Pancreatic trauma

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Pancreatic trauma

• Iain Cameron

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How does it happen?

• Blunt trauma to abdomen
• Deceleration injuries (seatbelts)
• Significant force needed
• Likely to have other injuries

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Diagnosis of injury

• Clinical history
• Serum amylase often elevated
• No correlation amylase severity injury
• CT scan - free fluid around pancreas
• - in lesser sac
• - oedema / changes in periP fat
• Often underestimates the problem

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Injury classification

• Grade 1 capsular injury with contusion
• Grade 2 major duct injury body/tail
• Grade 3 major duct injury head /- CBD
• Commonest site of injury neck
• Asssociated injury duodenal

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Sites of injury
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Initial treatment

• Integrity of main duct is key to management
• Delayed diagnosis associated with poor outcome
• CT reasonable identifying pancreatic injury
• Poor assessing duct integrity
• ERCP / MRCP needed

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ERCP/MRCP

• Early imaging in stable patient
• PD injury key to treatment plan
• No disruption trial of conservative Rx
• Major duct injury surgery likely
• ? Duodenal injury

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Laparotomy

• Open lesser sac, full kockerisation of D2
• Complete gland examination
• Most cases drainage only needed
• 60 G1, 20 grades 2 and 3
• Distal duct injury distal pancreatectomy

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HOP injury

• Controversial
• Drainage only risk pancreatic fistula
• Alternative drain into roux loop
• Duodenal injury 1 repair
• Drain into roux loop
• Treatment is tailored to individual injury

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Complications

• Pancreatic abscesses drain (USS guided)
• Fistula greater with drainage vs. resection
• Octreotide, NBM, TPN
• Pseudocysts as acute pancreatitis
• Options - Percutaneous drainage
• - Drainage into GI tract
• - Pancreatic stents ineffective

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Summary

• Suspect from MOI
• CT - presence not extent injury
• Evaluation of duct integrity essential
• Exploration / drainage main surgical Rx.
• Selected injuries treated with resection

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Case discussion

• MF, 30 year old male 2am
• AE, Alcohol , Fallen off bicycle
• Conscious but rambling
• Facial bruising, no fractures
• O/E abdominal tenderness
• AXR/CXR normal

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Next morning

• Abdomen still tender, no guarding
• Slight tachycardia
• Bloods o/a amylase 312
• What next?

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(No Transcript)
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Conservative treatment

• Stable until day 4
• Tachycardia 110, T 37.8
• Bloods WCC 14
• Amylase 751
• What next?

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Repeat CT
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Options

• Conservative
• Surgery
• Transfer to HPB unit

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RHH treatment

• XRC review transection of neck
• Surgery
• Questions
• How to deal with Head of gland
• Distal gland
• Any other injuries?

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Contrast swallow
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Operation

• Complete transection of neck
• Minimal contamination, 500ml fluid
• Two ends of pancreas healthy
• Head Duct oversewn, end glued
• Body/tail debridement / mobilised
• - drained into roux loop

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Progress

• Octreotide for 7 days
• Minimal drainage
• Allowed to E D
• Discharged day 9
• DNAd clinic