Pancreatic Injury

PANCREATIC TRAUMAPANCREATIC TRAUMA

Presented byPresented by

Manojit MandalManojit Mandal

OverviewOverview

General pointsGeneral points

Pancreas & Duodenum are difficult structures Pancreas & Duodenum are difficult structures for Surgical exposure.for Surgical exposure.

They are retroperitoneal structures; so, They are retroperitoneal structures; so, isolated pancreatic injuries don’t usually isolated pancreatic injuries don’t usually present with peritonitis. Also, the injuries present with peritonitis. Also, the injuries

present late.present late.

They have intimate anatomical relations with They have intimate anatomical relations with large vessels like SMA & vein, IVC, large vessels like SMA & vein, IVC,

Pancreaticoduodenal, hepatic & splenic Pancreaticoduodenal, hepatic & splenic vessels.vessels.

General pointsGeneral points

Prognosis is influenced by :Prognosis is influenced by :

Cause & complexity of injury.Cause & complexity of injury.

Amount of blood loss.Amount of blood loss.

Duration of shock.Duration of shock.

Speed of resuscitation.Speed of resuscitation.

Type of surgical intervention.Type of surgical intervention.

Delay in diagnosis is M/C cause of Delay in diagnosis is M/C cause of morbidity/ mortality.morbidity/ mortality.

Mechanism of injuryMechanism of injuryBlunt trauma :Blunt trauma : neck or body is compressed neck or body is compressed against lumbar spine usu. in steering wheel against lumbar spine usu. in steering wheel

injuryinjury (M<20%)(M<20%)

Penetrating trauma :Penetrating trauma : roughly 2/3roughly 2/3rd rd of cases of cases

Stab injuryStab injury (M<5%)(M<5%)

Single fragment missile injurySingle fragment missile injury (M<20%)(M<20%)

Shotgun injuryShotgun injury (M>50%)(M>50%)

Stab-injury damages along its tract, whereas, Stab-injury damages along its tract, whereas, in gunshot injures tissues in missile-tract and in gunshot injures tissues in missile-tract and surrounding pressure wave area are damaged.surrounding pressure wave area are damaged.

Pancr. ductal injury is mostly d/t penetrating Pancr. ductal injury is mostly d/t penetrating injury.injury.

Associated InjuriesAssociated Injuries

50-90%50-90% of patients have associated injuries.of patients have associated injuries.

A mean ofA mean of 3.53.5 other organs are injuredother organs are injured..

Most morbidity/mortalityMost morbidity/mortality depend upon the depend upon the associatedassociated injuries; not the Pancreatic injury injuries; not the Pancreatic injury

itself.itself.

M/c injured organsM/c injured organs are :Liver, Stomach, major are :Liver, Stomach, major vessels, Thoracic viscera, Colon & small-bowel, vessels, Thoracic viscera, Colon & small-bowel,

spinal-cord vertebra & Duodenum.spinal-cord vertebra & Duodenum.

Grading of injury : Organ injury Grading of injury : Organ injury scalescale

((Modified Lucas classification)Modified Lucas classification)((vis a vis AAST scale)vis a vis AAST scale)

Class-1 :Class-1 : Superficial contusion/lacerationSuperficial contusion/laceration

Without major ductal-injury Without major ductal-injury

Any part of pancreasAny part of pancreas

(AAST -1 :American association for the (AAST -1 :American association for the Surgery of Trauma scale )Surgery of Trauma scale )

Organ injury scaleOrgan injury scale((Modified Lucas classification)Modified Lucas classification)

Class- 2 & 3Class- 2 & 3 : : Deep laceration/transectionDeep laceration/transection

With/without ductal injuryWith/without ductal injury

Neck/body/tail Neck/body/tail (cl-2),(cl-2), headhead (cl-3)(cl-3)

(AAST-2 without duct injury, (AAST-2 without duct injury,

AAST-3 distal & AAST-4 proximal pancreatic AAST-3 distal & AAST-4 proximal pancreatic injury alongwith duct injury )injury alongwith duct injury )

Class- 4 :Class- 4 : Combined pancreatico-duodenal Combined pancreatico-duodenal injury injury (involving ampulla, AAST-5)(involving ampulla, AAST-5)

DiagnosisDiagnosis

DiagnosisDiagnosisInjury isInjury is clinicallyclinically not much evident d/t central not much evident d/t central

retroperitoneal position and abundance of retroperitoneal position and abundance of associatedassociated injuries.injuries. Usually diagnosed at Usually diagnosed at

laparotomy.laparotomy.

Serum biochemistrySerum biochemistry : : level of serum amylase level of serum amylase poorly correlate with pancreatic injury. It has poorly correlate with pancreatic injury. It has bothboth high false +ve:high false +ve: high amylase in intact high amylase in intact pancreaspancreas (10-90%) &(10-90%) & high false –ve :high false –ve :normal normal

amylase with injuryamylase with injury (25-97%).(25-97%).

Amylase measured after 3 hrs & serially rising Amylase measured after 3 hrs & serially rising amylase have a little better prognostic value.amylase have a little better prognostic value.

Diagnostic Radiology : CECTDiagnostic Radiology : CECT

Inv. Of choiceInv. Of choice inin haemodynamically stablehaemodynamically stable pt.&pt.& Late complicationLate complication of trauma.of trauma.

Overall 90% sensitiveOverall 90% sensitive..

For major ductal injuriesFor major ductal injuries low low sensitivity(43%)sensitivity(43%)

Low Low before 12 hrsbefore 12 hrs d/t overlying blood or d/t overlying blood or obscure obscure laceration planes.laceration planes.

Diagnostic Radiology : Diagnostic Radiology : CECTCECT

Features : for any injuryFeatures : for any injury : : focal/diffiuse focal/diffiuse pancreatic enlargement/oedemapancreatic enlargement/oedema; ; infiltration infiltration

of peripancreatic soft tissue.of peripancreatic soft tissue.

LacerationLaceration: : linear, irregular, low attenuation linear, irregular, low attenuation areas (fluid/ haematoma) within normal-areas (fluid/ haematoma) within normal-

looking parenchyma.looking parenchyma.

Subtle changes Subtle changes are found inare found in early casesearly cases; ; cases withcases with minimal retroperitoneal fatminimal retroperitoneal fat

Diagnostic Radiology : Diagnostic Radiology : othersothers

ERCP :ERCP :problemsproblems : : There may beThere may be distorted distorted recognisable mucosal landmarks incl. papillarecognisable mucosal landmarks incl. papilla

d/t haematoma or pacreatic- oedema. d/t haematoma or pacreatic- oedema. Pancreatography is problematic d/t failure to Pancreatography is problematic d/t failure to

cannulate ampulla (10%)cannulate ampulla (10%)

Helpful Helpful in late compl.in late compl. Of pancreatic injuryOf pancreatic injury : : in Fistulain Fistula – – for stenting;for stenting;in pseudocystin pseudocyst – – for transgastric drainagefor transgastric drainage

Diagnostic Radiology : Diagnostic Radiology : othersothers

MRCP :MRCP : non-invasive ; non-invasive ; No need for dye, since fluid-filled duct – shows No need for dye, since fluid-filled duct – shows

high signal density.high signal density.Duct anatomy upstream of injury is also Duct anatomy upstream of injury is also

visualised (cf.ERCP).visualised (cf.ERCP).Rapid MR takes <10 min.Rapid MR takes <10 min.

Plain X-ray :Plain X-ray : retroperitoneal gas-bubble;retroperitoneal gas-bubble; groundglass appearance etc.nonspecificgroundglass appearance etc.nonspecific. . USG USG (FAST)(FAST) && DPLDPL for free intraperitoneal fluid arefor free intraperitoneal fluid are

nonspecific, sononspecific, so rarely helpful.rarely helpful.

Intra-OP diagnosisIntra-OP diagnosis

Clues to Pancreatic injuryClues to Pancreatic injury: : Central Central retroperitoneal hematoma, & intra abdominal retroperitoneal hematoma, & intra abdominal

bile-staining.bile-staining.

Intra operative pancreatographyIntra operative pancreatography is done if Pre-is done if Pre-OP duct delineation not sufficient.OP duct delineation not sufficient. MethodsMethods are;are;

Trans-duodenal pancreatic duct Trans-duodenal pancreatic duct cathetarisation,cathetarisation,

Distal cannulation of duct in tail,Distal cannulation of duct in tail,

Needle cholecysto-cholangiogramNeedle cholecysto-cholangiogram..

ManagementManagement

ManagementManagement

CONTUSION & LACERATIONS WITHOUT CONTUSION & LACERATIONS WITHOUT DUCT INJURYDUCT INJURY

70% of injuries.70% of injuries.

Control of bleeding, closed external Control of bleeding, closed external drainage, without repair of capsular drainage, without repair of capsular

laceration is all that is required.laceration is all that is required.

ManagementManagementDISTAL INJURY WITH DUCT DISRUPTIONDISTAL INJURY WITH DUCT DISRUPTION

Treated best withTreated best with distal pancreatectomy with distal pancreatectomy with splenectomy.splenectomy.

Visible duct at cut end is ligated with Visible duct at cut end is ligated with transfixing suture, pancreas is oversewed.transfixing suture, pancreas is oversewed.

Spleen sparing surg.Spleen sparing surg. Requires ligation of 7-10 Requires ligation of 7-10 splenic art. Branches, & 13-22 splenic vein splenic art. Branches, & 13-22 splenic vein

branchesbranches ; ; so rarely done.so rarely done.

Roux en Y pancreatojejunostomyRoux en Y pancreatojejunostomy involving involving the resection margin hasthe resection margin has high risk of high risk of

anastomotic leak.anastomotic leak.

ManagementManagementPROXIMAL INJURY WITH PROBABLE DUCT PROXIMAL INJURY WITH PROBABLE DUCT

DISRUPTIONDISRUPTION

Best managed byBest managed by simple external drainagesimple external drainage

Provided there is no devitalisation & ampulla is Provided there is no devitalisation & ampulla is intact.intact.

A controlled fistula is formedA controlled fistula is formed ; ; either settle either settle spontaneously, or may later require elective spontaneously, or may later require elective internal drainage after definition of exact site internal drainage after definition of exact site

of duct leakage.of duct leakage.

ManagementManagementCOMBINED MAJOR PANCREATICODUODENAL INJURIESCOMBINED MAJOR PANCREATICODUODENAL INJURIES

Involves head of pancreasInvolves head of pancreas, , adjacent duodenum adjacent duodenum &/or papilla&/or papilla, , likely to include major vascular likely to include major vascular

structures. structures. They occur in 10% of cases.They occur in 10% of cases.

For unstable ptsFor unstable pts.,initial goal is.,initial goal is: : hemostasis hemostasis (may even req. pancreatoduodenectomy as (may even req. pancreatoduodenectomy as

initial Opn ), minimising contamination, initial Opn ), minimising contamination, repairing torn bowel, then associatd injuriesrepairing torn bowel, then associatd injuries (“damage control” ).(“damage control” ). Followed by aggressive Followed by aggressive

resuscitation > Definitive surgery.resuscitation > Definitive surgery.


More definitive operations toMore definitive operations to divert gastric, divert gastric, pancreatic & biliary secretions away from pancreatic & biliary secretions away from duodenumduodenum should be considered when pt. is should be considered when pt. is stablestable.. Occur in <10 % cases. Occur in <10 % cases.

Choices are:Choices are: Duodenal diverticularizationDuodenal diverticularizationPyloric exclusion/gastrojejunostomyPyloric exclusion/gastrojejunostomyTriple tube decompressionTriple tube decompression10% of patients require 10% of patients require pancreaticoduodenectomy , but Whipple’s pancreaticoduodenectomy , but Whipple’s reconstruction is not feasible, only “damage reconstruction is not feasible, only “damage control” is possible.control” is possible.


Duodenal diverticulization :Duodenal diverticulization : Aim is to convert a potentially uncontrolled Aim is to convert a potentially uncontrolled lateral duodenal fistula into a controlled end lateral duodenal fistula into a controlled end

fistula.fistula.

suture repair of duodenal injurysuture repair of duodenal injuryExtensive periduodenal & peripancreatic Extensive periduodenal & peripancreatic

drainagedrainage

Antrectomy & gastrojejunostomy (gastric Antrectomy & gastrojejunostomy (gastric diversion)diversion)

Choledochotomy & T–tube drain (biliary Choledochotomy & T–tube drain (biliary diversion)diversion)

Tube duodenostomy( for decompression) Tube duodenostomy( for decompression)


Pyloric exclusion/gastrojejunostomyPyloric exclusion/gastrojejunostomy

Through a gastrostomyThrough a gastrostomy, , the pylorus is closed the pylorus is closed with a purse-string suturewith a purse-string suture & antecolic & antecolic

gastrojejunostomy performed at gastrostomy gastrojejunostomy performed at gastrostomy site.site.

Duodenal injuries repaired & area extensively Duodenal injuries repaired & area extensively debrided.debrided.

Use ofUse of slowly absorbable (2-3 wks) sutureslowly absorbable (2-3 wks) suture in in pyloric closure results in a patent & functional pyloric closure results in a patent & functional

pylorus in 90% pts after 3 wks. pylorus in 90% pts after 3 wks.


Triple tube decompressionTriple tube decompression

Placement of gastrostomy tube (gastric Placement of gastrostomy tube (gastric decompression)decompression)

Drainage of duodenum via a tube passed Drainage of duodenum via a tube passed retrogradely through a jejunostomyretrogradely through a jejunostomy

Antegrade jejunostomy tube for enteral Antegrade jejunostomy tube for enteral nutritionnutrition

Rapid methodRapid method, , problem is inadequate problem is inadequate diversion & tube dislodgement.diversion & tube dislodgement.

ManagementManagementADJUNCTSADJUNCTS

Nutritional support : Nutritional support : Feeding jejunostomy is recommended in all Feeding jejunostomy is recommended in all

patients with major injuries precipitating patients with major injuries precipitating prolonged gastric ileus. TPN is required if prolonged gastric ileus. TPN is required if

enteral accss not possible.enteral accss not possible.

Somatostatin & analoguesSomatostatin & analoguesThey are recommended in post-OP pancreatic They are recommended in post-OP pancreatic

fistulas.fistulas.

ComplicationsComplications

ComplicationsComplicationsPost OP complication rate is 42%, even more Post OP complication rate is 42%, even more

with combined & associated injuries.with combined & associated injuries. Most morbidities are treatable.Most morbidities are treatable.

Complications are early or late.Complications are early or late.Early :Pancreatic fistulaEarly :Pancreatic fistulaFluid collection/abscessFluid collection/abscess

Secondary HgeSecondary HgePancreatitisPancreatitis

Late:PseudocystLate:PseudocystEndocrine & exocrine deficitEndocrine & exocrine deficit

ComplicationsComplicationsPancreatitis :Pancreatitis : may vary from transient may vary from transient

biochemical leak to fulminant Haemorrhageic biochemical leak to fulminant Haemorrhageic pancreatitis. Around 7% of traumas. Most pancreatitis. Around 7% of traumas. Most

respond to conservative Tm.respond to conservative Tm.

Pancreatic fistula:Pancreatic fistula:m/c specific compl. after injurym/c specific compl. after injury . .

Resolve within 1-2 wk if adequately drained.Resolve within 1-2 wk if adequately drained.

High output (>700 ml/d) persisting >10d; usu. High output (>700 ml/d) persisting >10d; usu. associated with major duct-injuryassociated with major duct-injury..

Supplimentary nutrition & octreotide , Supplimentary nutrition & octreotide , Sinogram to define ductal injury site, Sinogram to define ductal injury site,

Endoscopic papillary stenting, distal resection Endoscopic papillary stenting, distal resection for tail injury,for tail injury,

Fluid collection/abscess:Fluid collection/abscess: Usually Peripancreatic, subhepatic, subphrenic.Usually Peripancreatic, subhepatic, subphrenic.

True pancreatic abscess is uncommon.True pancreatic abscess is uncommon.Inf. Suggested by increased temp, leucocytosis, Inf. Suggested by increased temp, leucocytosis,

prolonged ileus.prolonged ileus.Guided FNAC for C/S & amylase, therapeutic Guided FNAC for C/S & amylase, therapeutic

aspiration if possible + antibiotic are required.aspiration if possible + antibiotic are required.

Secondary Haemorrhage :Secondary Haemorrhage :From pancreatic bed, & surrounding vessels.From pancreatic bed, & surrounding vessels.

d/t infected devitalised tissue, & retroperitoneal d/t infected devitalised tissue, & retroperitoneal autodigestion.autodigestion.

TryTry angiographic embolisation> operative angiographic embolisation> operative ligation. ligation.



Pseudocyst :Pseudocyst :D/t. Undetected duct disruption with contd. D/t. Undetected duct disruption with contd.

Leakage.Leakage.

For symptomatic/enlarging cyst: ERCP/MRCP for For symptomatic/enlarging cyst: ERCP/MRCP for duct delineation > intervention.duct delineation > intervention.

Distal duct leak/ minor leak:Distal duct leak/ minor leak: P/cut. guided P/cut. guided aspiration.aspiration.

Proximal leak :Proximal leak : endoscopic drainage, endoscopic drainage, if failed,if failed,

Cystoenterostomy.Cystoenterostomy.


Exocrine & endocrine deficit :Exocrine & endocrine deficit :resection distal to resection distal to SMA leaving head (20% of pancr. mass) is SMA leaving head (20% of pancr. mass) is functionally enough.functionally enough. For more resection For more resection

replacement therapy required.replacement therapy required.

Mortality:Mortality: early death d/t vascular & associated early death d/t vascular & associated injuryinjury

Late death is d/t sepsis & MOF.Late death is d/t sepsis & MOF.

TTHANKHANK Y YOUOU

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Pancreatic Injury