The Management of Pancreatic Trauma in the Modern Era

The Management of Pancreatic Trauma in the Modern Era from Sun YaiCheng

The Management of Pancreatic Trauma in the Modern Era
Surgical Clinics of North America. Volume 87, Issue 6 (December 2007)

Diagnosis

• Grading system
• Serum amylase levels
• CT
• ERCP
• DSS MRCP
• Exploratory laparotomy

Pancreas Organ Injury Scale of the American Association for the Surgery of Trauma

Grade	Injury	Description
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 injury
IV	Laceration	Proximal transection or parenchymal injury involving ampulla
V	Laceration	Massive disruption of pancreatic head

CT findings suspicious for an injury to the pancreas include the following:

• hematoma surrounding the pancreas
• fluid in the lesser sac
• thickening of the left anterior Gerota's fascia.

CT scans can also demonstrate parenchymal lacerations or transections of the main pancreatic duct.

ERCP is the most reliable method to define continuity of the main pancreatic duct accurately.

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

Exploratory Laparotomy

In those patients who are taken emergently to the operating room for abdominal trauma, pancreatic injuries are diagnosed at exploration and it is important to establish the continuity of the main pancreatic duct.

Nonoperative Management

If there is no evidence of a ductal injury on fine-cut CT, non-operative management is acceptable, although it may be wise to perform ERCP to establish normal ductal anatomy definitively.

Operative Treatment
Indications

• Peritonitis on physical examination
• Hypotension and a positive FAST
• Evidence of disruption of the pancreatic duct on fine-cut CT or on ERCP

Isolated injuries to the pancreas without ductal involvement

General principles and exposure

During laparotomy, the initial priorities are control of active hemorrhage and control of gross gastrointestinal contamination.

 Simple external drainage

In the hemodynamically stable patient, pancreatic contusions (AAST grade I), minor capsular injuries, and traumatic pancreatitis can be treated without drainage.
Most other injuries require drainage of some sort.

Treatment options for isolated pancreatic injuries based on the American Association for the Surgery of Trauma pancreas Organ Injury Scale

AAST grade	Treatment options
I	Observation
	Omental pancreatorrhaphy with simple external drainage
II	Simple external drainage
	Omental pancreatorrhaphy and drainage
III	Distal pancreatectomy ± splenectomy
	Roux-en-Y distal pancreatojejunostomy
IV	Pancreatoduodenectomy
	Roux-en-Y distal pancreatojejunostomy
	Anterior Roux-en-Y pancreatojejunostomy
	Endoscopically placed stent
	Simple drainage in damage control situations
V	Pancreatoduodenectomy

Isolated pancreatic injuries with ductal involvement
Distal pancreatectomy
In the hemodynamically stable patient with an isolated pancreatic injury, especially a child 10 years of age or younger, splenic salvage should be considered.




If the patient is hemodynamically unstable, an expeditious distal pancreatectomy with splenectomyshould be performed.






Roux-en-Y distal pancreatojejunostomy is indicated in hemodynamically stable patient who has a transection of the pancreas at the neck or just to the right of the mesenteric vessels and few associated injuries.


Combined pancreatoduodenal injuries

Pancreatoduodenectomy is indicated when there is extensive trauma to the head of the pancreas, a severe combined pancreatoduodenal injury, or destruction of the ampulla of Vater.

• In the hemodynamically stable patient, this procedure can be performed at the time of the original trauma laparotomy.
• In most of the patients who are hypothermic, acidotic, or coagulopathic, a damage control procedure is indicated. In this instance, the pancreatoduodenectomy or the reconstruction after a prior pancreatoduodenectomy should be performed at the reoperation.
• Control of hemorrhage and gastrointestinal contamination must occur first.