Pancreatic Injury Dr HK Leung Queen Elizabeth Hospital

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

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

Pancreatic injury 6 – 7 % of blunt trauma Overall mortality of 20% Commonly associated with multiple injuries Compounds an already high mortality rate

Mechanism of injury Blunt injury Direct force across the upper abdomen Seat belt, steering wheel and handlebar of bicycle / motorcycle Penetrating injury Stab and gunshot wound

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 level 1 Progressive rise over 24 to 48 hours strongly suggest injury and mandates further investigation 1. ) Management of pancreatic trauma. Ann Surg, May 1978

Investigation To identify main pancreatic duct injury Computed tomography ERCP / MRCP Exploratory laparotomy

Computed tomography 3 weeks after injury 2 months after injury

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

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

Exploratory laparotomy Establish the continuity of the main pancreatic duct Complete visualization with hematoma explored 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

Management Surgical intervention 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

Management Indication for 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)

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

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

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.

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

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

Grade IV ERCP + stenting Hemodynamically stable patients with isolated proximal ductal injuries Lin et al reported 6 case of ductal injury 1 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

Grade V Pancreatoduodenectomy 2 stage procedure with anastomosis at reoperation within 48 hour

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

Complication Intra-abdominal abscess Pancreatic fistula Pseudocyst Pancreatitis Ductal stricture (after stenting)

Take home message The integrity of the main pancreatic duct is key in the management and outcome of patients with pancreatic trauma.

Question?

Classification of pancreatic injuries by ERCP Grade Description I IIa IIb IIIa IIIb Normal main pancreatic duct on ERCP Injury to branches of main pancreatic duct on ERCP with contrast extravasation inside the parenchyma Injury to branches of main pancreatic duct on ERCP with contrast extravasation into the retroperitoneal space Injury to the main pancreatic duct on ERCP at the body or tail of the pancreas 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.

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

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.

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

“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