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