Review Article

Pancreatic Injury

Authors: Nasim Ahmed MD, FACS, Jerome J. Vernick MD, FACS

Abstract

Abstract:Injury to the pancreas, because of its retroperitoneal location, is a rare occurrence, most commonly seen with penetrating injuries (gun shot or stab wounds). Blunt trauma to the pancreas accounts for only 25% of the cases. Pancreatic injuries are associated with high morbidity and mortality due to accompanying vascular and duodenal injuries. Pancreatic injuries are not always easy to diagnose resulting in life threatening complications. Physical examination as well as serum amylase is not diagnostic following blunt trauma. Computed tomography (CT) scan can delineate the injury or transaction of the pancreas. Endoscopic retrograde pancreaticography (ERCP) is the main diagnostic modality for evaluation of the main pancreatic duct. Unrecognized ductal injury leads to pancreatic pseudocyst, fistula, abscess, and other complications. Management depends upon the severity of the pancreatic injury as well as associated injuries. Damage control surgery in hemodynamic unstable patients reduces morbidity and mortality.

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References

References1. Tyburski JG, Dente CJ, Wilson RF, et al. Infectious complications following duodenal and/or pancreatic trauma. Am Surg 2001;67:227–231; discussion 230–231.2. Lin BC, Chen RJ, Fang JF, et al. Management of blunt major pancreatic injury. J Trauma 2004;56:774–778.LinBC]]ChenRJ]]FangJF&etal;Management of blunt major pancreatic injury.J Trauma200456774-7783. Wind P, Tiret E, Cunningham C, et al. Contribution of endoscopic retrograde pancreatography in management of complications following distal pancreatic trauma. Am Surg 1999;65:777–783.WindP]]TiretE]]CunninghamC&etal;Contribution of endoscopic retrograde pancreatography in management of complications following distal pancreatic trauma.Am Surg199965777-7834. Wolf A, Bernhardt J, Patrzyk M, et al. The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma. Surg Endosc 2005;19:665–669.WolfA]]BernhardtJ]]PatrzykM&etal;The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma.Surg Endosc200519665-6695. Jones RC. Management of pancreatic trauma. Am J Surg 1985;150:698–704.JonesRCManagement of pancreatic trauma.Am J Surg1985150698-7046. Takishima T, Sugimoto F, Hirata M, et al. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg 1997;226:70–76.TakishimaT]]SugimotoF]]HirataM&etal;Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations.Ann Surg199722670-767. Ilahi O, Bochicchio GV, Scalea TM. Efficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study. Am Surg 2002;68:704–708.IlahiO]]BochicchioGV]]ScaleaTMEfficacy of computed tomography in the diagnosis of pancreatic injury in adult blunt trauma patients: a single-institutional study.Am Surg200268704-7088. Udekwu PO, Gurkin B, Oller DW. The use of computed tomography in blunt abdominal injuries. Am Surg 1996;62:56–59.UdekwuPO]]GurkinB]]OllerDWThe use of computed tomography in blunt abdominal injuries.Am Surg19966256-599. Feliciano DV. Abdominal Trauma, in Schwart SI, Ellis H (eds): Maingot’s Abdominal Operations. East Norwalk, Appleton & Lange, 1989, ed 9, pp 457–512.10. Lin BC, Liu NJ, Fang JF, et al. Long- term results of endoscopic stent in the management of blunt major pancreatic duct injuries. Surg Endosc 2006;20:1551–1555.LinBC]]LiuNJ]]FangJF&etal;Long- term results of endoscopic stent in the management of blunt major pancreatic duct injuries.Surg Endosc2006201551-155511. Patel SV, Spencer JA, el-Hasani S, et al. Imaging of pancreatic trauma. Br J Radiol 1998;71:985–990.PatelSV]]SpencerJA]]el-HasaniS&etal;Imaging of pancreatic trauma.Br J Radiol199871985-99012. Buccimazza I, Thomason SR, Anderson F, et al. Isolated main pancreatic duct injuries spectrum and management. Am J Surg 2006;191:448–452.BuccimazzaI]]ThomasonSR]]AndersonF&etal;Isolated main pancreatic duct injuries spectrum and management.Am J Surg2006191448-45213. Gillams AR, Kurzawinski T, Lees WR. Diagnosis of duct disruption and assessment of pancreatic leak with dynamic secretin-stimulated MR cholangiopancreatography. AJR Am J Roentgenol 2006;186:499–504.GillamsAR]]KurzawinskiT]]LeesWRDiagnosis of duct disruption and assessment of pancreatic leak with dynamic secretin-stimulated MR cholangiopancreatography.AJR Am J Roentgenol2006186499-50414. Hikida S, Sakamoto T, Higaki K, et al. Intraoperative ultrasonography is useful for diagnosing pancreatic duct injury and adjacent tissue damage in a patient with penetrating pancreas trauma. J Hepatobiliary Pancreat Surg 2004;11:272–275.HikidaS]]SakamotoT]]HigakiK&etal;Intraoperative ultrasonography is useful for diagnosing pancreatic duct injury and adjacent tissue damage in a patient with penetrating pancreas trauma.J Hepatobiliary Pancreat Surg200411272-27515. Canty TG Sr, Weinman D. Treatment of pancreatic duct disruption in children by an endoscopically placed stent. J Pediatr Surg 2001;36:345–348.CantyTGSr]]WeinmanDTreatment of pancreatic duct disruption in children by an endoscopically placed stent.J Pediatr Surg200136345-34816. Wales PW, Shuckett B, Kim PC. Long-term outcome after nonoperative management of complete traumatic pancreatic transaction in children. J Pediatr Surg 2001;36:823–827.WalesPW]]ShuckettB]]KimPCLong-term outcome after nonoperative management of complete traumatic pancreatic transaction in children.J Pediatr Surg200136823-82717. Rickard MJ, Brohi K, Bautz PC. Pancreatic and duodenal injuries: keep it simple. ANZ J Surg 2005;75:581–586.RickardMJ]]BrohiK]]BautzPCPancreatic and duodenal injuries: keep it simple.ANZ J Surg200575581-58618. Vasquez JC, Coimbra R, Hoyt DB, et al. Management of penetrating pancreatic trauma: an 11-year experience of a level-I trauma center. Injury 2001;32:753–759.VasquezJC]]CoimbraR]]HoytDB&etal;Management of penetrating pancreatic trauma: an 11-year experience of a level-I trauma center.Injury200132753-75919. Subramanian A, Dente CJ, Feliciano DV. The management of pancreatic trauma in the modern era. Surg Clin North Am 2007;87:1515–1532, x.SubramanianA]]DenteCJ]]FelicianoDVThe management of pancreatic trauma in the modern era.Surg Clin North Am2007871515-1532, x20. Cushman JG, Feliciano DV, Renz BM, et al. Contemporary Management of Pancreatic Trauma, in Maull KI, Cleveland HC, Feliciano DV, et al (eds): Advances In Trauma and Criticl Care St. Louis, MO, Mosby, 1995, vol 10, pp 309–336.CushmanJG]]FelicianoDV]]RenzBM&etal;Contemporary Management of Pancreatic Trauma, in Maull KI, Cleveland HC, Feliciano DV, et al (eds): Advances In Trauma and Criticl Care St.Louis, MOMosby199510309-33621. Walt AJ. Commentary, in Ivatury RR, Gayten GG (eds): Textbook of Penetrating Trauma. Baltimore, MD, Williams & Wilkins, 1996, pp 641–642.WaltAJCommentary,Ivatury RR, Gayten GGTextbook of Penetrating Trauma.Baltimore, MDWilliams & Wilkins1996641-64222. Asensio JA, Petrone P, Roldán G, et al. Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries. J Am Coll Surg 2003;197:937–942.AsensioJA]]PetroneP]]RoldánG&etal;Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries.J Am Coll Surg2003197937-94223. Krige JE, Bornman PC, Beningfield SJ, et al. Pancreatic Trauma, in Pitt H, Carr-locke D, Ferrucci J (eds): Hepatobiliary and Pancreatic Disease. Philadelphia, Little, Brown and Co., 1995.KrigeJE]]BornmanPC]]BeningfieldSJ&etal;Pancreatic Trauma,Pitt H, Carr-locke D, Ferrucci JHepatobiliary and Pancreatic Disease.Philadelphia, LittleBrown and Co199524. Krige JE, Bornman PC, Terblanche J. The Role of Pancreatoduodenectomy in the Management of Complex Pancreatic Trauma, in Hanyu F, Takasaki K (eds): Pancreatoduodenectomy. Tokyo, Spring-Verlag, 1997, pp 49–62.KrigeJE]]BornmanPC]]TerblancheJThe Role of Pancreatoduodenectomy in the Management of Complex Pancreatic Trauma,Hanyu F, Takasaki KPancreatoduodenectomy.TokyoSpring-Verlag199749-6225. Berne CJ, Donovan AJ, White EJ, et al. Duodenal “diverticulization” for duodenal and pancreatic injury. Am J Surg 1974;127:503–507.BerneCJ]]DonovanAJ]]WhiteEJ&etal;Duodenal “diverticulization” for duodenal and pancreatic injury.Am J Surg1974127503-50726. Vaughan GD III, Frazier OH, Graham DY, et al. The use of pyloric exclusion in the management of severe duodenal injuries. Am J Surg 1977;134:785–790.VaughanGDIII]]FrazierOH]]GrahamDY&etal;The use of pyloric exclusion in the management of severe duodenal injuries.Am J Surg1977134785-79027. Stone HH, Fabian TC. Management of duodenal wounds. J Trauma 1979;19:334–339.StoneHH]]FabianTCManagement of duodenal wounds.J Trauma197919334-33928. Lopez PP, Benjamin R, Cockburn M, et al. Recent trends in the management of combined pancreatoduodenal injuries. Am Surg 2005;71:847–852.LopezPP]]BenjaminR]]CockburnM&etal;Recent trends in the management of combined pancreatoduodenal injuries.Am Surg200571847-85229. Kauder DR, Schwab CW, Rotondo MF. Damage Control, in Ivantury RR, Cayten CG (eds): The Textbook of Penetrating Trauma. Baltimore, MD, Williams and Wilkins, 1996, pp 717–725.KauderDR]]SchwabCW]]RotondoMFDamage Control,Ivantury RR, Cayten CGThe Textbook of Penetrating Trauma.Baltimore, MDWilliams and Wilkins1996717-72530. Fleming WR, Collier NA, Banting SW. Pancreatic trauma: Universities of Melbourne HPB group. Aust N Z J Surg 1999;69:357–362.FlemingWR]]CollierNA]]BantingSWPancreatic trauma: Universities of Melbourne HPB group.Aust N Z J Surg199969357-36231. Oláh Attila, Issekutz A, Haulik L, et al. Pancreatic transection from blunt abdominal trauma: early versus delayed diagnosis and surgical management. Dig Surg 2003;20:408–414.OláhAttila]]IssekutzA]]HaulikL&etal;Pancreatic transection from blunt abdominal trauma: early versus delayed diagnosis and surgical management.Dig Surg200320408-41432. Patton JH, Lyden SP, Croce MA, et al. Pancreatic trauma: a simplified management guidline. J Trauma 1997;43:234–241; discussion 239–241.33. Flynn WJ Jr, Cryer HG, Richardson JD. Reappraisal of pancreatic and duodenal injury. Management based on injury severity. Arch Surg 1990;125:1539–1541.FlynnWJJr]]CryerHG]]RichardsonJDReappraisal of pancreatic and duodenal injury. Management based on injury severity.Arch Surg19901251539-154134. Balasegaram M. Surgical management of pancreatic trauma. Curr Probl Surg 1979;16:1–59.BalasegaramMSurgical management of pancreatic trauma.Curr Probl Surg1979161-5935. Demetriades D, Asensio JA. Trauma Management. George town, TX, Landes Bioscience, 2000.DemetriadesD]]AsensioJATrauma Management.George town, TXLandes Bioscience200036. Büchler M, Friess H, Klempa I, et al. Role of octreotide in the prevention of post operative complications following pancreatic resection. Am J Surg 1992;163:125–130; discussion 130–131.37. Lowy AM, Lee JE, Pisters PW, et al. Prospective randomized trial of octreotide to prevent pancreatic fistulas after pancreaticoduodenectomy for malignant disease. Ann Surg 1997;226:632–641.LowyAM]]LeeJE]]PistersPW&etal;Prospective randomized trial of octreotide to prevent pancreatic fistulas after pancreaticoduodenectomy for malignant disease.Ann Surg1997226632-64138. Vassiliu P, Toutouzas KG, Velmahos GC. A prospective study of post–traumatic biliary and pancreatic fistuli. The role of expectant management. Injury 2004;35:223–227.VassiliuP]]ToutouzasKG]]VelmahosGCA prospective study of post–traumatic biliary and pancreatic fistuli. The role of expectant management.Injury200435223-22739. Lewis G, Kriege JE, Bornman PC, et al. Traumatic pancreatic pseudocyst. Br J Surg 1993;80:89–93.LewisG]]KriegeJE]]BornmanPC&etal;Traumatic pancreatic pseudocyst.Br J Surg19938089-9340. Bornman PC, Krige JE, Bukingham IJ. Non Operative Management of Pancreatic Pseudocysts, in Schein M, Wise L (eds): Crucial Controversies in Surgery. Baltimore, Lipponcott Williams & Wilkins, 1999, vol 3, pp 170–181.BornmanPC]]KrigeJE]]BukinghamIJNon Operative Management of Pancreatic Pseudocysts, in Schein M, Wise L (eds): Crucial Controversies in Surgery.BaltimoreLipponcott Williams & Wilkins19993170-18141. Funnell IC, Bornman PC, Krige JE et al. Endoscopic drainage of traumatic pancreatic pseudocyst. Br J Surg 1994;81:879–881.FunnellIC]]BornmanPC]]KrigeJE&etal;Endoscopic drainage of traumatic pancreatic pseudocyst.Br J Surg199481879-88142. Beckingham IJ, Krige JE, Bornman PC, et al. Edoscopic management of pancreatic pseudocysts. Br J Surg 1997;84:1638–1645.BeckinghamIJ]]KrigeJE]]BornmanPC&etal;Edoscopic management of pancreatic pseudocysts.Br J Surg1997841638-164543. Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling, II: pancreas, duodenum, small bowel, colon and rectum. J Trauma 1990;30:1427–1429.MooreEE]]CogbillTH]]MalangoniMA&etal;Organ injury scaling, II: pancreas, duodenum, small bowel, colon and rectum.J Trauma1990301427-1429