Trauma: Pancreas Trauma

Pancreas Trauma

General

  • Most Common After Penetrating Trauma
    • Relatively Protected Anatomically from Most Blunt Traumas
  • When Recognized Early – Management is Typically Straightforward with Low Morbidity & Mortality
  • High Complication Rates Associated with Missed Injury & Delay in Diagnosis
  • Primary Concern in Evaluation is Identifying Duct Injury

AAST Pancreas Injury Grade

Pancreatic Neck Laceration 1

Diagnosis

  • Dx: CT
    • Consider MRCP/ERCP to Evaluate Ductal Injury if Grade I/II

Exposure

  • Head/Uncinate Process – Kocher Maneuver
  • Body/Tail – Open Lesser Sac (Through Greater Omentum)
    • Tail May Require Exposure of Splenic Hilum

Distal Pancreas Laceration 2

Pancreatic Duct Transection MRCP 3

Treatment

  • Minor Contusion: Nothing
  • Hematoma or Laceration without Duct Injury: Peripancreatic Drain
    • If Uncertain, Hematoma Should Be Explored to Determine Ductal Injury
  • Duct Injury Mn
    • Distal to SMV: Distal Pancreatectomy
      • Conserve ≥ 20% of the Pancreas (Can Take Up To 80%)
      • Splenic Management:
        • Stable: Splenic Preservation
        • Unstable: Concurrent Splenectomy
          • Shorter OR; Longer LOS; Same M&M
      • During a Damage Control Operation – Place a Drain Near the Injury with Temporary Abdominal Closure & Plan to Definitively Manage Later
    • Proximal to SMV: Damage Control & Drain
      • If Fistula Fails to Heal:
        • Major Head Disruption: Pancreaticoduodenectomy
        • No Major Head Disruption: Pancreaticoenteric Anastomosis
  • Massive Destruction of Duodenum & Pancreatic Head: Pancreaticoduodenectomy
    • When Stable (Never Emergent)
  • Considerations:
    • Always Leave Closed-Suction Drain
      • Minimum of 10 Days (Time for Fistula to Develop)
      • Treats 80% of Injuries
    • Consider Feeding Jejunostomy if Duct Injured
    • Most Common Complication Following Injury: Pancreatic Fistula

Distal Pancreatectomy & Splenectomy 4

Mnemonics

Management of Pancreatic Ductal Injury

  • Treat the Pancreas Like a Crawfish
    • Suck (Drain) the Head
    • Eat (Resect) the Tail

References

  1. Doley RP, Yadav TD, Kang M, Dalal A, Jayant M, Sharma R, Wig JD. Traumatic Transection of Pancreas at the Neck: Feasibility of Parenchymal Preserving Strategy. Gastroenterology Res. 2010 Apr;3(2):79-85.(License: CC BY-2.0)
  2. Al-Jazaeri AH. Short hospitalization after early intervention in managing grade III pancreatic injuries in children: a possible new trend. Saudi J Gastroenterol. 2011 Sep-Oct;17(5):363-6. (License: CC BY-NC-SA-3.0)
  3. Kottapalli DC, Devashetty S, Suryanarayana VR, Kilari M, Ismail MD, Mathew P, Chetty PK. Complete pancreatic duct disruption in an isolated pancreatic injury: successful endoscopic management. Oxf Med Case Reports. 2016 Mar 16;2016(3):44-6. (License: CC BY-NC-4.0)
  4. Hasanovic J, Agic M, Rifatbegovic Z, Mehmedovic Z, Jakubovic-Cickusic A. Pancreatic injury in blunt abdominal trauma. Med Arch. 2015 Apr;69(2):130-2.(License: CC BY-NC-4.0)