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7 TRAUMA AND THERMAL INJURY
ACS Surgery: Principles and Practice
9 INJURIES TO THE PANCREAS AND DUODENUM — 1
9 INJURIES TO THE PANCREAS AND
DUODENUM
Gregory J. Jurkovich, MD, FACS
Duodenal and pancreatic injury continues to challenge the
trauma surgeon. The relatively rare occurrence of these
injuries, the difficulty in making a timely diagnosis, and high
morbidity and mortality rates justify the anxiety these unforgiving injuries invoke. These issues also likely explain the
hesitancy of many to address pancreatic injuries with operative intervention and the most recent literature exploring the
options and consequences of nonoperative managment.1–3
Mortality rates for pancreatic trauma range from 9 to 34%,
with a mean rate of 19%. Duodenal injuries are similarly
lethal, with mortality rates ranging from 6 to 25%. Complications following duodenal or pancreatic injuries are alarmingly
frequent, occurring in 30 to 60% of patients.4–6 Recognized
early, the operative treatment of most duodenal and pancreatic injuries is straightforward, with low morbidity and
mortality. Recognized late, these injuries result in a protracted, difficult clinical course, often ending in a devastating
outcome.7–11
History
An 1827 report of a traumatic transection of the pancreas
as a result of a stagecoach wheel running over a patient is
generally recognized as the first literature on pancreatic
trauma.12 By 1903, Mickulicz was able to identify 45 cases
of pancreatic trauma in the literature, of which 21 involved
penetrating and 24 blunt injuries.13,14 He noted that all 20
patients not operated on died, and 18 of the 25 (72%) who
were operated on survived—a remarkable success for the
time. Mickulicz recommended a thorough exploration
through a midline incision, suture control for hemostasis, and
the placement of drains in all cases, recommendations that
still hold today.13 In 1930, Stern reviewed 62 reported cases
of pancreatic trauma, in which 30 of the patients survived and
32 died.14 His treatment recommendations were essentially
the same as Mickulicz’s, although Stern perhaps foresaw
the role of diagnostic peritoneal lavage in his recommendation to use “abdominal puncture” to aid in the diagnosis of
pancreatic trauma.
The occurrence of complications was also noted early. In
1982, Kulenkampff reported what was likely a pancreatic
pseudocyst following blunt trauma.15 In 1905, Korte reported
a case of isolated pancreatic injury with total transection and
resultant pancreatic fistula.16 The fistula closed spontaneously
(as most do), and the patient survived. In 1946, Whipple
reported that the catgut sutures used in and about the
pancreas were likely to dissolve, leading to hemorrhage,
fistula formation, duodenal leaks, and peritonitis; the use of
silk was recommended.17
Wartime experience with pancreatic trauma emphasizes
the high morbidity and mortality but also the infrequent
occurrence of this injury. There were only 5 case reports of
pancreatic injury from the American Civil War, with an 80%
mortality18; 5 reported cases from British troops in World
War I, with an 80% mortality; 62 cases (of 3,154 abdominal
injuries) reported by the 2nd Auxiliary Surgical Group in
1944 and 1945 during World War II, with a 56% mortality19;
and 9 cases from the Korean War, with a 22% mortality.20
More direct surgical management of pancreatic wounds also
occurred in each of these wartime experiences.
Diagnosis
The two most important determinants of outcome following pancreatic injury are the status of the main pancreatic
duct and the time from injury to definitive management of
a ductal injury. This was probably first recognized and
emphasized by Baker and colleagues in 1962.21 Two subsequent reviews of the experience with pancreatic trauma at the
University of Louisville confirmed and emphasized the importance of determining the status of the pancreatic duct. Heitsch
and colleagues found that resection of distal ductal injuries
as opposed to drainage alone significantly lowered postoperative morbidity and mortality,22 and Smego and colleagues
confirmed this observation one decade later by noting that
pancreatic resection distal to the site of ductal injury resulted
in a decrease in the mortality rate at that institution from 19
to 3%.23 Our experience at Harborview Medical Center in
Seattle supports this in that accurate determination of the
status of the pancreatic duct with intraoperative pancreatography results in a decrease in complications from 55% to
15%.24 Although improvements in image quality have been
noted,25 cross-sectional body imaging techniques currently
used in the multitrauma patient (computed tomography [CT]
of the abdomen) do not routinely have adequate sensitivity
to assess the ductal status, and magnetic resonance
imaging (MRI) is usually too unwieldy in the acute trauma
patient.26 Hence, the challenge remains in making an early
determination of the status of the pancreatic duct.
The diagnostic techniques of most use in a patient with a
possible pancreatic injury depend on the mechanism of injury,
other indications for early laparotomy, and the time interval
following the initial abdominal insult. Patients with clear indications for laparotomy need little or no preoperative evaluations directed at identifying a possible pancreatic injury as the
diagnosis of pancreatic injury must be made intraoperatively.
However, establishing the presence of pancreatic injury in
those not requiring immediate laparotomy for hemorrhage
or bowel perforation is a challenge made more difficult by
the knowledge that a missed pancreatic duct injury has dire
consequences.27–30
DOI 10.2310/7800.S07C09
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7 TRAUMA AND THERMAL INJURY
Although there are isolated reports of patients with complete ductal transection being asymptomatic for weeks to
months to years following the initial injury,23,27,29,31 it is more
common for patients with initially missed pancreatic injuries
to manifest an abdominal crisis within a few days of their
injury.32–34 The failure of physical signs and symptoms to
develop promptly is related to the retroperitoneal location of
the pancreas, pancreatic enzymes remaining inactive following an isolated injury, and decreased secretion of pancreatic
fluid after injury. Early identification of a subtle pancreatic
injury therefore requires a high index of suspicion, a carefully
planned approach, and close observation.
A high index of suspicion is warranted in all patients with
high-energy direct blows to the epigastrium. The classic
examples are a crushed steering wheel with an adult driver
and a handle bar injury in a child.35,36 The energy of impact
results in a crushing of the retroperitoneal structures against
the spine and typically transecting the pancreas at this point.
Soft tissue contusion in the upper abdomen and disruption of
the lower ribs or costal cartilage are physical findings that
should suggest possible pancreatic injury. Epigastric pain out
of proportion to the abdominal examination is often another
clue to a retroperitoneal injury.
hyperamylasemia
Although the highest concentration of amylase in the
human body is in the pancreas, hyperamylasemia is not a
reliable indicator of pancreatic trauma. In one series, only 8%
of blunt abdominal injuries with hyperamylasemia had
pancreatic injury.37 Conversely, as many as 40% of patients
with a pancreatic injury may initially have a normal serum
amylase.38,39 In addition, there is evidence that isolated brain
injury can cause elevated amylase40 or lipase41 via an unclear
central mechanism. Nonetheless, the presence of hyperamylasemia should heighten suspicion for pancreatic injury.
The time between pancreatic injury and serum amylase
determination may be critical. In a report of 73 patients with
documented blunt injury to the pancreas, serum amylase was
elevated in 61 patients (84%) and normal in 12 (16%).42
All 12 patients with a normal amylase were evaluated within
3 hours of injury. Patients with an elevated amylase were
assayed 7 P 1.5 hours after injury compared with 1.3 P 0.2
hours after injury in those patients with normal serum amylase. These investigators concluded that serum amylase levels
determined within 3 hours of injury are not diagnostic.
Our review of the available data led us to conclude that the
sensitivity of serum amylase in detecting blunt pancreatic
trauma varies from 48 to 85% and the specificity varies from
0 to 81%.5 The negative predictive value of serum amylase
following blunt trauma is about 95%.38,39,43 Sensitivity and
positive predictive value may improve if serum amylase is
assayed more than 3 hours after injury. What this means
is that 95% of patients with blunt trauma with a negative
amylase will indeed not have a pancreatic injury. An elevated
serum or peritoneal lavage effluent amylase does not necessarily confirm the presence of a pancreatic injury, but it does
mandate further evaluation.
imaging studies
Blunt abdominal trauma patients with hyperamylasemia
who present with a reliable, benign abdominal examination
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9 INJURIES TO THE PANCREAS AND DUODENUM — 2
are carefully observed and serial amylase is remeasured after
several hours. Persistent elevation or the development of
abdominal symptoms is grounds for further evaluation, which
may include abdominal CT scan, endoscopic retrograde
cholangiopancreatography (ERCP), or surgical exploration.
If the abdominal examination is initially equivocal or unreliable, hemodynamically stable patients with hyperamylasemia
should undergo a dual-contrast (intravenous and oral)
abdominal CT scan as part of the initial evaluation. If
the patient subsequently develops abdominal symptoms or
the amylase fails to normalize, a directed evaluation of the
pancreas is warranted, either by repeat abdominal CT, ERCP,
or surgical exploration.
Abdominal CT scans have a reported sensitivity and specificity of 70 to 80% in diagnosing pancreatic injury, although
the accuracy of this examination is largely dependent on
interpreter experience, the quality of the scanner, and the
time from injury.44–46 The CT findings of pancreatic injury
include direct visualization of a parenchymal fracture [see
Figure 1], an intrapancreatic hematoma, fluid in the lesser
sac, fluid separating the splenic vein and pancreatic body,
thickened left anterior renal fascia, and retroperitoneal
hematoma or fluid. These findings are often subtle, and rarely
are they all present in one patient.47 Some of the CT signs of
pancreatic injury may not yet be apparent if the patient is
examined immediately after injury, perhaps attributing to the
reports of false-negative CT scans in up to 40% of patients
with significant pancreatic injuries.48 This, however, is not
grounds for delaying a CT evaluation but is an argument for
repeating a CT scan if symptoms persist.
Although ERCP has no role in the acute evaluation of the
hemodynamically unstable patient, there has been a flurry of
reports over the past decade regarding the utility of ERCP in
diagnosing and managing pancreatic trauma. ERCP is currently the best imaging technique of the pancreatic duct and
its divisions but usually requires anesthesia and is not readily
or widely available. Most experience has been with ERCP in
the late or missed diagnosis of pancreatic duct injury, occasionally with transductal stenting used to manage the injury,
particularly in children.49–53 This is an evolving issue that will
continue to foster investigations, but the principle of timely
diagnosis and recognition and management of ductal injury
remains.22,54 Early ERCP showing intact pancreatic ducts,
including the secondary and tertiary radicals, without any
extravasation permits nonoperative therapy if no associated
injuries are present.55 The difficulty in this management
scheme is determining which patients warrant ERCP and
getting the ERCP accomplished promptly.56,57
MRI has emerged as a potential technique in the evaluation
of the pancreatic duct in the earliest part of the 21st
century26,58 Although primarily used to date in elective circumstances, magnetic resonance pancreatography (MRCP)
has been reported as a noninvasive alternative to determine
the status of the main pancreatic duct in a small series of
patients with pancreatic injury. To date, most reports suggest
that MRCP is either unreliable or too unwieldy in the very
acute phase after injury, but MRCP appears to be gaining
increased interest in delayed diagnosis and managment.59
Further study of its sensitivity and specificity in this setting is
warranted, but the initial enthusiasm appears to have been
tempered.
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9 INJURIES TO THE PANCREAS AND DUODENUM — 3
Figure 1. Contusion to the body of the pancreas. Illustrated is the appearance of a contusion to the body of the pancreas
overlying the vertebral column, as seen from the lesser sac (a). The pancreas is mobilized to determine whether a fracture is
present and to assess the likelihood of a duct injury. This exposure is best accomplished by dissecting along the inferior border of
the gland, dividing the inferior mesenteric vein if necessary, and reflecting the pancreas superiorly (b).
intraoperative evaluation
Classification of pancreatic injuries is based on the status
of the pancreatic duct and the site of injury relative to the
neck of the pancreas. Careful pancreatic inspection and injury
classification are often complicated by the extent and severity
of associated injuries and occasionally by the reluctance of the
surgeon to mobilize retroperitoneal structures. Clues suggesting potential pancreatic injury include the injury mechanisms
previously described, the presence of upper abdominal wall
contusion or abrasion, and concomitant lower thoracic spine
fractures. The presence of a upper abdominal central retroperitoneal hematoma, edema about the pancreatic gland and
lesser sac, and retroperitoneal bile staining mandate thorough
pancreatic inspection.
Inspection of the pancreas requires complete exposure of
the gland. The initial steps in exposure are to open the lesser
sac through the gastrocolic ligament just outside the gastroepiploic vessels. Carry this exposure far to the patient’s left,
fully opening the lesser sac and freeing up the transverse
colon. The transverse colon is retracted downward and the
stomach upward and anteriorly [see Figure 1]. Frequently, a
few adhesions between the posterior stomach and the anterior
surface of the pancreas need to be incised. A complete Kocher
maneuver is required next to provide adequate visualization
of the pancreatic head and uncinate process. In addition,
mobilization of the hepatic flexure of the colon (a frequently
overlooked maneuver) greatly facilitates visualization and
bimanual examination of the head and neck. Inspection of
the tail of the pancreas requires exposure of the splenic hilum.
If injury involves the tail of the pancreas, mobilization is
achieved first by division of the peritoneal attachments lateral
to the spleen and colon. The colon, spleen, and body and tail
of the pancreas are then mobilized forward and medially by
creating a plane between the kidney and the pancreas with
blunt finger dissection. This maneuver permits bimanual
palpation of the pancreas and inspection of its posterior
surface.
It is worth noting that injuries to the major duct occur in
perhaps 15 to 20% of pancreatic trauma. In our institution,
we managed 193 pancreatic injuries over a 15-year time
frame.4 Only 27 (14%) had grade III injuries and 10 (5%)
grade IV or V injuries. In the 1970s and 1980s, penetrating
wounds were documented as more likely to cause pancreatic
duct injury,60,61 but more recent reviews have not substantiated that observation.4,62 Regardless of the mechanism, the
majority of pancreatic duct injuries can be diagnosed by
careful inspection of the tract of injury following adequate
exposure. All penetrating wounds should be traced from their
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7 TRAUMA AND THERMAL INJURY
entry point through the surrounding tissue to the point of exit
or lodging of the missile. If the pancreas has been damaged
by a knife or a bullet, it is necessary to determine the integrity
of the major pancreatic duct. Most penetrating wounds to the
margins of the gland can be inspected directly and duct integrity confirmed. However, penetrating wounds in the head or
neck or central portion of the pancreas often require further
evaluation. Occasionally, intravenous injection of 1 to 2 µg
of cholecystokinin pancreatozymin (1 to 2 mL of sincalide)
may stimulate pancreatic secretions enough to localize an
otherwise unrecognized major duct injury. The remaining
few injuries may require the more elaborate investigative
techniques, including intraoperative pancreatography (see
below).
Minor blunt contusions or lacerations of the pancreatic
substance usually do not require further evaluation of the
pancreatic duct and are effectively managed with closed
suction drainage. An intact pancreatic capsule, however, does
not necessarily rule out complete division of the pancreatic
duct, and, rarely, blunt impact to the pancreas can result in
transection of the major duct without complete transection of
the gland.23 Establishing the status of the major ductal system
under these circumstances remains an important step in
determining therapy and in anticipating late morbidity and
mortality. Routine performance of intraoperative pancreatography when proximal duct injury was suspected decreased
the postoperative morbidity rate from 55% to 15% at our
institution.24
Intraoperative imaging of the pancreatic duct can be
performed by one of three techniques: ERCP, direct open
ampullary cannulation, or needle cholangiopancreatography.
Intraoperative ERCP is cumbersome and often difficult to
coordinate during an emergency operation, but it has been
used and reported.63 Duodenotomy and direct ampullary
cannulation, or even transection of the tail of the pancreas
and distal duct cannulation, have been reported as useful
techniques in the past, but current perioperative imaging,
improved exposure and direct visualization of the pancreas,
and effective use of wide closed-suction drainage and postoperative ERCP have largely abolished the use of these very
invasive diagnostic techniques of imaging the pancreatic
duct.64 Needle cholecystocholangiopancreatography remains
a useful intraoperative adjunct in the evaluation of the
pancreatic duct. This technique involves cannulating the
gallbladder with an 18-gauge angiocatheter and injecting 30
to 75 mL of three-quarter-strength water-soluble contrast
under fluoroscopic imaging. Clear images of the biliary tree
are readily obtained, and in our experience, this technique is
successful in imaging the pancreatic duct 64% (7 of 11) of
the time.4 Contracture of the sphincter of Oddi with intravenous morphine may enhance the likelihood of pancreatic duct
visualization. A cholecystectomy is not necessary following
this procedure.
Classification of Pancreatic Injuries
Although a number of classification systems have been
devised to catalogue pancreatic injuries,60,64,65 the American
Association for the Surgery of Trauma (AAST) Committee
on Organ Injury Scaling addresses the key issues of treatment
of parenchymal disruption and major pancreatic duct status
by focusing on the anatomic location of the injury for the
more severe (grade III to V) injuries [see Table 1].66 Table 1
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9 INJURIES TO THE PANCREAS AND DUODENUM — 4
also defines the Abbreviated Injury Scale (AIS) value that
corresponds to the AAST grading system.67 The AIS has
undergone a revision in 1998 and again in 2005. These differences are important since most commercially available
trauma registries use AIS coding. The AIS coding system is
sponsored and owned by the Association for the Advancement of Automotive Medicine. Duct injuries have different
management alternatives than distal duct and parenchymal
injuries [see Figure 2]. Parenchymal contusions or lacerations
with minimal or no parenchymal tissue loss and no ductal
injury (grade I or II) need only be externally drained.
Combined duodenal and pancreatic head injuries that include
the major duct or ampulla require a combined pancreatoduodenectomy, commonly known as the Whipple procedure, but
uncommonly required for trauma. The difficult decisions
in managing pancreatic trauma involve patients with parenchymal disruption and major duct injury. By focusing on
the anatomic location of the duct and parenchymal injury
(proximal versus distal), this classification provides a useful
management guide.
Treatment of Pancreatic Injuries
contusions and lacerations without duct injury
Minor pancreatic contusions, hematomas, and capsular
lacerations (grade I) account for about 50% of all pancreatic
injuries; lacerations of the pancreatic parenchyma without
major ductal disruption or tissue loss (grade II) account for
an additional 25% of pancreatic injuries. These injuries are
the injury pattern commonly managed nonoperatively. If
identified at operation, they require only hemostasis and
adequate external drainage.2,68 No attempt should be made
to repair capsular lacerations because closure may result in a
pancreatic pseudocyst, whereas a controlled pancreatic fistula
is usually self-limiting. Soft closed-suction drains (JacksonPratt) are preferred over Penrose drains or sump drains as
intra-abdominal abscess formation is less likely, effluent is
more reliably collected, and the excoriation of the skin at the
exit site is significantly less with closed-suction drains.35,69,70
Drains are removed when the amylase concentrations in the
drain are less than that of serum, generally within 24 to 48
hours. An international consensus group definition of pancreatic fistula is the persistence of any measurable volume of
drain output on or after postoperative day 3 with an amylase
content greater than three times serum amylase activity.71 As
described below, there are three grades of pancreatic fistula
complications [see Complications, below]. Drains are generally left in situ until there is no evidence of pancreatic leak.
Nutrition should be provided via the oral or gastric route
as soon as possible. However, a prolonged gastric ileus or
pancreatic complications may preclude standard gastric feeding in patients with severe injuries. Also, since most tube
feeding formulas are high in fat and increase pancreatic
effluent volume and amylase concentration, the low fat and
higher pH (4.5) of elemental diets are preferred as they tend
to be less stimulating to the pancreas.72,73
distal transection and distal parenchymal injury
with duct disruption
The anatomic distinction between proximal and distal
pancreas is generally defined by the superior mesenteric
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7 TRAUMA AND THERMAL INJURY
Table 1
Injured Structure
Pancreas
Duodenum
AAST
Grade*
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9 INJURIES TO THE PANCREAS AND DUODENUM — 5
AAST Organ Injury Scales for Pancreas and Duodenum
Characteristics of Injury
AIS-90 Score
AIS-2005
Score
I
Small hematoma without duct injury; superficial laceration
without 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
I
Single-segment hematoma; partial-thickness laceration without
perforation
2; 3
2
II
Multiple-segment hematoma; small (< 50% of circumference)
laceration
2; 4
2
III
50–75% disruption (laceration) of segment D2 or 50–100%
disruption of segment D1, D3, or D4
4
3
IV
Very large (75–100%) laceration of segment D2; rupture of
ampulla or distal CBD
5
4
V
Massive duodenopancreatic injury; devascularization of
duodenum
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.
vessels passing behind the pancreas at the junction of the
pancreatic head and body. Although there is no anatomic
distinction in the gland itself between the head, body, or tail,
this anatomic division is useful in estimating residual pancreatic endocrine and exocrine function. Innes and Carey have
shown that a distal pancreatic resection at the portal vein
removes an average of 56% (range 36 to 69%) of the gland
by weight.74 Since most blunt trauma pancreatic injuries
occur at the spine, which is just to the patient’s left of the
portal vein as it crosses behind the pancreas, a “distal pancreatectomy” in this circumstance averages as a 56% gland
resection. A resection at the common bile duct removes an
average of 89% (range 64 to 95%) of the gland. Although
reports of normal endocrine and exocrine function after 90%
pancreatectomy do occur, every effort should be made, if
possible, to leave at least 20% residual pancreatic tissue to
minimize postoperative complications.75,76
Distal parenchymal transection, particularly with disruption of the main pancreatic duct, is best treated by distal
pancreatectomy. This is true in children and adults. CT,
particularly if done more than 4 hours after the injury has
occurred, is usually accurate enough to confirm complete
transection. Operative intervention in this case is superior to
nonoperative management in that the operation is definitive,
the residual gland is adequate to preserve exocrine and
endocrine function, and the recovery is relatively short.
Nonoperative management is typically fraught with the complications of pseudocysts, abscess, prolonged and recurrent
hospital admissions, and repetitive drainage procedures,
including the technically challenging and invasive attempts at
endoscopically traversing a transected distal duct.1,10,77
If at celiotomy there is any concern regarding the status of
the remaining proximal main pancreatic duct, intraoperative
pancreatography should be performed through the open end
of the proximal duct. If the remaining proximal duct is
normal, the transected duct should be identified and closed
with a direct “U”-stitch suture ligature with a nonabsorbable
monofilament suture.78 The parenchyma can be closed with
the large (4.8 mm) TA-55 staple,78,79 but we find that this
excessively crushes the residual pancreas, so we prefer
mattress sutures placed through the full thickness of the
pancreatic gland from anterior to posterior capsule to minimize leak from the transected parenchyma. Although most
surgeons prefer nonabsorbable suture for pancreatic stump
closure, one report suggests that a lower complication rate is
obtained with absorbable polyglycolic acid suture to oversew
the pancreatic stump.54 A small omental patch can be used
to buttress the surface, and a drain should be left near the
transection line.
Concern for the possibility of postsplenectomy sepsis and
subphrenic abscess formation following splenectomy has
prompted several authors to describe distal pancreatectomy
without splenectomy [see Figure 3]. The technical challenge
in pancreatectomy with splenic salvage is in isolating and
ligating the pancreatic branch vessels off the splenic vein and
artery yet preventing injury to the splenic hilum and thrombosis of the splenic vein. Generous mobilization of the entire
pancreatic gland and spleen is a prerequisite. An average of
22 tributaries of the splenic vein and seven branches of the
splenic artery must be ligated.80 One report suggests that
this maneuver will add an average of 50 minutes (range 37 to
80 minutes) to the operative time.81 Patton and colleagues
reported splenic salvage in 21 of 33 patients (64%) who
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9 INJURIES TO THE PANCREAS AND DUODENUM — 6
Patient has possible pancreatic injury
History of high-energy direct blow to epigastrium
is suggestive.
Obtain serum amylase levels.
Perform CT with oral IV contrast (repeated if necessary).
Grade I
Grade II
Grade III
Grade V
Provide nonoperative
management.
Repeat CT as needed.
Provide operative or
nonoperative management.
Repeat CT between 4 and
24 hours.
Perform distal
pancreatectomy, with
or without splenic salvage.
Perform
pancreaticoduodenectomy
(Whipple procedure).
Operation
Nonoperative management
Grade IV
Unroofing: Carefully
inspect to confirm
absence of duct injury;
close suction drainage.
Perform ERCP to determine
status of duct. If duct not
injured, follow with a CT
scan or ultrasonography.
Unstable paient: treat with hemostasis and drainage, with
postoperative ERCP to define duct anatomy and allow duct
stenting if indicated.
Stable patient: divide pancreas completely, oversew proximal
stump, and perform Roux-en-Y anastomosis of distal pancreatic
remnant to jejunal limp.
Consider adding pyloric exclusion.
Duct injury
If duct injury is confirmed,
perform either transductal
stenting or operative
exploration as a Grade III-V.
Figure 2. Treatment of pancreatic injury. Algorithm outlining the treatment of pancreatic injury. CT = computed tomography;
ERCP = endoscopic retrograde cholangiopancreatography.
underwent distal pancreatic resection (8 blunt, 13 penetrating).34 The increased operative time and potential blood loss
incurred while performing pancreatectomy without splenectomy must be balanced against the slight risk of overwhelming postsplenectomy sepsis. The balance would seem to favor
splenic salvage only when the patient is completely hemodynamically stable and normothermic and the pancreatic injury
is isolated or present with only minor associated injuries.
proximal transection or injury with probable duct
disruption
Injuries to the pancreatic head represent the most challenging management dilemmas. The key principles of immediate
management are, in order, control bleeding, halt contamination, and define the anatomy of the injury. Effective management can only follow these steps. It is essential that the
surgeon define the pancreatic duct anatomy in proximal
pancreatic injuries. This can usually be accomplished by local
inspection and exploration of the defect to determine the
duct status. Techniques of intraoperative pancreatography
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have been described above and are strongly recommended if
local exploration alone is inadequate to determine the status
of the main pancreatic duct. The only exception to this
approach is the hemodynamic unstable patient with hypothermia, acidosis, and coagulopathy, in which case, simple
damage control surgery is advised. Most experienced
surgeons express reservations regarding performance of
a duodenotomy to perform pancreatography, but a needle
cholecystocholangiopancreatography can often image the
pancreatic duct along with the distal common bile duct (64%
in our experience).4 If this proves unsuccessful, then wide
external drainage with several closed-suction drains should
be performed with planned early postoperative ERCP
(preferred), or MRCP should be the plan. If major proximal
duct injury is confirmed by postoperative ERCP, pancreatic
duct stenting rather than near-total pancreatectomy may be
an option depending on local expertise.1,49,50,53 However, at
least one report has had discouraging results with stenting,
notable for long-term stricture development and acute
sepis.30
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9 INJURIES TO THE PANCREAS AND DUODENUM — 7
Figure 3. Distal pancreatectomy with and without splenic salvage. Illustrated is distal pancreatectomy with salvage of the
spleen (a) and without splenic salvage (b).
If the proximal duct is injured, but the ampulla and
duodenum are spared (rare), two options are available. One
option is extended distal pancreatectomy, resulting in subtotal removal of the gland. The proximal residual gland will
drain into the duodenum in a normal fashion if the duct is
intact. Wide external drainage of the residual pancreatic
surface must be provided. We have not added pyloric exclusion or duodenal defunctionalization or diverticulization
to this procedure, although others advocate its use in this
circumstance.72,82 If there is concern that the residual proximal pancreatic tissue is inadequate to provide endocrine
or exocrine function, the second option is to preserve the
pancreatic tail distal to the injury using a Roux-en-Y pancreaticojejunostomy [see Figure 4]. This requires division of the
pancreas at the site of injury, débridement of injured parenchyma, secure closure of the proximal duct and parenchyma,
and anastomosis of the open end of the divided distal pancreas to the Roux-en-Y jejunal limb. A review of 399 patients
with pancreatic injury from four separate publications revealed
that only 2 (0.5%) patients underwent Roux-en-Y drainage
of the distal segment of a transected pancreatic gland.34,54,83,84
Although rarely employed and complicated by the need for
a combination of pancreatic resection, pancreatic-jejunal
anastomosis, and construction of the Roux-en-Y limb, this
operation needs to be in the armamentarium of trauma
surgeons.
The report by Patton and colleagues from Memphis,
supported by the experience of University of Mississippi
reported by Duchesne and colleagues, is compelling for the
effectiveness of drainage alone rather than extended pancreatectomy, particularly for proximal pancreatic gland injury
in which the duct status is unclear.2,34 In the Patton and
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9 INJURIES TO THE PANCREAS AND DUODENUM — 8
Figure 4. Roux-en-Y pancreaticojejunostomy. If a patient has a grade IV injury to the pancreatic head and there is concern
regarding whether the proximal residual gland would have adequate endocrine and exocrine function if the distal gland is
resected in an extended distal pancreatectomy, an option is to preserve the uninjured portion of the distal gland. This is done by
dividing the pancreas at the site of the injury and performing a Roux-en-Y pancreaticojejunostomy to allow the distal pancreas to
drain into the jejunal limb.
colleagues’ study, 37 patients with proximal pancreatic injury
were managed by closed-suction drainage alone, resulting in
a modest 13.5% fistula and abscess rate. Pancreatography
was not performed in these patients, so the status of the pancreatic duct was not defined, and it remains unclear whether
this technique is truly effective in the presence of a major
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pancreatic duct injury. In the Duchesne and colleagues
report, 35 patients had AAST grade I or II pancreatic injuries
by CT scan and were intentionally managed nonoperatively.
Five (14.3%) failed nonoperative management because of
missed bowel injury (n = 2) and pancreatic abscess (n = 3),
all classified as AAST grade II injuries. These failures of
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7 TRAUMA AND THERMAL INJURY
nonoperative management survived but had a significantly
longer length of stay (19 days versus 9 days). Operative
exploration and drainage of even low-grade pancreatic
injuries remain a prudent approach.
Both of these reports emphasize the importance of determining the status of the pancreatic duct. If the duct and its
branches are not injured, nonoperative management is likely
to be successful, and the role for detailed description of pancreatic duct anatomy advocated by Takishima and colleagues
is relevant.85 If no effort is made at determining the status of
the pancreatic duct, at least wide drainage is mandatory. This
approach is likely to be successful most of the time since
injury to the main pancreatic duct is unusual; when it fails,
however, the consequences are significant and morbid.4,6
If the main pancreatic duct is injured or transected, distal
resection is preferred, with the option of Roux-en-Y drainage
of a long or significant distal pancreas that the surgeon is
loath to sacrifice. Damage control drainage remains a viable
lifesaving first opertion. Finally, postoperative ERCP and
transductal injury stenting appear to be another viable
option, particularly in children, and particularly with very
experienced endoscopists.1,53
In the case of an incomplete pancreatic parenchymal
transection, some surgeons have described an end jejunumto-side pancreas anastomosis. This technique is not recommended because of the difficulty in ensuring the integrity of
the anastomosis and potential for a high-output pancreatic
fistula from the posterior pancreatic wound. Stone and
colleagues from Emory University illustrated the high
complication rate associated with this dated technique. Of
7 patients in whom the technique was used (among 283
patients), 5 (71%) developed a fistula and 3 (43%) died.68
Insertion of a needle catheter jejunostomy or small feeding
tube jejunostomy at the time of initial celiotomy should
be considered for all patients with grade III to V pancreatic
injuries. This allows early postoperative enteral nutrition,
rather than committing the patient who cannot tolerate oral
or gastric feedings to total parenteral nutrition.86 There is
some morbidity related to surgically placed feeding tubes.
Our experience is that feeding jejunostomies have a major
complication rate of 4% in severely injured patients.87 Needle
catheter jejunostomies were associated with fewer complications than the larger, Witzel tube jejunostomy—hence, our
preference for this smaller-caliber feeding tube and elemental
or short-chain polypeptide feeding formulas, which we
prefer.73,87
Combined Pancreatic-Duodenal Injuries
Fortunately, severe combined pancreatic head and duodenal injuries are rare. Forty-eight of 1,404 patients (3%) with
pancreatic injuries reported between 1981 and 1990 underwent pancreatoduodenectomy.88 These injuries are most
commonly caused by penetrating wounds and occur in association with multiple other intra-abdominal injuries. In fact,
these associated injuries are the primary cause of mortality
and emphasize again the priorities of hemorrhage control and
contamination control in dealing with pancreatic or duodenal
injury. The major immediate mortality in patients with
combined pancreatic and duodenal injuries is attributable
to major vascular injury in the vicinity of the head of the
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9 INJURIES TO THE PANCREAS AND DUODENUM — 9
pancreas. If immediate control of hemorrhage and resuscitation can be obtained, the Whipple resection remains the
preferred option in that select group of patients with unreconstructable injury to the ampulla or proximal pancreatic duct
or with combined massive destruction of the duodenal and
pancreatic head. Essentially, in these patients, pancreatoduodenectomy is the completion of surgical débridement of
devitalized tissue. For patients with hemodynamic instability,
hypothermia, coagulopathy, and acidosis, a staged operative
approach (damage control surgery) is advocated, first obtaining control of hemorrhage, then managing bowel and bacterial contamination, and, lastly, identifying the anatomy of the
injury, followed by resuscitation in the intensive care unit.
The patient is returned to the operating room for definitive
reconstruction and anastomoses when stabilized, generally 24
to 48 hours later.
Because of the large number of possible combinations of
injuries to the pancreas and duodenum, no one form of
therapy is appropriate for all patients. In Feliciano and
colleagues’ review of 129 cases of combined pancreaticduodenal injuries, 24% of the patients were treated with
simple repair and drainage, 50% underwent repair and pyloric
exclusion, and only 10% required a Whipple procedure.82
The best treatment option is predicated on the integrity of the
distal common bile duct and ampulla, as well as the severity
of the duodenal injury [see Figure 5]. For that reason, every
patient with a combined pancreatic-duodenal injury requires
a cholangiogram, a pancreatogram, and evaluation of the
ampulla. When the common bile duct and ampulla are intact
(as is the situation in the majority of the cases), the duodenum can be closed primarily and the pancreatic injury treated
as previously described. If the status of the pancreatic duct
cannot be made intraoperatively, wide external drainage of
the pancreatic head with closed suctions drains should be
performed rather than a total pancreatectomy and early
postoperative ERCP or MRCP performed.
It may be advisable to divert gastric contents away from
the duodenal repair in the presence of severe injury to the
duodenum. Duodenal “diverticulization” employs primary
closure of the duodenal wound, antrectomy, vagotomy,
end-to-side gastrojejunostomy, T-tube common bile duct
drainage, and lateral tube duodenostomy. The concept is to
completely divert both gastric and biliary contents away from
the duodenal injury, provide enteral nutrition via the gastrojejunostomy, and convert a potential uncontrolled lateral
duodenal fistula to a controlled fistula [see Figure 6]. A less
formidable and less destructive alternative is the “pyloric
exclusion,” which does not employ antrectomy, biliary
diversion, or vagotomy [see Figure 7].72,89–91 This procedure is
performed through a gastrotomy and consists of grasping
the pylorus with a Babcock clamp and suturing closed the
pylorus with an absorbable size 0 polyglycolic acid or Maxon
suture and constructing a loop gastrojejunostomy. This
diverts gastric flow away from the duodenum for several
weeks while the duodenal and pancreatic injuries heal. The
pylorus eventually opens (2 weeks to 2 months), and the
gastrojejunostomy functionally closes. Fang and colleagues
at Chang-Gung Memorial Hospital in Taiwan described
a technical method of controlled release of the pyloric
exclusion knot, thereby timing the opening of the pyloric
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9 INJURIES TO THE PANCREAS AND DUODENUM — 10
Patient has possible duodenal injury
History of direct blow to epigastrium is suggestive.
Obtain serum amylase levels and WBC count.
Perform abdominal x-ray and contrast studies.
If duodenal trauma is likely, perform laparotomy for
inspection of duodenum and grading of injury.
Grade I or II hematoma
If hematoma is detected at laparotomy,
treat with evacuation.
If hematoma is detected by nonoperative
means, observe patient, and support with
NG suction and TPN.
Grade III
Attempt primary suture closure as first option, with
concomitant pyloric exclusion.
If primary repair is technically not feasible, treat as
follows:
Injury proximal to ampulla: perform antrectomy plus
gastrojejunostomy and stump closure.
Injury distal to ampulla: perform Roux-en-;
duodenojejunostomy to proximal end of duodenal
injury, with oversewing of distal duodenum.
Grade I or II laceration
Grade IV or V
Perform primary suture closure in one or two layers.
Consider pyloric exclusion or buttressing only
if there is associated pancreatic injury.
Management options are as follows:
• Pancreaticoduodenectomy
• Reimplantation of ampulla or distal CBD into
duodenum or Roux-en-; jejunal limb
• Reconstruction with hepaticojejunostomies
• Delayed reconstruction.
Pancreaticoduodenectomy is mandatory for grade
V injuries.
Figure 5. Treatment of duodenal injury. Algorithm outlining the treatment of duodenal injury. CBD = common bile duct;
NG = nasogastric; TPN = total parenteral nutrition; WBC = white blood cell count.
occlusion.92 Marginal ulceration at the site of gastrojejunostomy has been reported from 5 to 33% of patients in whom
a vagotomy was not performed.90–93 Pyloric exclusion is generally reserved for severe combined duodenal and pancreatic
head and duodenal injuries in which a Whipple procedure
is not required. Few advocate pyloric exclusion for isolated
pancreatic injuries.
In very massive injuries of the proximal duodenum and
head of the pancreas, destruction of the ampulla and proximal pancreatic duct or distal common bile duct may preclude
reconstruction. In addition, because the head of the pancreas
and the duodenum have a common arterial supply, it is
essentially impossible to entirely resect one without making
the other ischemic. In this situation, a pancreatoduodenectomy is required. Between 1961 and 1994, 184 Whipple
procedures were reported for trauma, with 26 operative
deaths (14%) and 39 delayed deaths, for a 64% overall survival rate.88 However, more recent experience suggests that
with appropriate selection criteria, pancreatoduodenectomy
for injury can be performed with morbidity and mortality
similar to those described for resections done for cancer.94–96
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Nonoperative Management in Children
Major pancreatic duct injury in children is rare, with an
incidence of 0.12% of children with blunt abdominal trauma.52
Most pediatric pancreatic injuries are grade I or II injuries,
without major pancreatic duct injury. As a result, several
authors have advocated managing all blunt pediatric pancreatic injuries nonoperatively, with bowel rest, serial abdominal
CT to observe for pseudocyst formation, and subsequent
percutaneous drainage as required.7,97–99 However, the high
morbidity and prolonged hospital course of these patients
may not be justified given the good recovery from distal
pancreatectomy with splenic salvage.10 Pseudocysts develop
in 40 to 100% of children with major ductal injury,7,8,100 and
recurrent episodes of pancreatitis can occur remote to the
time of injury.36,101 ERCP with proximal stenting of ductal
injuries is an additional adjunct to care in these patients but
requires the availability of a skilled pediatric endoscopist. A
report from Toronto details the management of 35 children
with pancreatic trauma over a 10-year time period.7 Twentythree had early diagnosis (< 24 hours), whereas in 12, the
diagnosis was initially missed. Twenty-eight were managed
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9 INJURIES TO THE PANCREAS AND DUODENUM — 11
Figure 6. Duodenal
diverticularization. Duodenal
diverticularization consists
of antrectomy with gastrojejunostomy, tube duodenostomy,
vagotomy, and peripancreatic
drainage.
nonoperatively. A subsequent report examined in more detail
10 of these patients having a pancreatic duct transection.99
Forty-four percent developed pseudocyst, and all were
managed with percutaneous drainage; 75% had atrophy of
the distal pancreatic remnant, but there was no evidence of
endocrine or exocrine dysfunction. A report from Japan
demonstrated 100% pseudocyst development in five children
with pancreatic duct injury managed nonoperatively.8 The
data seem to suggest that pediatric pancreatic injuries can
be successfully managed nonoperatively, but with a high
incidence of pseudocyst formation requiring further hosptalization and interventions and with atrophy of the distal
remnant. Other pediatric surgical authors point out the
benefits of distal pancreatectomy in terms of shortening
hospital stay and interventions.10,52,102
Complications
The incidence of complications following pancreatic injury
remains uncomfortably high. Between 20 and 40% of patients
who undergo surgical intervention of a pancreatic injury have
a complicated postoperative course and even higher if a combined pancreatoduodenal wound has occurred [see Table 2].5
Although the majority of complications related to pancreatic
injury are self-limiting or treatable, sepsis and multisystem
organ failure are responsible for nearly 30% of the deaths in
pancreatic trauma. In some series, up to one half of the postoperative complications could have been avoided with careful
inspection of the pancreas and accurate determination of the
status of the main pancreatic duct.28
fistula
Postoperative pancreatic fistula has been defined as any
measurable drain output with an amylase greater than three
times serum.71 This is the most common complication following pancreatic injury, with an incidence of 7 to 20%, rising to
26 to 35% after combined pancreaticoduodenal injury.34,61,103,104
Direct suture closure of the main pancreatic duct may help
minimize this complication, but fibrin sealants do not seem
to provide any advantage.105 The vast majority of these are
minor (less that 200 cc/day) and spontaneously resolve within
2 weeks of injury, providing that adequate external drainage
has been provided. In a multicenter review of distal pancreatectomy for trauma, the postoperative fistula rate was
14% (10 of 71), with spontaneous fistula closure in 89% (8
of 9) of survivors in 6 to 54 days.83 One patient required
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Figure 7. Pyloric exclusion. Pyloric exclusion consists of
closure of the pylorus from within the stomach, followed by
gastrojejunostomy. The procedure eliminates discharge of
gastric acid into the duodenum, thus minimizing the stimulation of pancreatic secretion and reducing morbidity if there is
breakdown of a repair.
extirpation of a residual pancreatic sequestrum to facilitate
fistula closure. This compares with a 3.3% fistula rate in
elective distal pancreatectomy for chronic pancreatitis.76
High-output fistulae (greater than 700 cc/day) are rare and
generally require longer periods of external drainage or surgical intervention for resolution. If a high-output fistula fails
to progressively decrease in volume or persists more that
Table 2
10 days, ERCP is indicated and can be most helpful in establishing the cause of the persistent fistula and planning further
therapy. Nutritional support must be provided throughout
this period. The surgeon’s foresight in placing a feeding
jejunostomy at the time of initial trauma laparotomy is now
rewarded. Low-fat, higher pH elemental feeding formulas
cause less pancreatic stimulation than standard enteral formulas and should be tried prior to committing the patient to
total parenteral nutrition.73 A somatostatin analogue (octreotide acetate [Sandostatin]) has shown promise in treating
prolonged, high-output pancreatic fistulae, but only after
eradicating any infection and in the absence of pancreatic
duct obstruction or stricture.106
Octreotide as an adjuvant to standard fistula management
probably diminishes fistula output, but its shortening of the
time to fistula closure remains to be proven.107 Somatostatin
analogues do seem to prevent postoperative complications
and fistula formation in patients undergoing elective pancreatic resection, although nonrandomized reports on the efficacy of somatostatin analogues in pancreatic trauma patients
are contradictory.108,109 In addition, the trials demonstrating a
decrease in postoperative complications with octreotide use
in elective pancreatic resection initiated octreotide in the preoperative period, a time frame not applicable to the trauma
setting.109 Treatment typically begins with 50 µg subcutaneously every 12 hours but can increase to 1,000 µg/day.
Octreotide has been included in total parenteral nutrition
solutions, although this remains controversial and is not
recommended by the 1997 package insert because of the
formation of glycosyl octreotide conjugates that may decrease
efficacy.110 Major side effects are unpredictable changes in
serum glucose, pain at the injection site, and a variety of
nonspecific gastrointestinal complaints.
abscesses
The incidence of abscess formation after pancreatic trauma
ranges from 10 to 25%, depending on the number and type
of associated injuries. Early operative or percutaneous decompression or evacuation is critical, although the mortality rate
in this group of patients remains about 25%.82,111 The intraabdominal abscess is most often subfascial or peripancreatic;
a true pancreatic abscess is unusual, resulting from inadequate débridement of dead tissue or inadequate initial
drainage.61,84,104,112 True pancreatic abscesses are often not
amenable or responsive to percutaneous drainage, and prompt
surgical débridement and drainage are required. Percutaneous decompression may be helpful in distinguishing between
abscess and pseudocyst.
Factors Determining Severity of Duodenal Injury
Factor
Degree of Injury
Mild
Stab
Blunt force or missile
Size of injury
f 75% of circumference
> 75% of circumference
Location of injury in duodenum
D3, D4
D1, D2
Interval between injury and repair
f 24 hr
> 24 hr
Adjacent injury to CBD
Absent
Present
CBD = common bile duct.
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Severe
Means of injury
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9 INJURIES TO THE PANCREAS AND DUODENUM — 13
pancreatitis
Transient abdominal pain and a rise in the serum amylase
concentration may be anticipated in 8 to 18% of postoperative patients.23,84,113 This type of pancreatitis is treated with
nasogastric decompression, bowel rest, and nutritional support and can be expected to resolve spontaneously. A much
more infrequent but deadly complication is hemorrhagic
pancreatitis. The first sign of this complication may be bloody
pancreatic drainage or a fall in the serum hemoglobin
concentration, with the patient rapidly becoming desperately
ill. It is fortunate that this complication occurs in less than
2% of operative pancreatic trauma patients since mortality
may approach 80% with no effective treatment.61,75
treatment of a pancreatic pseudocyst. If the pancreatic duct
is intact, percutaneous drainage of the pseudocyst is likely to
be effective. If the pseudocyst is secondary to a major pancreatic ductal disruption, percutaneous drainage will not provide
definitive therapy but will convert a pseudocyst to a chronic
fistula. ERCP should therefore precede any percutaneous
drainage. If pancreatic duct stenosis or injury is demonstrated,
treatment options include (1) reexploration and partial gland
resection, (2) distal gland internal Roux-en-Y drainage, and
(3) endoscopic transpapillary stenting of the pancreatic duct.49
The experience of Kouchi and colleagues of Japan suggests
that a pseudocyst greater than 10 cm in size will require
surgical decompression.8
exocrine and endocrine insufficiency
secondary hemorrhage
Postoperative hemorrhage requiring blood transfusion may
occur in 5 to 10% of pancreatic trauma patients, particularly
when inadequate external drainage has been afforded after
pancreatic débridement or when intra-abdominal infection
has developed.113,114 These patients generally require reoperation for control, although angiographic embolization may be
an effective alternative.
pseudocysts
Missed blunt pancreatic injuries, or those intentionally
managed nonoperatively, often result in the formation of a
pseudocyst. One report tabulated 22 pseudocysts in 42 blunt
pancreatic trauma patients managed nonoperatively.27
The status of the pancreatic duct is the key determinant to
Both exocrine and endocrine insufficiency are unusual after
pancreatic trauma. Animal and human studies suggest that a
residuum of 10 to 20% of normal pancreatic tissue is adequate for pancreatic function,24,115 implying that any resection
distal to the mesenteric vessels should leave adequate functioning pancreatic tissue. The multicenter study of 74 cases
of distal pancreatic resection described earlier documented
only 1 case of endocrine deficiency (diet-controlled hyperglycemia following 80% pancreatectomy) and no instance of
exocrine insufficiency.84 Balasegaram reported no pancreatic
insufficiency after resections of up to 90% of the pancreas.103
In contrast, patients with chronic pancreatitis who undergo
distal pancreatectomy have an incidence of diabetes ranging
from 15% (0 to 33% gland resected) to 64% (50 to 75%
gland resected).76
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