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 level1
 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
Exploratory laparotomy
 Establish the continuity of the main pancreatic duct
 Complete visualization with hematoma explored

Ductal injury
 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 Hematoma Minor contusion without duct injury
  Laceration Superficial laceration without duct injury            
II Hematoma Major contusion without duct injury or tissue loss
Laceration Major laceration without duct injury or tissue loss
III Laceration Distal transection or parenchymal injury with duct involvement
IV Laceration Proximal transection or parenchymal injury involving
ampulla
(Proximal pancreas is to the patients’ right of the SMV)
V Laceration 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 Hemodynamically
stable patient, especially unstable patient
in children Distal pancreatectomy
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 injury1
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 Normal main pancreatic duct on ERCP
IIa Injury to branches of main pancreatic duct on ERCP with contrast
extravasation inside the parenchyma
IIb Injury to branches of main pancreatic duct on ERCP with contrast
extravasation into the retroperitoneal space
IIIa Injury to the main pancreatic duct on ERCP at the body or tail of the
pancreas
IIIb 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