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    Pancreatic and Duodenal Injuries: DR Paul Simpson Alfred Hospital

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    samer falcon
    Pancreatic and duodenal injuries are uncommon, occurring in 1-4% of severe abdominal injuries. Blunt trauma is the most common cause, often due to deceleration injuries. Diagnosis involves imaging like CT scans and ERCP. Injuries are classified based on their severity. For pancreatic injuries, debridement and drainage is sufficient unless there is ductal involvement, then distal pancreatectomy may be needed. More severe injuries to the pancreatic head with duct involvement in unstable patients can be drained. Duodenal injuries can often be repaired primarily or with resection and anastomosis. Complications include pseudocysts, abscesses, fistulas, and leaks.

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    Pancreatic and Duodenal Injuries: DR Paul Simpson Alfred Hospital

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    samer falcon
    29 views16 pages
    Pancreatic and duodenal injuries are uncommon, occurring in 1-4% of severe abdominal injuries. Blunt trauma is the most common cause, often due to deceleration injuries. Diagnosis involves imaging like CT scans and ERCP. Injuries are classified based on their severity. For pancreatic injuries, debridement and drainage is sufficient unless there is ductal involvement, then distal pancreatectomy may be needed. More severe injuries to the pancreatic head with duct involvement in unstable patients can be drained. Duodenal injuries can often be repaired primarily or with resection and anastomosis. Complications include pseudocysts, abscesses, fistulas, and leaks.

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    Pancreatic and duodenal injuries are uncommon, occurring in 1-4% of severe abdominal injuries. Blunt trauma is the most common cause, often due to deceleration injuries. Diagnosis involves imaging like CT scans and ERCP. Injuries are classified based on their severity. For pancreatic injuries, debridement and drainage is sufficient unless there is ductal involvement, then distal pancreatectomy may be needed. More severe injuries to the pancreatic head with duct involvement in unstable patients can be drained. Duodenal injuries can often be repaired primarily or with resection and anastomosis. Complications include pseudocysts, abscesses, fistulas, and leaks.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    29 views16 pages

    Pancreatic and Duodenal Injuries: DR Paul Simpson Alfred Hospital

    Uploaded by

    samer falcon
    Pancreatic and duodenal injuries are uncommon, occurring in 1-4% of severe abdominal injuries. Blunt trauma is the most common cause, often due to deceleration injuries. Diagnosis involves imaging like CT scans and ERCP. Injuries are classified based on their severity. For pancreatic injuries, debridement and drainage is sufficient unless there is ductal involvement, then distal pancreatectomy may be needed. More severe injuries to the pancreatic head with duct involvement in unstable patients can be drained. Duodenal injuries can often be repaired primarily or with resection and anastomosis. Complications include pseudocysts, abscesses, fistulas, and leaks.

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    of 16

    Pancreatic and Duodenal

    Injuries
    Dr Paul Simpson
    Alfred Hospital
    Mechanism
    „ Blunt trauma:
    „ Pancreas:
    • deceleration injury at junction of head and body of
    pancreas across the vertebral column.
    „ Duodenum:
    • Crushing/burst due to direct abdominal trauma
    • Shearing associated with deceleration
    „ Penetrating - gunshot/stabbings
    „ Iatrogenic
    Pancreatic and duodenal
    injuries

    „ Uncommon: 1-4% of severe abdominal


    injuries.
    „ Associated with multiple major intra-
    adbominal vascular and solid organ injuries
    in 65-100% and fractures in 28-30%1.
    Diagnosis
    „ Imaging
    „ ERCP: assess ductal integrity, ? stenting.
    „ Laparotomy
    „ Amylase: unreliable
    Imaging
    „ U/S: intra-abdominal fluid, liver lesions.
    „ Erect CXR
    „ CT if pt haemodynamically stable - repeat at
    48hrs if clinical suspicion.
    „ Free intraperitoneal fluid/gas
    „ Localised fluid in lesser sac
    „ Retroperitoneal fluid/gas
    „ Pancreatic oedema
    „ Peripancreatic fat changes
    „ MRI pancreatography: reliability not yet
    established
    Classification
    „ Grading: Organ Injury Scaling (OIS) -
    Committee of the American Association of the
    Surgery of Trauma2.
    „ Higher OIS scores probably associated with
    increased mortality3.
    „ Proximal pancreatic injuries: right of mesenteric
    vessels
    „ Distal pancreatic injuries: left of mesenteric
    vessels.
    Pancreatic injury classification
    Grade Severity

    I Haematoma Minor contusion without duct injury


    Laceration Superficial laceration without duct
    injury
    II Haematoma Major contusion without duct injury
    Laceration Major laceration without duct injury
    III Laceration Distal transection or parenchymal
    injury with duct injury
    IV Laceration Proximal transection or parenchymal
    injury involving the ampulla
    V Laceration Massive disruption involving the
    pancreatic head
    Duodenal injury classification
    Grade Severity
    I Haematoma Single portion of duodenum
    Laceration Partial thickness, no perforation
    II Haematoma More than one portion
    Laceration Disruption < 50% of circumference
    III Laceration Disruption 50-75% of circumference D2
    Disruption 50-100% of D1,3,4
    IV Laceration Disruption > 75% circumference D2
    Involving ampulla of CBD
    V Laceration Massive destruction of
    duodenopancreatic complex
    Vascular Devascularisation of duodenum
    Surgical principles
    „ Cease active haemorrhage.
    „ Prevent: coagulopathy, hypothermia and
    acidosis.
    „ Avoid lengthy procedures.
    „ ? Staged approach - involvement of
    specialist pancreatic surgeon.
    Surgical management of
    pancreatic injuries
    „ Close inspection:
    • Open lesser sac via gastrocolic omentum.
    • Kocher maneuver to palpate head and uncinate process of
    pancreas.
    • Mobilization of spleen and splenic flexure.
    „ Is the main pancreatic duct intact?4
    • Direct visualisation of injury
    • Complete transection of gland
    • Laceration > 1/2 of gland
    • Central perforation
    • Severe maceration
    „ Is the CBD involved?
    Pancreatic surgical protocol
    Distal Injuries:
    Duct not involved (I, II) - drainage alone
    Duct involved (III, IV, V) - distal resection and
    drainage (splenic preservation)
    Proximal Injuries:
    Drainage with formation of a controlled fistula - lower
    mortality and acceptable morbidity
    Surgical management of
    duodenal injuries
    „ Visualisation of all four parts of the
    duodenum:
    „ Kocher maneuver
    „ D4 can be visualised by transecting the
    ligament of Trietz

    „ Rarely an isolated injury


    Duodenum surgical protocol
    „ Simple traumatic perforations (I, II) - primary
    repair.
    „ Severe duodenal injuries (III, IV, V) -
    „ Primary repair or segmental resection with end-to-
    end anastomosis
    „ Nasogastric decompression of stomach - ? Need
    for pyloric exclusion6.
    „ Peripancreatic and periduodenal drainage
    „ Feeding jejunostomy
    „ Catastrophic pancreatoduodenal injuries:
    „ ? Whipples
    „ Temporary duodenal ligation and subsequent
    reconstruction.
    Complications
    „ Pancreatic specific:
    • Pseudocyst
    • Pancreatic abscess
    • Pancreatic fistula
    • Pancreatitis
    „ Duodenal specific:
    • Suture line leak
    • Duodenal stenosis
    • Bleeding at suture repair
    „ Physiologic presentation is the most important
    predictor of mortality6.
    Summary
    „ Pancreatic injuries:
    • debridement and drainage unless ductal
    involvement then distal pancreatectomy.
    • Injuries to the pancreatic head with ductal
    involvement in patient with multiple injuries -
    debride and drain.
    • Whipples only in stable patients - uncommon
    „ Duodenal injuries:
    • Most can be fixed with primary repair or resection
    and anastomosis.
    References
    1. Mayer JM et al. Pancreatic Injury in Severe Trauma: Early Diagnosis
    and Therapy Improve the Outcome. Dig Surg 2002; 19:291-299
    2. Moore EE, Cogbill TH, Malangoni MA et al. Organ Injury Scaling II;
    pancreas, duodenum, small bowel, colon and rectum. J. Trauma 1990;
    30:1427-9
    3. Rickard MJ, Brohi K, Bautz PC. Pancreatic and duodenal injuries: keep
    it simple. ANZ J. Surg. 2005; 75: 581-586
    4. Heitsch RC, Knutson CO, Fulton RL et al. Deliniation of critical factors in
    the treatment of pancreatic trauma. Surgery. 1976;80:523
    5. Velmahos GC, Canstantinou C, Kasotakis G. Safety of Repair for
    Severe Duodenal Injuries. World J. Surg 2008; 32:7-12
    6. Huerta S, Bui T, Porral D et al. Predictors of morbidity and mortality in
    patients with traumatic duodenal injuries. Am J. Surg. 71:763-767
    7. Chrysos E, et al. Pancreatic Trauma in the Adult: Current knowledge in
    diagnosis and management. Pancreatology 2002;2:365-378
    8. Leppaniemi A. Management of pancreatic and duodenal injuries.
    Lithuanian Surgery 2007, 5(2):102-107

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