Pancreatic and Duodenal Trauma

Pancreatic trauma

· key feature is the presence or absence of ductal injury

· overall mortality 20% (mostly from associated injury)

Grading

I minor contusion or lac - NO ductal injury

II major contusion or lac - NO ductal injury

III distal injury / transection with duct involvement

IV proximal injury or transection involving ampulla (with duct involvement)

V massive disruption of the pancreatic head

Clinical

Either blunt or penetrating injury

- if blunt, found on CT; if penetrating, found at laparotomy.
- in blunt, crushed against the spine in deceleration injuries; chance #s.

Commonly associated solid organ injuries; head is near liver; tail is near spleen
· 
vague and non-specific signs

· physical exam, serum amylase, DPL are poorly sensitive

— 1/3 with a complete pancreatic transection have a normal amylase. Amylase can raise in head injury pt without pancreatic injury

Ix

· helical CT is the best test

· serial if there is doubt over the diagnosis (eg at 48hrs)

· if positive then ERCP in the stable patient should be done to assess the duct

· Alternative is MRCP
Hyperamylasaemia is useful but non-specific as can be associated with salivary gland problems
- rise in 24-48h is associated with post-traumatic pancreatitis, but this is a rare condition.

Operative Assessment

· control haemorrhage

· limit contamination

· clues to damage

— central haematoma

— bile staining

— peripancreatic oedema

— saponification of the retroperitoneal fat

· enter the lesser sac through the gastrocolic omentum (outside the gastroepiploic arcade)

· kocherise the duodenum to allow bimanual palpation of the pancreatic head

· Mobilize the splenic flexure of the colon from the pancreas for wide exposure of the lesser sac

· Visualize the tail by division of the lenorenal ligament and mobilisation of spleen and pancreatic tail medially

· Need to Obtain ductal anatomy

n   Direct cannulation of injured duct

n   Needle cholecystopancreatogram

n   Intra-operative ERCP

· ?ductal injury

— transection of the duct?

— division of more than 50% of the gland?

— massive maceration of the gland?

· if planning a resection then visualisation of the duct to prove injury is required

— intra-op ERCP

— transcystic cholangiogram/ pancreaticogram: rarely visualizes the pancreatic duct

— resect tail and use feeding tube down this

— transduodenal access to ampulla (risk of lateral duodenal fistula)

Mx

· Grade I and II

   non-operative
external drainage with closed drains

   Leave the drains for 7 days as pancreatic fistula develop on a delayed basis.

   Drain output >200mL suggests a fistula

   Day 7 amylase >100,000iU/L has a strong positive predictive value
If found at laparotomy, some surgeons will take a pedicle of viable omentum into a grade I-II lac.

· Grade III

— distal pancreatectomy if the injury is to the L of the SMA (usual pattern is transection over the vertebral bodies)

— up to 80% of the gland can be taken without endocrine deficiency

— specialists will preserve the spleen in the stable patient

— approach through the lesser sac

— divide peritoneum at the lower border

— mobilise the pancreas off the splenic vessel dividing the vessels between ligaclips or take the vessels and the spleen

— mobilise 2cm proximal to the proposed resection line

— divide with diathermy

— ligate the duct individually with figure of 8 suture

— oversew the end of the pancreas with prolene
- another option is a stapled transection of the distal duct and Roux loope to end-to-side pancreaticojejunostomy.

· Grade IV

— proximal to the SMA

— rare

— in a minority resection of up to 90% of the gland is possible

— in the majority resection is not technically possible: the morbidity of internal drainage or pancreaticoduodenectomy is greater than the morbidity of simple drainage.

wide drainage works well

diversion may be indicated but only if ductal injury is proven by radiology

· Grade V and Pancreatico duodenal injuries

Requiring Whipple and Roux-and-Y Bypass

— 3 tube drainage for less severe injuries

— pyloric exclusion and gastrojejunostomy diversion for more extensive injuries

Adjunctive Measures

· ERCP and Pancreatic Duct Stent

· Percutanous Drainage of Pancreatic Collection

· Enteral Feeding:

No evidence for pancreatic rest but pancreatic injury accompanies ileus or duodenum injury so upper digestive system may not work,

so

TPN

Nas jejunostomy

jejunostomy feeding

· octreotide

Controversial

Prophylactic (no surgerical complication yet)

Equivocal for post-pancreatic surgical pt

No evidence in trauma injury

Waste money

Surgical Complication:

?decreases fistula output and increases the rate of spontaneous closure on pancreatic surgery

Complications

· rate of 40%

· Pancreatic fistula

— most often with head injuries

— proportional to the severity of injury

— conservative managment is indicated for 6-8weeks

— ~5% require operative intervention

— Roux en Y limb to the damaged pancreatic segment

· Abscess

— 10%

— CT guided drainage in the first instance

— retroperitoneal or transperitoneal open drainage is occassionally required

· Pseudocyst

— uncommon

— usually related to inadequete drainage

— most can be drained percutaneously

· Pancreatitis

— <5%

   rarely fatal haemorrhagic pancreatitis occurs

Blunt pancreatic injuries

Often diagnosed late.

Pancreas compressed between the anterior abdominal wall and vertebral column.

Repeat clinical examination and serial CT with GI contrast to evaluate duodenal injury.

ERCP can be used to provide information about the pancreatic duct

For severe injuries, a pancreatectomy proximal to line of transection with splenic salvage is performed.


Summary

75%  managed with simple drainage
15% with subtotal resection
2% need a Whipples
The rest need variations of other procedures above.

 


Duodenal trauma

· 5% trauma

· most commonly of the 2nd part

· fixation at the point of the bile duct and ligament of Trietz allow for shearing injuries at these points

Grade

Injury

Description

I

Haematoma

Single portion

 

Laceration

Partial thickness; no perforation

II

Haematoma

More than one portion

 

Laceration

<50% circumference

III

laceration

D2:50-75%

D1/D3/D4: 50-100%

IV

Laceration

>75% D2 involving the ampulla or CBD

V

Laceration

Massive disruption of pancreatico-duodenal complex

 

Vascular

Devascularization

 

Clinical

· high index of suspicion is required

· hyperamylasaemia may be a pointer to upper GI injury in up to 50% but is not a reliable indicator

· plain XR’s may show retroperitoneal air

· CT with oral contrast is the best test

o however the sensitivity of CT is low even with oral contrast.

o Signs on CT include paraduodenal oedema, retroduodenal air, stranding in the fat planes.

· exploratory laparotomy may be required to settle the issue

— kocherise if exposure is not wide enough use the Cattell maneuver

— upward displacement of the small bowel and mobilization of the ligament of Trietz to visualize the 3rd and 4th parts respectively

— pancreatogram can be done through the laceration in the duodenum

— pointers

retroperitoneal haematoma

bubbles of air in the periduodenal tissues

small periduodnal haematomas

bile staining of the tissues

Rx

Haemodynamically stable

Isolated Duodenal Injury

· Injury of <50% of duodenal wall: primary closure in two layers with PDS carried out transversely if possible

· Injury of >50% of duodenal wall can be repair by

· End-to-end ansatomosis

· Roux-en-Y duodenojejunostomy large (especially 2nd part) injuries

· serosal patch – A loop of jejunum is brought up along side the duodenal injury and sutured so that its serosal buttresses the repair.

Combined pancreatico duodenal injury

· grade III

— repair of duodenum as above

— distal pancreatectomy

— duodenal exclusion – A gastrotomy on the greater curvature through which the pylorus is closed. A gastrojejunostomy is then performed to re-establish continuity. Wide drainage is accomplished. The pyloric closure will breakdown after a few weeks and then the gastojejunostomy will close.

· grade IV, V

— pancreatogram

— resection of pancreas and primary repair of duodenum with duodenal exclusion

— Whipple’s

Blunt injuries to the duodenum

· If a duodenal haematoma is found on exploration it should be explored to exclude a perforation.

· This involves a Kocher maneuver and exposure of the lesion

· A subserosal haematoma will be drained by Kocherization

· A submucosal haematoma requires a myotomy-type incision.

· If diagnosed late the patient develops obstruction some days after injury.

· If non-operative treatment fails to resolve after 2 weeks explore the injury to drain haemtoma and rule out other injury.

Haemodynamically Unstable

Damage Control

· control haemorrhage

· rapid closure of GI perforations

· packing

· ICU resussitation

· repeat laparotomy

Techniques

· Primary repair

— debridement, mobilization and end to end anastamosis for injuries to 1st, 3rd and 4th parts

· Serosal Patch

— 2nd part may require a serosal patch

— serosal patch can be used to reinforce the suture line for a primary repair

· Roux-en-Y

— preferred for large 2nd part defects

· Duodenal Exclusion

— suture closure of the defect

— gastrotomy and purse string 2/0 prolene in the pylorus

— gastrojejunostomy

— feeding jejunostomy

— duodenal fistula rate of 5%

— 95% will have a patent pylorus at 4weeks

— marginal ulceration occurs in ~10% and many would do a vagotomy ?value

· Whipple’s

— reserved for massive destruction with devasculaisation of the duodenum

— almost always extensive drainage with TPN and intensive care is a better option

SUMMARY

Damage Control: T-tube diversion

Definitive Surgery:

Grade I/II : Primary repair and omental patch

Grade III: Debridement and re-anastomosis

Grade IV: Closure with Roux-en-Y Duodenojejunostomy or pyloric exclusion with gastrojejunostomy

Grade V: Whipples after damage control

Consider enteral feeding via jejunostomy