Brief Review of Traumatic Pancreatic Injuries

We had an interesting case last week where a patient sustained an injury to her pancreas from blunt trauma (bicyclist vs bus). This patient’s CT scan demonstrated a laceration in the pancreatic body, for which she underwent an exploratory laparotomy, pancreatic mobilization and exploration, and drain placement. A preop ERCP in the OR did not demonstrate a main duct injury, nor was there one recognized at the time of operative exploration. Below is a brief review of traumatic pancreatic injuries.

Mechanism:

Most pancreatic injuries (80%) are sustained from penetrating trauma though injuries do occur from blunt trauma as was the case with our patient

Typically, the liver or stomach may also be concomitantly injured. Less commonly, the duodenum, ampulla, or biliary tract may also be concomitantly injured. To note, blunt trauma may cause perpendicular pancreatic duct fractures.

Diagnosis:

CT Abdomen/Pelvis (preferably with PO and IV contrast) is the best diagnostic modality available.

ERCP (preoperative or intraoperative) or MRCP can help identify ductal injury in the stable patient.

Pancreatic Enzymes and LFTs do not have a role in diagnosis.

Classification  of Pancreatic Injuries

Below is the classification system set forth by the American Association for the Surgery of Trauma (AAST) with corresponding AIS score.

Injured Structure	AAST Grade*	Characteristics of Injury	AIS-90 Score	AIS-2005 Score
Pancreas	I	Small hematoma without duct injury; superficial lacerationwithout duct injury	2	2
	II	Large hematoma without duct injury or tissue loss; major laceration without duct injury or tissue loss	2; 3	2
	III	Distal transection or parenchymal laceration with duct injury	3	3
	IV	Proximal† transection or parenchymal laceration involving ampulla	4	4
	V	Massive disruption of pancreatic head	5	5

AAST = American Association for the Surgery of Trauma; AIS-90 = Abbreviated Injury Score, 1990 version; AIS-2005 = Abbreviated Injury Score, 2005 version; CBD = common bile duct.

* Advance one grade for multiple injuries, up to grade III.

† Proximal pancreas is to the patient's right of the superior mesenteric vein.

Treatment:

Most pancreatic injuries warrant operative exploration especially if pancreatic duct injury is suspected. A missed pancreatic duct injury may have dire consequences. Timely recognition is vital.

Below is a nice algorithm outlining the treatment of pancreatic injury based on the grade of injury. *

Pearls of Operative Exploration of Pancreatic Injuries:

- Pancreatic hematomas should be opened and explored.

- The pancreas may be accessed via the omentum/gastrocolic ligament to enter the lesser sac. Additionally a kocher maneuver may be necessary to explore the head of pancreas and duodenum.

- In addition to control of any hemorrhage, it is vital to evaluate the integrity of the main pancreatic duct intraoperatively and identify any injury. Intraoperative pancreaticography may be utilized in the stable patient if necessary.

- Always leave a drain (if not two)!  80% of pancreatic injuries noted on exploration are treated with just drain placement. Closed suction drains should be used.

- The splenic vein is directly posterior the pancreas. The splenic artery is superior and posterior. They are identified from behind the pancreas and when pancreatic transection is necessary, they should be individually suture ligated at a  point 1 cm proximal (right) to the point of pancreatic transection.

- When transecting the pancreas, the remnant proximal end of the pancreatic duct should be identified and suture ligated with fine nonabsorbable suture (e.g. 4-0 prolene) and then oversewn with interrupted horizontal mattress sutures (using silk or prolene). A gastrointestinal stapling device may also be used.

- There is an avascular plane between the neck of the pancreas and the superior mesenteric vein posterior that allows for safe mobilization of the gland.

- Always leave a drain!

Sources:

*Jurkovich, GG. 7 Trauma and Thermal Injury/ Injuries to the Pancreas and Duodenum. ACS Surgery: Principles and Practice. October 2008. BC Decker Inc.

Thanks to Faaiza Vaince MD for this post.