600.

Pachter H. L., Hoffstetter S. R., Liang H. G. and Hoballah J. (1989) Traumatic injuries to the pancreas: the role of distal pan- createctomy with splenic preservation. J. Trauma 29, 1352.

Robey E., Mullen J. T. and Schwab C. W. (1982) Blunt transection

of the pancreas treated by distal pancreatectomy, splenic salvage and hyperalimentation. Four cases and review of the literature. Ann. Surg. 196, 695.

Schein M., Frienkel W. and D’Egidio A. (1991) Splenic conserva- tion in distal pancreatic injury: stay away from the hilum! j. Trauma 31,431.

Warshaw A. L. (1988) Conservation of the spleen with distal pancreatectomy. Arch. Swg. 123, 550.

Paper accepted 24 June 1994.

Requests for reprints should be addressed to: Robert L. Sheridan MD,

Shriners Bums Institute, 51 Blossom Street, Boston, MA 02114, USA.