Br. J. Surg. Vol. 67 (1980) 845-850 Printed in Great Britain

The management of pancreatic and pancreaticoduodenal injuries R O B E R T CAMPBELL A N D T E R E N C E K E N N E D Y *

SUMMARY From 1969 to 1979 39 injuries of the pancreas and duodenum were treated at the Royal Victoria Hospital, Belfart. The mortality was 31 per cent. Twenty-six injuries were due to stab, bomb or bullet. Two of the 17 with low velocity gunshot wounds died, whereas all 5 cases of high velocity missile injury died (P<0401). Ten of the 13 cases of blunt trauma were due to road trajic accidents. In 21 cases the body and tail of the gland were injured, and in 13 the headandneck. There were 5 isolated duodenal injuries and in 7 a combined pancreatico- duodenal injury. The mortality was directly related to the number of other organs damaged.

Three main methodr of treatment were use&simple drainage, suture and drainage, and primary distal pan- creatic resection. Serious complications, pancreatitis. fistula, secondary haemorrhage and sepsis were frequent after the first two methodr but rare after distal resection.

Diagnosis was delayed in 4 cases of closed injury and I of these patients died. Pancreatic injury was missed 6 times at operation; in 4 cases retroperitoneal haematoma was not explored and 2 of these patients died.

Five of the 12 deaths were due to overwhelming bomb and bullet injury. In one case resuscitation was in- adequate. The remaining 6 died of the complications of the original pancreatic injury, either because operation was delayed or because the injury was missed.

Our management was deficient in three areas: aware- ness of the need for laparotomy. recognition of the injury at operation and inadequate surgery. All open abdominal injuries must be explored; suspicion and careful assess- ment are essential in closed trauma. At operation the pancreas must be carefully examined; an upper retro- peritoneal haematoma is an absolute indication for this. Simple drainage is only sujicient for trivial injury; for major injury of the body and tail we prefer distal resection. Roux loop drainage is suggested for injury to the head and neck, especially when associated with duodenal injury.

THE pancreas, lying in the retroperitoneum, is rarely damaged in closed abdominal injuries. Open wounds of the abdomen are relatively rare in the United Kingdom, though quite common in the United States (1-8) and Malaysia (9). The incidence in both closed and open abdominal injury-about 1-2 per cent (1)-is rising largely as the result of major road traffic accidents (1, 5,6,7,9).

The mortality is high-20-40 per cent-and there is no general agreement on the best method of manage- ment. As a result of urban guerilla warfare we have Seen many penetrating wounds of the abdomen in the past decade (10). The purpose of this paper is to present our experience of both open and closed pancreatico- duodenal injuries, to analyse the causes of our failures and to suggest methods of management of the different types of injury.

Patients and methods Thirty-nine patients with ancreatic and duodenal injuries have been seen and treate! at the Royal Victoria Hospital, Belfast, between 1969 and 1979. The overall mortality was 31 per cent. This hospital is the major accident centre for the Province of Northern Ireland, serving a population of approximately 1.5 million. In one-third of our patients the pnmary treatment was carried out at other hospitals and patients were referred for special care because of the severity of their injuries-of both pancreas and other organs. The remain- ing two-thirds were admitted directly to this hospital, often very soon after injury.

Resuits Nature of injury There were 26 patients with open abdominal injuries, 24 resulting from terrorist violence (Table I). Twenty-two of these were gunshot wounds and 2 were due to bomb blast. Two patients were stabbed. Nine of these atients died (35 per cent). Five patients were injured g y high velocity rifle bullets and all 5 died, whereas only 2 of the 17 injured by low velocity bullets died. This difference is statistically significant (P <0.001). Terrorists frequently use hl velocity rifles because of their ‘stopping power’. A higf?velocity missile injury causes severe and wide- spread injury by producing temporary cavitation, in which a positive pressure wave is followed by one of negative pressure (1 1). Injury is caused far beyond the track of the missile and is devastating because of the tremendous release of kinetic energy.

Table I: NUMBERS AND NATURE OF INJURIES Nature of iniurv Patients Deaths

26 9 (35%)

(32%) 5 5 Bullet: HV

LV 17 2 Stab 2 1 Bomb 2 1

Motor accident 10 2 Other 3 1

open

Closed 13 3 (23%)

Total 39 12 (31%)

HV, High velocity, LV, low velocity.

Thirteen pancreatico-duodenal injuries were due to closed abdominal trauma. One patient was crushed at work between a lorry and a trailer; one was struck by the butt of a rifle and in one the crush was inflicted by an ill- fitting seat belt. Motor accidents accounted for the majority, the usual wounding agent being the steering- wheel. Three patients with closed injuries died (23 per cent).

* Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6LA. Correspondence to: T. Kennedy.

846 R. Campbell a d T. Kennedy

Fig. 1. Mortality of pancreatico-duodenal injuries rises steadily when other organs are injured. (The number on each column is the number of patients.)

Associated injuries An average of three other organs (range 0-7) was injured either within the abdomen or elsewhere. Major vascular damage occurred in 7 patients. In 2, laceration ot the vena cava was successfully repaired by suture; one aortic injury required a graft for its reconstruction, but this patient died due to inadequacy of resuscitation. The splenic artery was directly damaged three times; splen- ectomy or simple ligation was performed, but two of these cases were followed by secondary haemorrhage. The superior mesenteric vein was successfully repaired on one occasion. Surprisingly, there were no recorded injuries of the portal vein. Liver injury occurred in 20 patients and was usually treated by suture; only one required resection. There were 12 renal injuries; left nephrectomy was needed in 5 cases, all associated with distal pancreatic injury. Of the 4 spinal cord injuries, 3 resulted in paraplegia, and 2 of these patients died. Massive defects in anterior and posterior abdominal wall resulted from high velocity missile injury in 2 cases, and from a bomb blast at close range in 1. These 3 patients died. There were also 12 major chest injuries, 12 major limb injuries and 7 severe head injuries. Overall, the mortality rose synchronously with increasing numbers of these injuries (Fig 1).

Sites of injury Injuries of the pancreas were grouped anatomically into those of the head and neck and those of the body and tail (see Table Zr). There were only 5 cases of isolated duodenal injury. In 7 patients a combined injury of the head of the pancreas and the duodenal loop was present. When injury was limited to the duodenum there were no deaths, but with open injuries of the head and neck the mortality was 57 per cent.

Management Initial assessment and resuscitation was performed in the usual way in all patients. Immediate laparotomy was performed in all cases of open injury. In closed trauma the decision to operate was based primarily on careful clinical examination. Serum amylase levels were raised

Fig. 2. A retroperitoneal haematoma was not explored in 4 patients, 2 of whom subsequently died.

Table II: SITE OF PRINCIPAL INJURY Site Total Open Closed

7 (4) 6 (1) I 3 ( 5 ) 15 (5) 6 (2) Body and tail 21 (7)

Duodenum only 5 (0) 4 (0) 1 (0)

Head and neck

Figures in brackets are numbers of deaths.

Table 111: PRIMARY TREATMENT AND COMPLICATIONS

Distal Drainage Suture and pancreatic

only drainage resection (n = 18) (n = 14) (n = 7)

Pancreatitis 6 4 - Fistula 6 5 - Secondary 2 2 -

Sepsis 6 2 2 haemorrhage

Inevitable I 3 1 Preventable 3 3 1

Death

at 660 and 1571 Somogyi units in 2 patients in whom it was determined before operation. Peritoneal tap and lavage was not used in this series.

Three procedures were used at the initial operation (Table HI): (a) drainage of the injured area; (b) suture of the gland (or duodenum) with drainage; (c) primary distal pancreatic resection with splenectomy and drainage.

There were many serious complications following each of the first two procedures. Pancreatitis was recognized clinically and by elevation of the serum amylase, or at reoperation. There were 10 pancreatic fistulas and 4 cases of severe secondary haemorrhage. Major sepsis developed in 10 cases. Those patients in whom a distal pancreatic resection was performed had far fewer complications and a generally smoother postoperative course. Four of the 5 cases of duodenal

Pancreatic injuries 847

injury, which were all treated by suture and drainage, made an uncomplicated recovery. In the fifth a duodenal fistula closed spontaneously. All of the other complications, and all of the problems of diagnosis and management, occurred in the patients with pancreatic and pancreatico-duodenal injury. Eleven patients needed a total of 17 further laparotomies because of direct complications of the pancreatic injury. Usually, further drainage was established. In 3 cases drainage was internal, into a Roux-en-Y loop attached directly on to the pancreas. In one case a secondary distal resection was performed.

Two pseudocysts were seen. One resulted from a football injury in a young boy who, treated expectantly as an outpatient, later presented with a mass. The second followed an injury of the tail of the pancreas which was missed at laparotomy when a splenic rupture was treated by splenectomy.

Delayed operation in closed trauma In 4 cases laparotomy was delayed for 24 h or more. In the patient whose seat belt was the wounding agent, a fracture-dislocation of the lumbar spine was treated initially by plating and laparotomy was delayed for 48 h. The patient made a complete recovery. The other 3 patients all had laparotomy delayed for 2 weeks. One by then had gross pancreatitis, fat necrosis and peritonitis and subsequently died. The other 2 survived.

Table IV ANALYSIS OF DEATHS Inevitable Preventable

Massive damage from 3 Missed diagnosis 3 high velocity bullet

Massive shotgun injury 1 Suture and drainage 3 only

resuscitation Massive blast injury 1 Inadequate 1

- - Totals 5 I

Retroperitoneal haematoma Pancreatic injury was missed at operation in 6 patients. A significant retroperitoneal haematoma, associated with pancreatic injury, was present in 4 cases (3 due to closed injury) in which it was not properly explored (Fig. 2). Two of these patients had a prolonged and stormy illness with multiple laparotomies. Both eventually recovered after internal drainage into a Roux loop. The other 2 patients both developed pancreatitis and fistula. Both needed further emergency laparotomy because of severe secondary haemorrhage and both died.

Cause of death Twelve patients died (Table IV). Five patients had severe, multiple injuries and death occurred soon after admission. The magnitude of their injuries, to the great vessels, spinal cord and other organs made death virtually certain. The other two cases of high velocity missile injury had severe, but not overwhelming, damage to other organs, and could-barring their pancreatic injury-possibly have survived.

In 7 patients, by better or by different treatment, death could, we think, have been avoided. In one stab wound the aorta had been divided and was repaired; death was due to inadequate resuscitation. In another

case laparotomy was delayed for 14 days, and in 2 more the diagnosis was missed at laparotomy (see above). The remaining 3 cases all had an injury to the head of the pancreas treated by simple suture and drainage. All 3 developed severe pancreatitis and fistula and 1 a secon- dary haemorrhage. Despite further laparotomy all 3 subsequently died. Six of these 7 patients therefore died as a direct result of inadequate treatment of their pancreatic injury.

Discussion Our experience of pancreatic and pancreatico-duodenal injuries is largely due to unusual local circumstances. Many surgeons will never have to treat a gunshot wound of the abdomen, and blunt trauma to the

ancreas is uncommon. Management of these injuries t! ollows similar lines whatever their cause. Injuries of the head of the pancreas and of the duodenal loop are best considered together because of their anatomical proximity, and the likelihood of their concomitant occurrence. While many of our patients recovered after simple drainage, an appreciable number had many serious complications, from which 6 of them died. Analysis of our results shows deficiency in three main areas of management: awareness of injury, diagnosis and definition of its extent, and the operative procedure performed. Similar experience has been reported pre- viously (1).

In all cases of open abdominal injury we insist that laparotomy be performed (10, 12). In gunshot injuries there is an 86 per cent chance of intraperitoneal injury. An expectant policy has been advocated for these injuries but it has been our experience that there is no significant risk in negative laparotomy, while the risks of delay can be fatal. Abdominal examination, and in particular auscultation, are quite unreliable in the early stages of intraperitoneal trauma.

The indications for laparotomy in closed trauma are more difficult to establish. Pancreatic injuries alone, being retroperitoneal, produce only minimal signs in the early stages, which are easily overlooked. Suspicion of injury and careful and repeated examination are the most useful means to diagnosis. Ancillary aids include estimation of the serum amylase; elevated levels have been reported in about 90 per cent of cases of blunt trauma causing pancreatic injury (1,2,5,7,9). Several hours must elapse before raised amylase levels become apparent. Peritoneal tap and particularly peritoneal lavage are reliable methods for detecting haemoperi- toneum. Amylase levels in the returned fluid are also elevated in 90 per cent of cases of pancreatic injury (1 3, 14). Retroperitoneal air may be seen on radiographs after duodenal rupture, and this can be confirmed by contrast studies (1 5) . If doubt still exists after a short but reasonable period of observation-say 12 h-we feel it advisable to explore the abdomen. Delay much beyond this time is associated with an increased mortality. Sophisticated methods of investigation, by angio- graphy, isotope scan and computerized tomography, are not often applicable in the emergency situation.

At laparotomy pancreatic injury should be con- sidered if the trauma was to the epigastrium, and particularly if it was of a crushing nature. Gunshot missiles are often deflected by other organs and along tissue planes, a fact which should be remembered when predicting which organ might be injured. Damage to adjacent structures is common. Pancreatic injury is

848 R. Campbell pad T. Kennedy

(4 Fig. 3. Injury to the left of the midline (a) is best treated by distal resection (6). Suture and drainage is not recom- mended (c).

often inconspicuous, and careful and complete exami- nation of the gland is vital. Three manoeuvres are necessary for this: (a) an extended Kocher mobilization of the duodenum and head of the pancreas, particularly their posterior aspects; (b) a generous opening through the gastrocolic omentum to examine the neck and body; and (c) division of the ligament of Treitz to inspect the third part of the duodenum. When the spleen is ruptured concomitant injury to the tail of the pancreas is easily overlooked-careful palpation of the tail at the time of splenectomy is essential.

A particularly important and suggestive feature is the presence of a retroperitoneal haematoma above the level of the iliac vessels. ‘An upper retroperitoneal haematoma should be considerd presumptive evidence of a pancreatic injury’ (2). This haematoma may be fairly small, when it is best Seen presenting at the root of the transverse mesocolon or jejunal mesentery. Such a finding demands full exploration, and the custom of leaving such a haematoma undisturbed should be abandoned. When the patient’s condition is stable and there is a retroperitoneal haematoma, there is a natural tendency to ‘let sleeping dogs lie’. This is highly dangerous.

Great importance is placed in the literature on the presence or absence of duct damage, differentiating between a major and a minor injury. While theoretically correct, we have found this to be difficult to determine in practice, unless there has been a complete transection of the gland. Often the minor ducts are obscured by

oedema and bruising. A hand lens or loupe is helpful if the ducts are small. Pancreatography, either by contrast radiology, or using methylene blue, has its advocates (2, 5, 7). The duct is cannulated either after amputation of the pancreatic tail, or through the papilla after opening the duodenum. We have no experience of this technique which may be too complicated for routine use in emergencies.

Duct injury could be inferred if there was rapid pooling of secretion after intravenous injection of secretin. We have successfully used secretin to detect duct damage after enucleation of islet cell tumours. We have not used it in traumatic cases, but suggest that it might be helpful. Small areas of bruising may hide a more serious injury, and the capsule may need to be opened for a full examination. The aims of treatment are to limit the extent of pancreatitis and to prevent the internal pooling of secretions. It is for this reason that the presence of a duct laceration is so important.

Extensive drainage by wide-bore soft tubes, or by sump drains, is essential in all cases of pancreatic injury, and after any operative procedure. Drainage alone is sufficient for a trivial injury, but we have not found it possible to define this group even at operation. Our experience of the considerable complications, the frequent need for further surgery and the raised mor- tality makes us now more aggressive in all cases at the time of the initial operation.

Injuries to the left of the midline are best treated by distal pancreatic resection with or without splenectomy (Fig. 3). This is a safe and reliable procedure. There has been no case of pancreatic insufficiency, which is most unusual in previously healthy patients where less than two-thirds of the gland are resected. We suture the proximal remnant after ligation of the duct. Other workers (5 ,6, 16) have used drainage into a Roux-en-Y loop in a variety of ways. We feel that this is unnecessary where the injured part of the gland is removed, unless duct stenosis from proximal injury or previous chronic pancreatitis is suspected. For injuries to the right of the midline extended resection has been advocated, with good results (8). We feel that this is too extensive a procedure for routine use. Instead, we suggest internal drainage of the damaged area into a Roux-en-Y loop (Fig. 4).

This is attached directly to the pancreas and duodenum. Its terminal aperture can be made any size required to cover the area of trauma. This is a relatively simple technique, and has the advantage that it obviates the need to search for a divided duct, which is more common in injuries of the pancreatic head, when the volume of leaking secretions is greater. If the ductal

Pancreatic injuries 849

. - .. . (6) (a)

Fig. 4. A lacerated pancreas and duodenum (a) treated by direct application of a Row loop (6).

system is intact no harm has been done. Furthermore, leaking secretions will quickly digest any sutured repair of a lacerated duodenum, stomach or other viscus, and we have found such a combination of fistulas cannot be controlled unless a Roux loop is attached. One practical objection to the use of Roux loops is that when the posterior capsule of the pancreas has been breached there may be leakage from the posterior surface (5) ; we have not experienced this difficulty. A variety of other procedures is described in the literature. Whipple’s operation has been largely abandoned because of the very high associated mortality (7). Berne et al. (3) described the operation of ‘duodenal diverticuliz- ation’ with encouraging results. In this procedure a Billroth I1 hemigastrectomy with truncal vagotomy is performed; the pancreatic and duodenal lacerations are sutured and a formal duodenal fistula created. This is a formidable operation in a severely injured patient, almost as formidable as a pancreatico-duodenectomy, and we are hesitant to suggest its use, unless the pancreatic head and duodenum have been reduced to a pulp. The use of a T tube placed in a lacerated duct and routed through the stomach has been described (17). This technique is only applicable where a large duct is injured.

The principles of duodenal repair by suture in early cases, and by jejunal patch in late cases, are well established. Neither of these two procedures is suitable if there is a concomitant pancreatic injury.

Nasogastric suction should be used routinely and is probably effective in reducing pancreatic secretions; it may need to be continued for several days (15). In the past we have not followed any particular antibiotic policy; we now use a combination of cephalosporin or gentamicin and metronidazole.

We have had many serious complications, the majority of which were due to inadequate initial surgery. Postoperative pancreatitis is best treated conservatively. If this fails and operation becomes necessary, wide drainage with sump suction should be instituted. More extensive procedures are very hazardous.

External fistula is common in our experience, and the reported incidence may be as high as 61 per cent and 29 per cent in open and closed trauma respectively (6), though the type of operative procedure makes no difference (7). While distressing, a fistula may prevent the internal pooling of secretions which is so dangerous,

Open injury --

\ Closed injury

Observe Serum amylase

Peritoneal lavaae

---r-

IT Retroperitoneal

Pancreatic injury -Explore--, Other injury

+ \ 4 Mar, Mino, Treat accordingly

Headtneck Body+tail Drain

Roux loop Distal resection Fig. 5. Flow diagram of suggested management.

and be to some extent beneficial. If a fistula drains for more than 4 weeks (the so-called ‘major’ fistula) ( l ) , reoperation and internal drainage into a Roux-en-Y loop is the procedure of choice.

Secondary haemorrhage is very ominous. Often very little can be achieved by further surgery because of intense pancreatitis, which is the underlying cause. Reoperation was performed in 4 cases, but 3 died.

We have Seen only two traumatic pseudocysts. Both developed after pancreatic injury was missed. Both were drained, one externally because of its situation and one by cystgastrostomy. Both made a full recovery.

Scheme of diagnosis and management Fig. 5 shows a flow diagram based on our experience, and what we now feel to be the methods of choice. The main steps are: to recognize the need for laparotomy, to diagnose and define the nature and the extent of the

850

injury and to treat accordingly. For left-sided injuries, distal resection is preferred; for injuries of the head of the pancreas drainage into a Roux-en-Y loop is advocated; where the head and duodenal loop are

be indicated.

R. CpmpbeU and T. Kennedy

shattered, pancreatico-duodenectomy may occasionally

conclusioas Although injury of the pancreas is relatively rare, its effects are often devastating. In closed abdominal injuries diagnosis is often difficult and it may be dangerously delayed. Even at laparotomy injury of the pancreas is often overlooked, particularly when a retroperitoneal haematoma is not carefully explored. In these cases there is an increase in both mortality and morbidity from pancreatitis, fistula, sepsis and secon- dary haemorrhage.

Simple suture and drainage is inadequate and more aggressive treatment should be applied. All, except the most trivial, injuries of the pancreas between the neck and tail should be treated by primary distal resection. When the head is damaged, with or without duodenal injury, primary Roux loop drainage may be the best option.

Ac knowledgements We wish to thank our many colleagues for permission to study their patients.

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52 649-65.

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