1. Pancreatic Injury Dr HK Leung Queen Elizabeth Hospital
Joint Hospital Surgical Grand Round

2. Pancreas Retroperitoneal organ
Divided into uncinate process, head, neck, body and tail with respect to SMA and SMV
Tip of tail extends to splenic hilum

3. Pancreatic injury 6 – 7 % of blunt trauma Overall mortality of 20%
Commonly associated with multiple injuries
Compounds an already high mortality rate
Less common because of its retroperitoneal location, but with subtle symptom and sign, diagnosis and management often delayed
Erosion of adjacent vascular and visceral structure
Associated injury: duodenum and vascular structure

4. Mechanism of injury Blunt injury Penetrating injury
Direct force across the upper abdomen
Seat belt, steering wheel and handlebar of bicycle / motorcycle
Penetrating injury
Stab and gunshot wound
Blunt trauma: Part of pancreas injured at left of PV / SMV, associated injuries
1/3 blunt injury

5. Diagnostic challenge Before the era of CT scan Physical examination
USG or peritoneal diagnostic lavage
Serum amylase
Jones reported one third of the 400 pancreatic injuries had normal serum amylase level1
Progressive rise over 24 to 48 hours strongly suggest injury and mandates further investigation
1.) Management of pancreatic trauma. Ann Surg, May 1978
AXR: Fracture lumbar spine, retroperitoneal air bubbles along psoas / kidney; displacement of stomach and T colon, generalized ground glass appearance
Limitation of PDL fluid to lesser sac
Pancreatic lesion missed on USG due to retroperitoneal location and overlying T colon, gastric bubble and duodenum, obesity, subcutaneous emphysema
Akhrass: pancreatic trauma: a ten year multi institutional experience: 400 cases, 82% with raised amylase (1997)
Bradley: all patient had raised amylase after 3 hours in pancreatic trauma (1998)
Isolated brain injury can also cause increased serum amylase level, also in duodenal, small, bowel, hepatic trauma lung injury, rupture of stomach, alcohol intoxication, acute renal failure
Delay = increased mortality
90% of injury would ultimately develop increased serum amylase level
Level not in proportion to severity of injury

6. Investigation To identify main pancreatic duct injury
Computed tomography
ERCP / MRCP
Exploratory laparotomy
CT: extraperitoneal fluid; fluid in lesser sac, arterial pararenal space, between splenic vein and pancreatic parenchymal space, pancreatic edema, hematoma, fracture and thickening of anterior renal fascia
Normal initial findings does not exclude pancreatic injury
ERCP + non contrast CT for extravasation

7. Computed tomography 3 weeks after injury 2 months after injury
M/23 RTA victim
LUQ: swollen hypo enhancing ill - defined pancreatic head
LLQ: Lacerated pancreatic head – uncinate process region
F/26, go kart injury, treated with drainage
Right: hypodense non – enhancing area at pancreatic neck with surrounding hypodense peripancreatic fluid with subsequent CT: linear hypodensity corresponding to previous laceration
3 weeks after injury
2 months after injury

8. Computed tomography Pancreatic fracture, edema or hematoma
Fluid between splenic vein and pancreatic parenchyma
Increased attenuation of fat around pancreas
Extraperitoneal or lesser sac fluid
Thickening of anterior renal fascia
Fluid in pararenal space, transverse mesocolon, lesser sac and around SMA
Hemorrhage into peripancreatic fat, mesocolon and mesentry
Duodenal hematoma / laceration
Left kidney / adrenal gland / spleen injury
Chance fracture
Pancreatic ductal dilation and pseudocyst formation

9. ERCP / MRCP
ERCP
Localize ductal injury by contrast extravasation or cutoff
Therapeutic role of stenting
Limit to stable cases without associated injury
MRCP
Non invasive
Not therapeutic
ERCP has been used more frequently to assist in diagnosis
If CT scan is equivocal or a small parenchymal laceration is present, ERCP is the most reliable method to define continuity of the main pancreatic duct accurately
Suggested in all patient treated conservatively and with delayed presentation
Localize the injury to plan treatment
Complicates pancreatitis, cholangitis, sepsis, GIT injury
MRCP for patient who had pancreatic fistula complicated drainage or pancreatic fistula who had pyloric exclusion, unreliable early after injury, but good for chronic stage

10. Exploratory laparotomy
Establish the continuity of the main pancreatic duct
Complete visualization with hematoma explored
Ductal injury
Ductal injury unlikely in the absence of parenchymal disruption
Extensive fat necrosis in lesser sac
Intraoperative ERCP / USG
Administration of secretin to observe clear fluid from injured duct
Taken emergently to the operating room for abdominal trauma (unstable, stab injury)
Secretin (1 unit / kg)
Head and neck of pancreas - Kocher maneuver
Body of pancreas - Gastrocolic omentum & retroperitoneum
Tail of pancreas - Gastrocolic omentum & spleen
Lesser sac fluid collection, retroperitoneal bile staining, overlying hematoma
Intraoperative criteria of main pancreatic duct injury: complete transection, laceration of more than half, central perforation, severe maceration
Other than integrity of duct, presence of devitalised pancreatic head or duodenum, extent of duodenal injury, integrity of ampulla and bile duct, concomitant vascular injury
Intra operative cholangiogram via cystic duct, CBD or duodenum

11. Management Surgical intervention Conservative management Role of ERCP
Presence or absence of main pancreatic duct injury
Location and severity
Co - existing abdominal injury (inc. concomitant duodenal injury)
Hemodynamic status (damage control surgery)
Conservative management
Serial physical examination and investigation
Change of condition mandates further management
Role of ERCP
Octreotide: some studies report that it can prevent pancreatic complication; mainly use as to treat fistula

12. Management Indication for surgery Damage control surgery Peritonitis
Hypotension
Evidence of disruption of the pancreatic duct
Damage control surgery
Control of bleeding and bowel contamination
Complex procedure after patient stabilized (e.g. anastomosis)
hypothermic, acidotic, or coagulopathic,

13. American Association of the Surgery of Trauma
Pancreas Injury Scale
Grade Type of Injury Description of Injury          
I Hematoma Minor contusion without duct injury
  Laceration Superficial laceration without duct injury            
II Hematoma Major contusion without duct injury or tissue loss
Laceration Major laceration without duct injury or tissue loss
III Laceration Distal transection or parenchymal injury with duct involvement
IV Laceration Proximal transection or parenchymal injury involving ampulla
(Proximal pancreas is to the patients’ right of the SMV)
V Laceration Massive disruption of pancreatic head
*Advance one grade for multiple injuries up to grade III

14. Grade I and II External drainage
Repair of laceration with tacking of viable omentum or suturing
Laceration oversewn often result in necrosis leading to fistula
Closure of capsule laceration might complicate pseudocyst
Drainage and debridement
Suspected ductal injury
Open duodenum, retrograde pancreatogram or omental pedicle with closed suction system

15. Grade I and II
Juan et al reported 35 cases of pancreatic injury managed conservatively
Exclude initial emergency laparotomy due to unstable hemodynamic status, evidence of peritonitis or associated injury
Grade I – 12 patients; Grade II – 23 patients
Failure of conservative management defined as subsequent exploratory laparotomy or development of pancreatic complication
1 out of 12 in Grade I (Missed bowel injury)
4 out of 23 in Grade II (3 pancreatic abscess and 1 liver injury)
Mortality
2 patients died of pulmonary embolism and myocardial infarct (both in conservative management group)
Selective nonoperative management of low-grade blunt pancreatic injury: are we there yet? J Trauma. July 2008 USA.
Especially in case which initial laparotomy is not performed
Non operative management of solid organ injuries is the recommended treatment in hemodynamically stable patients
At least a ERCP to rule out ductal injury

16. Grade III Hemodynamically stable patient, especially in children
Distal pancreatectomy with splenic salvage
Hemodynamically unstable patient
Distal pancreatectomy with splenectomy

17. Grade IV External drainage Roux-en-Y distal pancreatojejunostomy
Hemodynamically stable
Transection of the pancreas at the neck or just to the right of the mesenteric
Anterior Roux-en-Y Pancreatojejunostomy
In the rare patient, a penetrating wound through the pancreatic duct at the head of the pancreas preserves the parenchyma posterior to the transected duct.
In these cases, several investigators have recommended performance of an anterior Roux-en-Y pancreatojejunostomy.

18. Grade IV ERCP + stenting
Hemodynamically stable patients with isolated proximal ductal injuries
Lin et al reported 6 case of ductal injury1
3 cases of Grade III and 3 cases of Grade IV
1 died after distal pancreatectomy
4 recovered with ductal stricture
1 stent dislodged and defaulted follow up
1.) Long-term results of endoscopic stent in the management of blunt major pancreatic duct injury Surg Endosc. Oct 2006 Oct
Ductal stricture required prolonged stenting

19. Grade V Pancreatoduodenectomy
2 stage procedure with anastomosis at reoperation within 48 hour
Stomach, jejunum, pancreatic stump and CBD ligated and drained

20. Combined pancreaticoduodenal injury
Complete exposure of duodenum and pancreas with hematoma and bile staining area explored
Integrity of Common bile duct, pancreatic duct, ampulla and duodenum
Varies from simple repair and drainage to complex surgical procedures
Damage control surgery and diversion procedures
Choice of procedure based on the extent of the pancreatic and duodenal injuries, the hemodynamic status of the patient, and the expertise of the surgeon.
Complex repair
The pancreatic injury can be treated with the omental pancreatorrhaphy, distal pancreatectomy, or a Roux-en-Y distal pancreatojejunostomy.
A duodenal injury may require a transverse duodenorrhaphy, resection with end-to-end anastomosis, or Roux-en-Y jejunal limb to repair (mucosa-to-mucosa) a large defect in the wall of the duodenum.
In approximately 25% of the patients with combined pancreatoduodenal injuries, small duodenal injuries can be repaired primarily and moderate injuries to the pancreas can be widely drained

21. Complication Intra-abdominal abscess Pancreatic fistula Pseudocyst
Pancreatitis
Ductal stricture (after stenting)
Peripancreatic / parenchymal abscess
Hemorrhage secondary to infected retroperitoneal autodigestion, embolisation or OT
Pancreatic fistula: (low < 200ml per day/ high > 500ml per day) leakage of pancreatic fluid over 2 weeks in duration, usually resolve with drainage, or else ERCP and stenting, then operation
Pseudocyst: main determinant as integrity of duct; internal stent or OT
Pancreatitis: upstream secondary to fibrous formation or post – traumatic;

22. Take home message
The integrity of the main pancreatic duct is key in the management and outcome of patients with pancreatic trauma.
ERCP has been used more frequently to assist in diagnosis and, on occasion, for definitive management of ductal discontinuity in patients with contraindications to laparotomy.
Early operative intervention is warranted in most patients with confirmed or suspected ductal injury.
The integrity of the main pancreatic duct is key in the management and outcome of patients with pancreatic trauma.
Simple external drainage and distal pancreatectomy are commonly performed operative procedures and have a favorable outcome most of the time.
Pancreatoduodenectomy is indicated in those select patients with extensive combined pancreatoduodenal injuries who are hemodynamically stable with few associated injuries.
Post-operative complications after repair of major pancreatic injuries include intra-abdominal abscesses, postoperative fistulas, and an occasional pancreatic pseudocyst. Many of these complications may be treated successfully without re-operation.

23. Question?

25. Classification of pancreatic injuries by ERCP
Grade
Description I
Normal main pancreatic duct on ERCP
IIa
Injury to branches of main pancreatic duct on ERCP with contrast extravasation inside the parenchyma
IIb
Injury to branches of main pancreatic duct on ERCP with contrast extravasation into the retroperitoneal space
IIIa
Injury to the main pancreatic duct on ERCP at the body or tail of the pancreas
IIIb
Injury to the main pancreatic duct on ERCP at the head the pancreas
Data from Takishima T, Hirat M, Kataoka Y, et al. Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas. J Trauma 2000;48:745–52.

26. Diversion procedure Pyloric exclusion with gastrojejunostomy
Duodenal diverticulization
“Triple-tube” approach

27. Pyloric exclusion with gastrojejunostomy
The pyloric muscle ring is closed with a number 1 polypropylene suture through a dependent gastrotomy.
Antecolic gastrojejunostomy is then performed using this gastrotomy.

28. Duodenal diverticulization
Truncal vagotomy
Antrectomy with gastrojejunostomy
Duodenal closure
Tube duodenostomy
Drainage of the CBD
External drainage

29. “Triple-tube” approach
Placement of a gastrostomy tube for proximal decompression
Retrograde duodenostomy tube inserted by way of the jejunum for decompression of the repaired duodenum
Antegrade jejunostomy tube for enteral feeding