Pancreatic Transection from Blunt Abdominal Trauma: Early versus Delayed Diagnosis and Surgical Management

Abstract

Background and Aims: Pancreatic trauma is relatively uncommon, but carries high morbidity and mortality rates, especially when diagnosis is delayed or inappropriate surgery is attempted. Patient Material: The clinical course and surgical management of 14 patients with distal pancreatic transection or severe laceration with or without main pancreatic duct (MPD) injury caused by blunt abdominal trauma were analyzed in a university teaching hospital. The average age of the 14 patients (12 male, 2 female) was 28.9 years (range 5–56). Six patients had isolated pancreatic trauma, and intra-abdominal and extra-abdominal (mean 0.8) injuries associated with pancreatic transection were seen in the other 8 patients. Results: Nine patients were diagnosed and operated on within the first 24 h. Eight of them underwent transection of the gland with MPD injury; distal pancreatectomy with splenectomy was performed in 3 and without splenectomy in 2, distal pancreatogastrostomy in 1, and – due to associated duodenal laceration and/or contusion of the pancreatic head – pylorus-preserving pancreatoduodenectomy in 2. In 1 case (grade II laceration) only external drainage was necessary. All the patients with early, correctly diagnosed parenchymal and ductal injury survived. Only 1 patient required reoperation due to haemorrhage after pancreatoduodenectomy. The other 5 cases were referred elsewhere after initial treatment, and all of them underwent some kind of external drainage. Three had undetected MPD injury, and in the other 2 cases the parenchymal lesions were either underestimated or missed. All of these cases required subsequent resection (1), internal drainage due to fistula (2), or drainage of developed abscess (2). Three of them had severe septic and pulmonary complications; 1 patient with MPD injury was lost to follow-up. Conclusion: Patients requiring delayed surgical intervention after an unsuccessful period of observation or a subsequent operation due to undected MPD injury demonstrated a higher rate of pancreas-specific mortality and morbidity.

Pancreatic trauma

“…23 Entry into the lesser sac allows visualisation of the anterior surface of the pancreas. Mobilisation of the hepatic flexure, proximal transverse colon 22 and duodenum allows the head, uncinate process and posterior aspect of the duodenum to be evaluated.…”

“…Cannulation of the cystic duct or common bile duct (CBD) is a relatively straightfor- ward technique and is useful for assessing the distal CBD, proximal pancreatic duct and ampullary intergrity. 22,23 Cannulation of the pancreatic duct can be performed by concomitant ERCP although this may not be possible in cases of combined major pancreaticoduodenal trauma. The ampulla can be cannulated under direct vision following duodenotomy.…”

Spleen preserving distal pancreatectomy in an isolated blunt pancreatic trauma

“…Thus, this injury has high rates of morbidity and mortality, with overall complications rates up to 62% [1,3] , reaching 80% when diagnosis is made 24 h after injury [3] . The principal determinant of outcome in these patients is major duct involvement [1,3,14] . With the information above, one can understand why it is important to maintain a high suspicion in patients with unexplained abdominal signs after blunt trauma.…”

Pseudoquiste traumático de páncreas

“…Si existe fístula puede colocarse un stent transpapilar endoscópico para facilitar su resolución (5,6). La resección pancreática se limita únicamente a casos de pseudoquistes hemorrágicos, lesiones múltiples sobre una pancreatitis crónica o aquellos responsables de una sintomatología dolorosa (1). Por otra parte la cirugía derivativa interna es de elección en lesiones de pared gruesa generalmente secundarias a pancreatitis aguda necrotizante.…”