2008 BC Decker Inc ACS Surgery: Principles and Practice

7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 1

9 INJURIES TO THE PANCREAS AND
DUODENUM
Gregory J. Jurkovich, MD, FACS
DOI 10.2310/7800.S07C09
10/08
Duodenal and pancreatic injury continues to challenge the
trauma surgeon. The relatively rare occurrence of these
injuries, the difculty in making a timely diagnosis, and high
morbidity and mortality rates justify the anxiety these unfor-
giving injuries invoke. These issues also likely explain the
hesitancy of many to address pancreatic injuries with opera-
tive intervention and the most recent literature exploring the
options and consequences of nonoperative managment.
13

Mortality rates for pancreatic trauma range from 9 to 34%,
with a mean rate of 19%. Duodenal injuries are similarly
lethal, with mortality rates ranging from 6 to 25%. Complica-
tions following duodenal or pancreatic injuries are alarmingly
frequent, occurring in 30 to 60% of patients.
46
Recognized
early, the operative treatment of most duodenal and pancre-
atic injuries is straightforward, with low morbidity and
mortality. Recognized late, these injuries result in a pro-
tracted, difcult clinical course, often ending in a devastating
outcome.
711
History
An 1827 report of a traumatic transection of the pancreas
as a result of a stagecoach wheel running over a patient is
generally recognized as the rst literature on pancreatic
trauma.
12
By 1903, Mickulicz was able to identify 45 cases
of pancreatic trauma in the literature, of which 21 involved
penetrating and 24 blunt injuries.
13,14
He noted that all 20
patients not operated on died, and 18 of the 25 (72%) who
were operated on surviveda remarkable success for the
time. Mickulicz recommended a thorough exploration
through a midline incision, suture control for hemostasis, and
the placement of drains in all cases, recommendations that
still hold today.
13
In 1930, Stern reviewed 62 reported cases
of pancreatic trauma, in which 30 of the patients survived and
32 died.
14
His treatment recommendations were essentially
the same as Mickuliczs, although Stern perhaps foresaw
the role of diagnostic peritoneal lavage in his recommenda-
tion to use abdominal puncture to aid in the diagnosis of
pancreatic trauma.
The occurrence of complications was also noted early. In
1982, Kulenkampff reported what was likely a pancreatic
pseudocyst following blunt trauma.
15
In 1905, Korte reported
a case of isolated pancreatic injury with total transection and
resultant pancreatic stula.
16
The stula closed spontaneously
(as most do), and the patient survived. In 1946, Whipple
reported that the catgut sutures used in and about the
pancreas were likely to dissolve, leading to hemorrhage,
stula formation, duodenal leaks, and peritonitis; the use of
silk was recommended.
17

Wartime experience with pancreatic trauma emphasizes
the high morbidity and mortality but also the infrequent
occurrence of this injury. There were only 5 case reports of
pancreatic injury from the American Civil War, with an 80%
mortality
18
; 5 reported cases from British troops in World
War I, with an 80% mortality; 62 cases (of 3,154 abdominal
injuries) reported by the 2nd Auxiliary Surgical Group in
1944 and 1945 during World War II, with a 56% mortality
19
;
and 9 cases from the Korean War, with a 22% mortality.
20

More direct surgical management of pancreatic wounds also
occurred in each of these wartime experiences.
Diagnosis
The two most important determinants of outcome follow-
ing pancreatic injury are the status of the main pancreatic
duct and the time from injury to denitive management of
a ductal injury. This was probably rst recognized and
emphasized by Baker and colleagues in 1962.
21
Two subse-
quent reviews of the experience with pancreatic trauma at the
University of Louisville conrmed and emphasized the impor-
tance of determining the status of the pancreatic duct. Heitsch
and colleagues found that resection of distal ductal injuries
as opposed to drainage alone signicantly lowered postopera-
tive morbidity and mortality,
22
and Smego and colleagues
conrmed this observation one decade later by noting that
pancreatic resection distal to the site of ductal injury resulted
in a decrease in the mortality rate at that institution from 19
to 3%.
23
Our experience at Harborview Medical Center in
Seattle supports this in that accurate determination of the
status of the pancreatic duct with intraoperative pancreato-
graphy results in a decrease in complications from 55% to
15%.
24
Although improvements in image quality have been
noted,
25
cross-sectional body imaging techniques currently
used in the multitrauma patient (computed tomography [CT]
of the abdomen) do not routinely have adequate sensitivity
to assess the ductal status, and magnetic resonance
imaging (MRI) is usually too unwieldy in the acute trauma
patient.
26
Hence, the challenge remains in making an early
determination of the status of the pancreatic duct.
The diagnostic techniques of most use in a patient with a
possible pancreatic injury depend on the mechanism of injury,
other indications for early laparotomy, and the time interval
following the initial abdominal insult. Patients with clear indi-
cations for laparotomy need little or no preoperative evalua-
tions directed at identifying a possible pancreatic injury as the
diagnosis of pancreatic injury must be made intraoperatively.
However, establishing the presence of pancreatic injury in
those not requiring immediate laparotomy for hemorrhage
or bowel perforation is a challenge made more difcult by
the knowledge that a missed pancreatic duct injury has dire
consequences.
2730
2008 BC Decker Inc ACS Surgery: Principles and Practice
7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 2
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Although there are isolated reports of patients with com-
plete ductal transection being asymptomatic for weeks to
months to years following the initial injury,
23,27,29,31
it is more
common for patients with initially missed pancreatic injuries
to manifest an abdominal crisis within a few days of their
injury.
3234
The failure of physical signs and symptoms to
develop promptly is related to the retroperitoneal location of
the pancreas, pancreatic enzymes remaining inactive follow-
ing an isolated injury, and decreased secretion of pancreatic
uid after injury. Early identication of a subtle pancreatic
injury therefore requires a high index of suspicion, a carefully
planned approach, and close observation.
A high index of suspicion is warranted in all patients with
high-energy direct blows to the epigastrium. The classic
examples are a crushed steering wheel with an adult driver
and a handle bar injury in a child.
35,36
The energy of impact
results in a crushing of the retroperitoneal structures against
the spine and typically transecting the pancreas at this point.
Soft tissue contusion in the upper abdomen and disruption of
the lower ribs or costal cartilage are physical ndings that
should suggest possible pancreatic injury. Epigastric pain out
of proportion to the abdominal examination is often another
clue to a retroperitoneal injury.
nvicna:vLasc:ia
Although the highest concentration of amylase in the
human body is in the pancreas, hyperamylasemia is not a
reliable indicator of pancreatic trauma. In one series, only 8%
of blunt abdominal injuries with hyperamylasemia had
pancreatic injury.
37
Conversely, as many as 40% of patients
with a pancreatic injury may initially have a normal serum
amylase.
38,39
In addition, there is evidence that isolated brain
injury can cause elevated amylase
40
or lipase
41
via an unclear
central mechanism. Nonetheless, the presence of hyperamy-
lasemia should heighten suspicion for pancreatic injury.
The time between pancreatic injury and serum amylase
determination may be critical. In a report of 73 patients with
documented blunt injury to the pancreas, serum amylase was
elevated in 61 patients (84%) and normal in 12 (16%).
42

All 12 patients with a normal amylase were evaluated within
3 hours of injury. Patients with an elevated amylase were
assayed 7 P 1.5 hours after injury compared with 1.3 P 0.2
hours after injury in those patients with normal serum amy-
lase. These investigators concluded that serum amylase levels
determined within 3 hours of injury are not diagnostic.
Our review of the available data led us to conclude that the
sensitivity of serum amylase in detecting blunt pancreatic
trauma varies from 48 to 85% and the specicity varies from
0 to 81%.
5
The negative predictive value of serum amylase
following blunt trauma is about 95%.
38,39,43
Sensitivity and
positive predictive value may improve if serum amylase is
assayed more than 3 hours after injury. What this means
is that 95% of patients with blunt trauma with a negative
amylase will indeed not have a pancreatic injury. An elevated
serum or peritoneal lavage efuent amylase does not neces-
sarily conrm the presence of a pancreatic injury, but it does
mandate further evaluation.
i:aciNc s1cuics
Blunt abdominal trauma patients with hyperamylasemia
who present with a reliable, benign abdominal examination
are carefully observed and serial amylase is remeasured after
several hours. Persistent elevation or the development of
abdominal symptoms is grounds for further evaluation, which
may include abdominal CT scan, endoscopic retrograde
cholangiopancreatography (ERCP), or surgical exploration.
If the abdominal examination is initially equivocal or unreli-
able, hemodynamically stable patients with hyperamylasemia
should undergo a dual-contrast (intravenous and oral)
abdominal CT scan as part of the initial evaluation. If
the patient subsequently develops abdominal symptoms or
the amylase fails to normalize, a directed evaluation of the
pancreas is warranted, either by repeat abdominal CT, ERCP,
or surgical exploration.
Abdominal CT scans have a reported sensitivity and spec-
icity of 70 to 80% in diagnosing pancreatic injury, although
the accuracy of this examination is largely dependent on
interpreter experience, the quality of the scanner, and the
time from injury.
4446
The CT ndings of pancreatic injury
include direct visualization of a parenchymal fracture [see
Figure 1], an intrapancreatic hematoma, uid in the lesser
sac, uid separating the splenic vein and pancreatic body,
thickened left anterior renal fascia, and retroperitoneal
hematoma or uid. These ndings are often subtle, and rarely
are they all present in one patient.
47
Some of the CT signs of
pancreatic injury may not yet be apparent if the patient is
examined immediately after injury, perhaps attributing to the
reports of false-negative CT scans in up to 40% of patients
with signicant pancreatic injuries.
48
This, however, is not
grounds for delaying a CT evaluation but is an argument for
repeating a CT scan if symptoms persist.
Although ERCP has no role in the acute evaluation of the
hemodynamically unstable patient, there has been a urry of
reports over the past decade regarding the utility of ERCP in
diagnosing and managing pancreatic trauma. ERCP is cur-
rently the best imaging technique of the pancreatic duct and
its divisions but usually requires anesthesia and is not readily
or widely available. Most experience has been with ERCP in
the late or missed diagnosis of pancreatic duct injury, occa-
sionally with transductal stenting used to manage the injury,
particularly in children.
4953
This is an evolving issue that will
continue to foster investigations, but the principle of timely
diagnosis and recognition and management of ductal injury
remains.
22,54
Early ERCP showing intact pancreatic ducts,
including the secondary and tertiary radicals, without any
extravasation permits nonoperative therapy if no associated
injuries are present.
55
The difculty in this management
scheme is determining which patients warrant ERCP and
getting the ERCP accomplished promptly.
56,57

MRI has emerged as a potential technique in the evaluation
of the pancreatic duct in the earliest part of the 21st
century
26,58
Although primarily used to date in elective cir-
cumstances, magnetic resonance pancreatography (MRCP)
has been reported as a noninvasive alternative to determine
the status of the main pancreatic duct in a small series of
patients with pancreatic injury. To date, most reports suggest
that MRCP is either unreliable or too unwieldy in the very
acute phase after injury, but MRCP appears to be gaining
increased interest in delayed diagnosis and managment.
59

Further study of its sensitivity and specicity in this setting is
warranted, but the initial enthusiasm appears to have been
tempered.
2008 BC Decker Inc ACS Surgery: Principles and Practice
7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 3
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Figure 1. Contusion to the body of the pancreas. Illustrated is the appearance of a contusion to the body of the pancreas
overlying the vertebral column, as seen from the lesser sac (a). The pancreas is mobilized to determine whether a fracture is
present and to assess the likelihood of a duct injury. This exposure is best accomplished by dissecting along the inferior border of
the gland, dividing the inferior mesenteric vein if necessary, and reecting the pancreas superiorly (b).
iN1naoicna1ivc cvaLca1ioN
Classication of pancreatic injuries is based on the status
of the pancreatic duct and the site of injury relative to the
neck of the pancreas. Careful pancreatic inspection and injury
classication are often complicated by the extent and severity
of associated injuries and occasionally by the reluctance of the
surgeon to mobilize retroperitoneal structures. Clues suggest-
ing potential pancreatic injury include the injury mechanisms
previously described, the presence of upper abdominal wall
contusion or abrasion, and concomitant lower thoracic spine
fractures. The presence of a upper abdominal central retro-
peritoneal hematoma, edema about the pancreatic gland and
lesser sac, and retroperitoneal bile staining mandate thorough
pancreatic inspection.
Inspection of the pancreas requires complete exposure of
the gland. The initial steps in exposure are to open the lesser
sac through the gastrocolic ligament just outside the gastro-
epiploic vessels. Carry this exposure far to the patients left,
fully opening the lesser sac and freeing up the transverse
colon. The transverse colon is retracted downward and the
stomach upward and anteriorly [see Figure 1]. Frequently, a
few adhesions between the posterior stomach and the anterior
surface of the pancreas need to be incised. A complete Kocher
maneuver is required next to provide adequate visualization
of the pancreatic head and uncinate process. In addition,
mobilization of the hepatic exure of the colon (a frequently
overlooked maneuver) greatly facilitates visualization and
bimanual examination of the head and neck. Inspection of
the tail of the pancreas requires exposure of the splenic hilum.
If injury involves the tail of the pancreas, mobilization is
achieved rst by division of the peritoneal attachments lateral
to the spleen and colon. The colon, spleen, and body and tail
of the pancreas are then mobilized forward and medially by
creating a plane between the kidney and the pancreas with
blunt nger dissection. This maneuver permits bimanual
palpation of the pancreas and inspection of its posterior
surface.
It is worth noting that injuries to the major duct occur in
perhaps 15 to 20% of pancreatic trauma. In our institution,
we managed 193 pancreatic injuries over a 15-year time
frame.
4
Only 27 (14%) had grade III injuries and 10 (5%)
grade IV or V injuries. In the 1970s and 1980s, penetrating
wounds were documented as more likely to cause pancreatic
duct injury,
60,61
but more recent reviews have not substanti-
ated that observation.
4,62
Regardless of the mechanism, the
majority of pancreatic duct injuries can be diagnosed by
careful inspection of the tract of injury following adequate
exposure. All penetrating wounds should be traced from their
2008 BC Decker Inc ACS Surgery: Principles and Practice
7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 4
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entry point through the surrounding tissue to the point of exit
or lodging of the missile. If the pancreas has been damaged
by a knife or a bullet, it is necessary to determine the integrity
of the major pancreatic duct. Most penetrating wounds to the
margins of the gland can be inspected directly and duct inte-
grity conrmed. However, penetrating wounds in the head or
neck or central portion of the pancreas often require further
evaluation. Occasionally, intravenous injection of 1 to 2 g
of cholecystokinin pancreatozymin (1 to 2 mL of sincalide)
may stimulate pancreatic secretions enough to localize an
otherwise unrecognized major duct injury. The remaining
few injuries may require the more elaborate investigative
techniques, including intraoperative pancreatography (see
below).
Minor blunt contusions or lacerations of the pancreatic
substance usually do not require further evaluation of the
pancreatic duct and are effectively managed with closed
suction drainage. An intact pancreatic capsule, however, does
not necessarily rule out complete division of the pancreatic
duct, and, rarely, blunt impact to the pancreas can result in
transection of the major duct without complete transection of
the gland.
23
Establishing the status of the major ductal system
under these circumstances remains an important step in
determining therapy and in anticipating late morbidity and
mortality. Routine performance of intraoperative pancreato-
graphy when proximal duct injury was suspected decreased
the postoperative morbidity rate from 55% to 15% at our
institution.
24

Intraoperative imaging of the pancreatic duct can be
performed by one of three techniques: ERCP, direct open
ampullary cannulation, or needle cholangiopancreatography.
Intraoperative ERCP is cumbersome and often difcult to
coordinate during an emergency operation, but it has been
used and reported.
63
Duodenotomy and direct ampullary
cannulation, or even transection of the tail of the pancreas
and distal duct cannulation, have been reported as useful
techniques in the past, but current perioperative imaging,
improved exposure and direct visualization of the pancreas,
and effective use of wide closed-suction drainage and post-
operative ERCP have largely abolished the use of these very
invasive diagnostic techniques of imaging the pancreatic
duct.
64
Needle cholecystocholangiopancreatography remains
a useful intraoperative adjunct in the evaluation of the
pancreatic duct. This technique involves cannulating the
gallbladder with an 18-gauge angiocatheter and injecting 30
to 75 mL of three-quarter-strength water-soluble contrast
under uoroscopic imaging. Clear images of the biliary tree
are readily obtained, and in our experience, this technique is
successful in imaging the pancreatic duct 64% (7 of 11) of
the time.
4
Contracture of the sphincter of Oddi with intrave-
nous morphine may enhance the likelihood of pancreatic duct
visualization. A cholecystectomy is not necessary following
this procedure.
Classication of Pancreatic Injuries
Although a number of classication systems have been
devised to catalogue pancreatic injuries,
60,64,65
the American
Association for the Surgery of Trauma (AAST) Committee
on Organ Injury Scaling addresses the key issues of treatment
of parenchymal disruption and major pancreatic duct status
by focusing on the anatomic location of the injury for the
more severe (grade III to V) injuries [see Table 1].
66
Table 1
also denes the Abbreviated Injury Scale (AIS) value that
corresponds to the AAST grading system.
67
The AIS has
undergone a revision in 1998 and again in 2005. These dif-
ferences are important since most commercially available
trauma registries use AIS coding. The AIS coding system is
sponsored and owned by the Association for the Advance-
ment of Automotive Medicine. Duct injuries have different
management alternatives than distal duct and parenchymal
injuries [see Figure 2]. Parenchymal contusions or lacerations
with minimal or no parenchymal tissue loss and no ductal
injury (grade I or II) need only be externally drained.
Combined duodenal and pancreatic head injuries that include
the major duct or ampulla require a combined pancreatoduo-
denectomy, commonly known as the Whipple procedure, but
uncommonly required for trauma. The difcult decisions
in managing pancreatic trauma involve patients with paren-
chymal disruption and major duct injury. By focusing on
the anatomic location of the duct and parenchymal injury
(proximal versus distal), this classication provides a useful
management guide.
Treatment of Pancreatic Injuries
coN1csioNs aNu Laccna1ioNs wi1noc1 ucc1 iNcnv
Minor pancreatic contusions, hematomas, and capsular
lacerations (grade I) account for about 50% of all pancreatic
injuries; lacerations of the pancreatic parenchyma without
major ductal disruption or tissue loss (grade II) account for
an additional 25% of pancreatic injuries. These injuries are
the injury pattern commonly managed nonoperatively. If
identied at operation, they require only hemostasis and
adequate external drainage.
2,68
No attempt should be made
to repair capsular lacerations because closure may result in a
pancreatic pseudocyst, whereas a controlled pancreatic stula
is usually self-limiting. Soft closed-suction drains (Jackson-
Pratt) are preferred over Penrose drains or sump drains as
intra-abdominal abscess formation is less likely, efuent is
more reliably collected, and the excoriation of the skin at the
exit site is signicantly less with closed-suction drains.
35,69,70

Drains are removed when the amylase concentrations in the
drain are less than that of serum, generally within 24 to 48
hours. An international consensus group denition of pancre-
atic stula is the persistence of any measurable volume of
drain output on or after postoperative day 3 with an amylase
content greater than three times serum amylase activity.
71
As
described below, there are three grades of pancreatic stula
complications [see Complications, below]. Drains are gener-
ally left in situ until there is no evidence of pancreatic leak.
Nutrition should be provided via the oral or gastric route
as soon as possible. However, a prolonged gastric ileus or
pancreatic complications may preclude standard gastric feed-
ing in patients with severe injuries. Also, since most tube
feeding formulas are high in fat and increase pancreatic
efuent volume and amylase concentration, the low fat and
higher pH (4.5) of elemental diets are preferred as they tend
to be less stimulating to the pancreas.
72,73

uis1aL 1naNscc1ioN aNu uis1aL iancNcnv:aL iNcnv
wi1n ucc1 uisnci1ioN
The anatomic distinction between proximal and distal
pancreas is generally dened by the superior mesenteric
2008 BC Decker Inc ACS Surgery: Principles and Practice
7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 5
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Table 1 AAST Organ Injury Scales for Pancreas and Duodenum
Injured Structure AAST
Grade*
Characteristics of Injury AIS-90 Score AIS-2005
Score
Pancreas I Small hematoma without duct injury; supercial laceration
without duct injury
2 2
II Large hematoma without duct injury or tissue loss; major
laceration without duct injury or tissue loss
2; 3 2
III Distal transection or parenchymal laceration with duct injury 3 3
IV Proximal

transection or parenchymal laceration involving

ampulla
4 4
V Massive disruption of pancreatic head 5 5
Duodenum I Single-segment hematoma; partial-thickness laceration without
perforation
2; 3 2
II Multiple-segment hematoma; small (< 50% of circumference)
laceration
2; 4 2
III 5075% disruption (laceration) of segment D2 or 50100%
disruption of segment D1, D3, or D4
4 3
IV Very large (75100%) laceration of segment D2; rupture of
ampulla or distal CBD
5 4
V Massive duodenopancreatic injury; devascularization of
duodenum
5 5
AAST = American Association for the Surgery of Trauma; AIS-90 = Abbreviated Injury Score, 1990 version; AIS-2005 = Abbreviated Injury Score, 2005 version;
CBD = common bile duct.
*Advance one grade for multiple injuries, up to grade III.

Proximal pancreas is to the patients right of the superior mesenteric vein.

vessels passing behind the pancreas at the junction of the
pancreatic head and body. Although there is no anatomic
distinction in the gland itself between the head, body, or tail,
this anatomic division is useful in estimating residual pancre-
atic endocrine and exocrine function. Innes and Carey have
shown that a distal pancreatic resection at the portal vein
removes an average of 56% (range 36 to 69%) of the gland
by weight.
74
Since most blunt trauma pancreatic injuries
occur at the spine, which is just to the patients left of the
portal vein as it crosses behind the pancreas, a distal pancre-
atectomy in this circumstance averages as a 56% gland
resection. A resection at the common bile duct removes an
average of 89% (range 64 to 95%) of the gland. Although
reports of normal endocrine and exocrine function after 90%
pancreatectomy do occur, every effort should be made, if
possible, to leave at least 20% residual pancreatic tissue to
minimize postoperative complications.
75,76

Distal parenchymal transection, particularly with disrup-
tion of the main pancreatic duct, is best treated by distal
pancreatectomy. This is true in children and adults. CT,
particularly if done more than 4 hours after the injury has
occurred, is usually accurate enough to conrm complete
transection. Operative intervention in this case is superior to
nonoperative management in that the operation is denitive,
the residual gland is adequate to preserve exocrine and
endocrine function, and the recovery is relatively short.
Nonoperative management is typically fraught with the com-
plications of pseudocysts, abscess, prolonged and recurrent
hospital admissions, and repetitive drainage procedures,
including the technically challenging and invasive attempts at
endoscopically traversing a transected distal duct.
1,10,77

If at celiotomy there is any concern regarding the status of
the remaining proximal main pancreatic duct, intraoperative
pancreatography should be performed through the open end
of the proximal duct. If the remaining proximal duct is
normal, the transected duct should be identied and closed
with a direct U-stitch suture ligature with a nonabsorbable
monolament suture.
78
The parenchyma can be closed with
the large (4.8 mm) TA-55 staple,
78,79
but we nd that this
excessively crushes the residual pancreas, so we prefer
mattress sutures placed through the full thickness of the
pancreatic gland from anterior to posterior capsule to mini-
mize leak from the transected parenchyma. Although most
surgeons prefer nonabsorbable suture for pancreatic stump
closure, one report suggests that a lower complication rate is
obtained with absorbable polyglycolic acid suture to oversew
the pancreatic stump.
54
A small omental patch can be used
to buttress the surface, and a drain should be left near the
transection line.
Concern for the possibility of postsplenectomy sepsis and
subphrenic abscess formation following splenectomy has
prompted several authors to describe distal pancreatectomy
without splenectomy [see Figure 3]. The technical challenge
in pancreatectomy with splenic salvage is in isolating and
ligating the pancreatic branch vessels off the splenic vein and
artery yet preventing injury to the splenic hilum and throm-
bosis of the splenic vein. Generous mobilization of the entire
pancreatic gland and spleen is a prerequisite. An average of
22 tributaries of the splenic vein and seven branches of the
splenic artery must be ligated.
80
One report suggests that
this maneuver will add an average of 50 minutes (range 37 to
80 minutes) to the operative time.
81
Patton and colleagues
reported splenic salvage in 21 of 33 patients (64%) who
2008 BC Decker Inc ACS Surgery: Principles and Practice
7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 6
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underwent distal pancreatic resection (8 blunt, 13 penetrat-
ing).
34
The increased operative time and potential blood loss
incurred while performing pancreatectomy without splenec-
tomy must be balanced against the slight risk of overwhelm-
ing postsplenectomy sepsis. The balance would seem to favor
splenic salvage only when the patient is completely hemody-
namically stable and normothermic and the pancreatic injury
is isolated or present with only minor associated injuries.
inoxi:aL 1naNscc1ioN on iNcnv wi1n inonanLc ucc1
uisnci1ioN
Injuries to the pancreatic head represent the most challeng-
ing management dilemmas. The key principles of immediate
management are, in order, control bleeding, halt contamina-
tion, and dene the anatomy of the injury. Effective manage-
ment can only follow these steps. It is essential that the
surgeon dene the pancreatic duct anatomy in proximal
pancreatic injuries. This can usually be accomplished by local
inspection and exploration of the defect to determine the
duct status. Techniques of intraoperative pancreatography
have been described above and are strongly recommended if
local exploration alone is inadequate to determine the status
of the main pancreatic duct. The only exception to this
approach is the hemodynamic unstable patient with hypo-
thermia, acidosis, and coagulopathy, in which case, simple
damage control surgery is advised. Most experienced
surgeons express reservations regarding performance of
a duodenotomy to perform pancreatography, but a needle
cholecystocholangiopancreatography can often image the
pancreatic duct along with the distal common bile duct (64%
in our experience).
4
If this proves unsuccessful, then wide
external drainage with several closed-suction drains should
be performed with planned early postoperative ERCP
(preferred), or MRCP should be the plan. If major proximal
duct injury is conrmed by postoperative ERCP, pancreatic
duct stenting rather than near-total pancreatectomy may be
an option depending on local expertise.
1,49,50,53
However, at
least one report has had discouraging results with stenting,
notable for long-term stricture development and acute
sepis.
30
Provide nonoperative
management.
Repeat CT as needed.
Grade I
Unroofing: Carefully
inspect to confirm
absence of duct injury;
close suction drainage.
Operation
Perform
pancreaticoduodenectomy
(Whipple procedure).
Grade V
Unstable paient: treat with hemostasis and drainage, with
postoperative ERCP to define duct anatomy and allow duct
stenting if indicated.
Stable patient: divide pancreas completely, oversew proximal
stump, and perform Roux-en-Y anastomosis of distal pancreatic
remnant to jejunal limp.
Consider adding pyloric exclusion.
Grade IV
Perform distal
pancreatectomy, with
or without splenic salvage.
Grade III
Provide operative or
nonoperative management.
Repeat CT between 4 and
24 hours.
Grade II
Perform ERCP to determine
status of duct. If duct not
injured, follow with a CT
scan or ultrasonography.
Nonoperative management
If duct injury is confirmed,
perform either transductal
stenting or operative
exploration as a Grade III-V.
Duct injury
History of high-energy direct blow to epigastrium
is suggestive.
Obtain serum amylase levels.
Perform CT with oral IV contrast (repeated if necessary).
Patient has possible pancreatic injury
Figure 2. Treatment of pancreatic injury. Algorithm outlining the treatment of pancreatic injury. CT = computed tomography;
ERCP = endoscopic retrograde cholangiopancreatography.
2008 BC Decker Inc ACS Surgery: Principles and Practice
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If the proximal duct is injured, but the ampulla and
duodenum are spared (rare), two options are available. One
option is extended distal pancreatectomy, resulting in subto-
tal removal of the gland. The proximal residual gland will
drain into the duodenum in a normal fashion if the duct is
intact. Wide external drainage of the residual pancreatic
surface must be provided. We have not added pyloric exclu-
sion or duodenal defunctionalization or diverticulization
to this procedure, although others advocate its use in this
circumstance.
72,82
If there is concern that the residual proxi-
mal pancreatic tissue is inadequate to provide endocrine
or exocrine function, the second option is to preserve the
pancreatic tail distal to the injury using a Roux-en-Y pancre-
aticojejunostomy [see Figure 4]. This requires division of the
pancreas at the site of injury, dbridement of injured paren-
chyma, secure closure of the proximal duct and parenchyma,
and anastomosis of the open end of the divided distal pan-
creas to the Roux-en-Y jejunal limb. A review of 399 patients
with pancreatic injury from four separate publications revealed
that only 2 (0.5%) patients underwent Roux-en-Y drainage
of the distal segment of a transected pancreatic gland.
34,54,83,84

Although rarely employed and complicated by the need for
a combination of pancreatic resection, pancreatic-jejunal
anastomosis, and construction of the Roux-en-Y limb, this
operation needs to be in the armamentarium of trauma
surgeons.
The report by Patton and colleagues from Memphis,
supported by the experience of University of Mississippi
reported by Duchesne and colleagues, is compelling for the
effectiveness of drainage alone rather than extended pancre-
atectomy, particularly for proximal pancreatic gland injury
in which the duct status is unclear.
2,34
In the Patton and
Figure 3. Distal pancreatectomy with and without splenic salvage. Illustrated is distal pancreatectomy with salvage of the
spleen (a) and without splenic salvage (b).
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7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 8
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colleagues study, 37 patients with proximal pancreatic injury
were managed by closed-suction drainage alone, resulting in
a modest 13.5% stula and abscess rate. Pancreatography
was not performed in these patients, so the status of the pan-
creatic duct was not dened, and it remains unclear whether
this technique is truly effective in the presence of a major
pancreatic duct injury. In the Duchesne and colleagues
report, 35 patients had AAST grade I or II pancreatic injuries
by CT scan and were intentionally managed nonoperatively.
Five (14.3%) failed nonoperative management because of
missed bowel injury (n = 2) and pancreatic abscess (n = 3),
all classied as AAST grade II injuries. These failures of
Figure 4. Roux-en-Y pancreaticojejunostomy. If a patient has a grade IV injury to the pancreatic head and there is concern
regarding whether the proximal residual gland would have adequate endocrine and exocrine function if the distal gland is
resected in an extended distal pancreatectomy, an option is to preserve the uninjured portion of the distal gland. This is done by
dividing the pancreas at the site of the injury and performing a Roux-en-Y pancreaticojejunostomy to allow the distal pancreas to
drain into the jejunal limb.
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7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 9
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nonoperative management survived but had a signicantly
longer length of stay (19 days versus 9 days). Operative
exploration and drainage of even low-grade pancreatic
injuries remain a prudent approach.
Both of these reports emphasize the importance of deter-
mining the status of the pancreatic duct. If the duct and its
branches are not injured, nonoperative management is likely
to be successful, and the role for detailed description of pan-
creatic duct anatomy advocated by Takishima and colleagues
is relevant.
85
If no effort is made at determining the status of
the pancreatic duct, at least wide drainage is mandatory. This
approach is likely to be successful most of the time since
injury to the main pancreatic duct is unusual; when it fails,
however, the consequences are signicant and morbid.
4,6

If the main pancreatic duct is injured or transected, distal
resection is preferred, with the option of Roux-en-Y drainage
of a long or signicant distal pancreas that the surgeon is
loath to sacrice. Damage control drainage remains a viable
lifesaving rst opertion. Finally, postoperative ERCP and
transductal injury stenting appear to be another viable
option, particularly in children, and particularly with very
experienced endoscopists.
1,53

In the case of an incomplete pancreatic parenchymal
transection, some surgeons have described an end jejunum-
to-side pancreas anastomosis. This technique is not recom-
mended because of the difculty in ensuring the integrity of
the anastomosis and potential for a high-output pancreatic
stula from the posterior pancreatic wound. Stone and
colleagues from Emory University illustrated the high
complication rate associated with this dated technique. Of
7 patients in whom the technique was used (among 283
patients), 5 (71%) developed a stula and 3 (43%) died.
68

Insertion of a needle catheter jejunostomy or small feeding
tube jejunostomy at the time of initial celiotomy should
be considered for all patients with grade III to V pancreatic
injuries. This allows early postoperative enteral nutrition,
rather than committing the patient who cannot tolerate oral
or gastric feedings to total parenteral nutrition.
86
There is
some morbidity related to surgically placed feeding tubes.
Our experience is that feeding jejunostomies have a major
complication rate of 4% in severely injured patients.
87
Needle
catheter jejunostomies were associated with fewer complica-
tions than the larger, Witzel tube jejunostomyhence, our
preference for this smaller-caliber feeding tube and elemental
or short-chain polypeptide feeding formulas, which we
prefer.
73,87

Combined Pancreatic-Duodenal Injuries
Fortunately, severe combined pancreatic head and duode-
nal injuries are rare. Forty-eight of 1,404 patients (3%) with
pancreatic injuries reported between 1981 and 1990 under-
went pancreatoduodenectomy.
88
These injuries are most
commonly caused by penetrating wounds and occur in asso-
ciation with multiple other intra-abdominal injuries. In fact,
these associated injuries are the primary cause of mortality
and emphasize again the priorities of hemorrhage control and
contamination control in dealing with pancreatic or duodenal
injury. The major immediate mortality in patients with
combined pancreatic and duodenal injuries is attributable
to major vascular injury in the vicinity of the head of the
pancreas. If immediate control of hemorrhage and resuscita-
tion can be obtained, the Whipple resection remains the
preferred option in that select group of patients with unrecon-
structable injury to the ampulla or proximal pancreatic duct
or with combined massive destruction of the duodenal and
pancreatic head. Essentially, in these patients, pancreatoduo-
denectomy is the completion of surgical dbridement of
devitalized tissue. For patients with hemodynamic instability,
hypothermia, coagulopathy, and acidosis, a staged operative
approach (damage control surgery) is advocated, rst obtain-
ing control of hemorrhage, then managing bowel and bacte-
rial contamination, and, lastly, identifying the anatomy of the
injury, followed by resuscitation in the intensive care unit.
The patient is returned to the operating room for denitive
reconstruction and anastomoses when stabilized, generally 24
to 48 hours later.
Because of the large number of possible combinations of
injuries to the pancreas and duodenum, no one form of
therapy is appropriate for all patients. In Feliciano and
colleagues review of 129 cases of combined pancreatic-
duodenal injuries, 24% of the patients were treated with
simple repair and drainage, 50% underwent repair and pyloric
exclusion, and only 10% required a Whipple procedure.
82

The best treatment option is predicated on the integrity of the
distal common bile duct and ampulla, as well as the severity
of the duodenal injury [see Figure 5]. For that reason, every
patient with a combined pancreatic-duodenal injury requires
a cholangiogram, a pancreatogram, and evaluation of the
ampulla. When the common bile duct and ampulla are intact
(as is the situation in the majority of the cases), the duode-
num can be closed primarily and the pancreatic injury treated
as previously described. If the status of the pancreatic duct
cannot be made intraoperatively, wide external drainage of
the pancreatic head with closed suctions drains should be
performed rather than a total pancreatectomy and early
postoperative ERCP or MRCP performed.
It may be advisable to divert gastric contents away from
the duodenal repair in the presence of severe injury to the
duodenum. Duodenal diverticulization employs primary
closure of the duodenal wound, antrectomy, vagotomy,
end-to-side gastrojejunostomy, T-tube common bile duct
drainage, and lateral tube duodenostomy. The concept is to
completely divert both gastric and biliary contents away from
the duodenal injury, provide enteral nutrition via the gastro-
jejunostomy, and convert a potential uncontrolled lateral
duodenal stula to a controlled stula [see Figure 6]. A less
formidable and less destructive alternative is the pyloric
exclusion, which does not employ antrectomy, biliary
diversion, or vagotomy [see Figure 7].
72,8991
This procedure is
performed through a gastrotomy and consists of grasping
the pylorus with a Babcock clamp and suturing closed the
pylorus with an absorbable size 0 polyglycolic acid or Maxon
suture and constructing a loop gastrojejunostomy. This
diverts gastric ow away from the duodenum for several
weeks while the duodenal and pancreatic injuries heal. The
pylorus eventually opens (2 weeks to 2 months), and the
gastrojejunostomy functionally closes. Fang and colleagues
at Chang-Gung Memorial Hospital in Taiwan described
a technical method of controlled release of the pyloric
exclusion knot, thereby timing the opening of the pyloric
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7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 10
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occlusion.
92
Marginal ulceration at the site of gastrojejunos-
tomy has been reported from 5 to 33% of patients in whom
a vagotomy was not performed.
9093
Pyloric exclusion is gen-
erally reserved for severe combined duodenal and pancreatic
head and duodenal injuries in which a Whipple procedure
is not required. Few advocate pyloric exclusion for isolated
pancreatic injuries.
In very massive injuries of the proximal duodenum and
head of the pancreas, destruction of the ampulla and proxi-
mal pancreatic duct or distal common bile duct may preclude
reconstruction. In addition, because the head of the pancreas
and the duodenum have a common arterial supply, it is
essentially impossible to entirely resect one without making
the other ischemic. In this situation, a pancreatoduodenec-
tomy is required. Between 1961 and 1994, 184 Whipple
procedures were reported for trauma, with 26 operative
deaths (14%) and 39 delayed deaths, for a 64% overall sur-
vival rate.
88
However, more recent experience suggests that
with appropriate selection criteria, pancreatoduodenectomy
for injury can be performed with morbidity and mortality
similar to those described for resections done for cancer.
9496

Nonoperative Management in Children
Major pancreatic duct injury in children is rare, with an
incidence of 0.12% of children with blunt abdominal trauma.
52

Most pediatric pancreatic injuries are grade I or II injuries,
without major pancreatic duct injury. As a result, several
authors have advocated managing all blunt pediatric pancre-
atic injuries nonoperatively, with bowel rest, serial abdominal
CT to observe for pseudocyst formation, and subsequent
percutaneous drainage as required.
7,9799
However, the high
morbidity and prolonged hospital course of these patients
may not be justied given the good recovery from distal
pancreatectomy with splenic salvage.
10
Pseudocysts develop
in 40 to 100% of children with major ductal injury,
7,8,100
and
recurrent episodes of pancreatitis can occur remote to the
time of injury.
36,101
ERCP with proximal stenting of ductal
injuries is an additional adjunct to care in these patients but
requires the availability of a skilled pediatric endoscopist. A
report from Toronto details the management of 35 children
with pancreatic trauma over a 10-year time period.
7
Twenty-
three had early diagnosis (< 24 hours), whereas in 12, the
diagnosis was initially missed. Twenty-eight were managed
Figure 5. Treatment of duodenal injury. Algorithm outlining the treatment of duodenal injury. CBD = common bile duct;
NG = nasogastric; TPN = total parenteral nutrition; WBC = white blood cell count.
If hematoma is detected at laparotomy,
treat with evacuation.
If hematoma is detected by nonoperative
means, observe patient, and support with
NG suction and TPN.
Grade I or II hematoma
Perform primary suture closure in one or two layers.
Consider pyloric exclusion or buttressing only
if there is associated pancreatic injury.
Grade I or II laceration
Management options are as follows:
Pancreaticoduodenectomy
Reimplantation of ampulla or distal CBD into
duodenum or Roux-en-; jejunal limb
Reconstruction with hepaticojejunostomies
Delayed reconstruction.
Pancreaticoduodenectomy is mandatory for grade
V injuries.
Grade IV or V
Attempt primary suture closure as first option, with
concomitant pyloric exclusion.
If primary repair is technically not feasible, treat as
follows:
Injury proximal to ampulla: perform antrectomy plus
gastrojejunostomy and stump closure.
Injury distal to ampulla: perform Roux-en-;
duodenojejunostomy to proximal end of duodenal
injury, with oversewing of distal duodenum.
Grade III
History of direct blow to epigastrium is suggestive.
Obtain serum amylase levels and WBC count.
Perform abdominal x-ray and contrast studies.
If duodenal trauma is likely, perform laparotomy for
inspection of duodenum and grading of injury.
Patient has possible duodenal injury
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Figure 6. Duodenal
diverticularization. Duodenal
diverticularization consists
of antrectomy with gastrojeju-
nostomy, tube duodenostomy,
vagotomy, and peripancreatic
drainage.
nonoperatively. A subsequent report examined in more detail
10 of these patients having a pancreatic duct transection.
99

Forty-four percent developed pseudocyst, and all were
managed with percutaneous drainage; 75% had atrophy of
the distal pancreatic remnant, but there was no evidence of
endocrine or exocrine dysfunction. A report from Japan
demonstrated 100% pseudocyst development in ve children
with pancreatic duct injury managed nonoperatively.
8
The
data seem to suggest that pediatric pancreatic injuries can
be successfully managed nonoperatively, but with a high
incidence of pseudocyst formation requiring further hosptal-
ization and interventions and with atrophy of the distal
remnant. Other pediatric surgical authors point out the
benets of distal pancreatectomy in terms of shortening
hospital stay and interventions.
10,52,102
Complications
The incidence of complications following pancreatic injury
remains uncomfortably high. Between 20 and 40% of patients
who undergo surgical intervention of a pancreatic injury have
a complicated postoperative course and even higher if a com-
bined pancreatoduodenal wound has occurred [see Table 2].
5

Although the majority of complications related to pancreatic
injury are self-limiting or treatable, sepsis and multisystem
organ failure are responsible for nearly 30% of the deaths in
pancreatic trauma. In some series, up to one half of the post-
operative complications could have been avoided with careful
inspection of the pancreas and accurate determination of the
status of the main pancreatic duct.
28
ris1cLa
Postoperative pancreatic stula has been dened as any
measurable drain output with an amylase greater than three
times serum.
71
This is the most common complication follow-
ing pancreatic injury, with an incidence of 7 to 20%, rising to
26 to 35% after combined pancreaticoduodenal injury.
34,61,103,104

Direct suture closure of the main pancreatic duct may help
minimize this complication, but brin sealants do not seem
to provide any advantage.
105
The vast majority of these are
minor (less that 200 cc/day) and spontaneously resolve within
2 weeks of injury, providing that adequate external drainage
has been provided. In a multicenter review of distal pancre-
atectomy for trauma, the postoperative stula rate was
14% (10 of 71), with spontaneous stula closure in 89% (8
of 9) of survivors in 6 to 54 days.
83
One patient required
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extirpation of a residual pancreatic sequestrum to facilitate
stula closure. This compares with a 3.3% stula rate in
elective distal pancreatectomy for chronic pancreatitis.
76

High-output stulae (greater than 700 cc/day) are rare and
generally require longer periods of external drainage or surgi-
cal intervention for resolution. If a high-output stula fails
to progressively decrease in volume or persists more that
Table 2 Factors Determining Severity of Duodenal Injury
Factor Degree of Injury
Mild Severe
Means of injury Stab Blunt force or missile
Size of injury f 75% of circumference > 75% of circumference
Location of injury in duodenum D3, D4 D1, D2
Interval between injury and repair f 24 hr > 24 hr
Adjacent injury to CBD Absent Present
CBD = common bile duct.
Figure 7. Pyloric exclusion. Pyloric exclusion consists of
closure of the pylorus from within the stomach, followed by
gastrojejunostomy. The procedure eliminates discharge of
gastric acid into the duodenum, thus minimizing the stimula-
tion of pancreatic secretion and reducing morbidity if there is
breakdown of a repair.
10 days, ERCP is indicated and can be most helpful in estab-
lishing the cause of the persistent stula and planning further
therapy. Nutritional support must be provided throughout
this period. The surgeons foresight in placing a feeding
jejunostomy at the time of initial trauma laparotomy is now
rewarded. Low-fat, higher pH elemental feeding formulas
cause less pancreatic stimulation than standard enteral for-
mulas and should be tried prior to committing the patient to
total parenteral nutrition.
73
A somatostatin analogue (octreo-
tide acetate [Sandostatin]) has shown promise in treating
prolonged, high-output pancreatic stulae, but only after
eradicating any infection and in the absence of pancreatic
duct obstruction or stricture.
106

Octreotide as an adjuvant to standard stula management
probably diminishes stula output, but its shortening of the
time to stula closure remains to be proven.
107
Somatostatin
analogues do seem to prevent postoperative complications
and stula formation in patients undergoing elective pancre-
atic resection, although nonrandomized reports on the ef-
cacy of somatostatin analogues in pancreatic trauma patients
are contradictory.
108,109
In addition, the trials demonstrating a
decrease in postoperative complications with octreotide use
in elective pancreatic resection initiated octreotide in the pre-
operative period, a time frame not applicable to the trauma
setting.
109
Treatment typically begins with 50 g subcutane-
ously every 12 hours but can increase to 1,000 g/day.
Octreotide has been included in total parenteral nutrition
solutions, although this remains controversial and is not
recommended by the 1997 package insert because of the
formation of glycosyl octreotide conjugates that may decrease
efcacy.
110
Major side effects are unpredictable changes in
serum glucose, pain at the injection site, and a variety of
nonspecic gastrointestinal complaints.
ansccsscs
The incidence of abscess formation after pancreatic trauma
ranges from 10 to 25%, depending on the number and type
of associated injuries. Early operative or percutaneous decom-
pression or evacuation is critical, although the mortality rate
in this group of patients remains about 25%.
82,111
The intra-
abdominal abscess is most often subfascial or peripancreatic;
a true pancreatic abscess is unusual, resulting from inade-
quate dbridement of dead tissue or inadequate initial
drainage.
61,84,104,112
True pancreatic abscesses are often not
amenable or responsive to percutaneous drainage, and prompt
surgical dbridement and drainage are required. Percutane-
ous decompression may be helpful in distinguishing between
abscess and pseudocyst.
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7 TRAUMA AND THERMAL INJURY 9 INJURIES TO THE PANCREAS AND DUODENUM 13
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iaNcnca1i1is
Transient abdominal pain and a rise in the serum amylase
concentration may be anticipated in 8 to 18% of postopera-
tive patients.
23,84,113
This type of pancreatitis is treated with
nasogastric decompression, bowel rest, and nutritional sup-
port and can be expected to resolve spontaneously. A much
more infrequent but deadly complication is hemorrhagic
pancreatitis. The rst sign of this complication may be bloody
pancreatic drainage or a fall in the serum hemoglobin
concentration, with the patient rapidly becoming desperately
ill. It is fortunate that this complication occurs in less than
2% of operative pancreatic trauma patients since mortality
may approach 80% with no effective treatment.
61,75
sccoNuanv nc:onnnacc
Postoperative hemorrhage requiring blood transfusion may
occur in 5 to 10% of pancreatic trauma patients, particularly
when inadequate external drainage has been afforded after
pancreatic dbridement or when intra-abdominal infection
has developed.
113,114
These patients generally require reopera-
tion for control, although angiographic embolization may be
an effective alternative.
isccuocvs1s
Missed blunt pancreatic injuries, or those intentionally
managed nonoperatively, often result in the formation of a
pseudocyst. One report tabulated 22 pseudocysts in 42 blunt
pancreatic trauma patients managed nonoperatively.
27

The status of the pancreatic duct is the key determinant to
treatment of a pancreatic pseudocyst. If the pancreatic duct
is intact, percutaneous drainage of the pseudocyst is likely to
be effective. If the pseudocyst is secondary to a major pancre-
atic ductal disruption, percutaneous drainage will not provide
denitive therapy but will convert a pseudocyst to a chronic
stula. ERCP should therefore precede any percutaneous
drainage. If pancreatic duct stenosis or injury is demonstrated,
treatment options include (1) reexploration and partial gland
resection, (2) distal gland internal Roux-en-Y drainage, and
(3) endoscopic transpapillary stenting of the pancreatic duct.
49

The experience of Kouchi and colleagues of Japan suggests
that a pseudocyst greater than 10 cm in size will require
surgical decompression.
8

cxocniNc aNu cNuocniNc iNscrricicNcv
Both exocrine and endocrine insufciency are unusual after
pancreatic trauma. Animal and human studies suggest that a
residuum of 10 to 20% of normal pancreatic tissue is ade-
quate for pancreatic function,
24,115
implying that any resection
distal to the mesenteric vessels should leave adequate func-
tioning pancreatic tissue. The multicenter study of 74 cases
of distal pancreatic resection described earlier documented
only 1 case of endocrine deciency (diet-controlled hypergly-
cemia following 80% pancreatectomy) and no instance of
exocrine insufciency.
84
Balasegaram reported no pancreatic
insufciency after resections of up to 90% of the pancreas.
103

In contrast, patients with chronic pancreatitis who undergo
distal pancreatectomy have an incidence of diabetes ranging
from 15% (0 to 33% gland resected) to 64% (50 to 75%
gland resected).
76
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