Pancreatic Injuries

8/7/2019 Pancreatic Injuries

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PANCREATIC INJURIESPANCREATIC INJURIES


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Pancreatic traumaPancreatic trauma

Pancreatic trauma can occur after directPancreatic trauma can occur after direct

abdominal traumaabdominal trauma

Incidence 2Incidence 2--10% in major trauma10% in major trauma

Seen in 20Seen in 20--30% penetrating abdominal wounds30% penetrating abdominal wounds

Stabbing from back can cause itStabbing from back can cause it


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High mortality and morbidityHigh mortality and morbidity

Mortality 12Mortality 12--23%23% Mortality rises dramatically with shock and otherMortality rises dramatically with shock and other

organs traumaorgans trauma


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Morbidity 30Morbidity 30 49%49%

Necrosis, hemorrhage, abscess, fistula,Necrosis, hemorrhage, abscess, fistula,

pseudocystpseudocyst

Endocrine 20%Endocrine 20%

Morbidity >60% when diagnosis is delayedMorbidity >60% when diagnosis is delayed

Main pancreatic duct rupture seen in 1.6% bluntMain pancreatic duct rupture seen in 1.6% blunt

traumatrauma


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Associated injuriesAssociated injuries

9090--9595% have other injuries% have other injuries Liver 42Liver 42--32%32%

Spleen 25Spleen 25--40%40%

Stomach 20Stomach 20--40%40% Major vessel 25Major vessel 25--35%35%

Thorax 22Thorax 22--31%31%

Bowel 10Bowel 10--29%29%

CNS 25%CNS 25%

Duodenum 18%Duodenum 18%


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ANATOMYANATOMY


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Blood supplyBlood supply

ARTERIALARTERIALMultiple branches from celiac nd S.M.ArteryMultiple branches from celiac nd S.M.Artery

Pancreaticoduodenal arteriesPancreaticoduodenal arteries

Branches from Splenic arteryBranches from Splenic arteryVENOUSVENOUS

--Direct into PORTAL veinDirect into PORTAL vein

--pancreaticoduodenal vein join gastroepiploicpancreaticoduodenal vein join gastroepiploicvein to form common venous trunk TO SMVvein to form common venous trunk TO SMV

--Body and tail drain into splenic veinBody and tail drain into splenic vein

--Inferior arcade to IMVInferior arcade to IMV


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Pancreas with accessory pancreatic ductPancreas with accessory pancreatic duct


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ImagingImaging

CTCT

USUS

MRCPMRCP ERCPERCP

Serum amylase elevated in 73Serum amylase elevated in 73--82%82%

Amylase also elevated with bowel injury andAmylase also elevated with bowel injury andrenal failurerenal failure


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Acute CT findingsAcute CT findings

Direct findingsDirect findingsPancreatic enlargementPancreatic enlargement

LacerationLaceration

Inhomogeneous enhancementInhomogeneous enhancement Secondary findingsSecondary findings

Peripancreatic strandingPeripancreatic stranding

Peripancreatic fluid collectionPeripancreatic fluid collectionFluid between splenic vein and pancreasFluid between splenic vein and pancreas

HaemorrhageHaemorrhage


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Acute CT findingsAcute CT findings

Pancreatic duct disruption often not appreciatedPancreatic duct disruption often not appreciated

Sensitivity 40Sensitivity 40--69%69%

Other injury may obscure pancreatic findingsOther injury may obscure pancreatic findings


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GRADE-I Contusion Superficial laceration not involving duct


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GRADE - I


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GRADEGRADE -- II


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GRADE - II Laceration disrupting the main ductin the body or tail


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GRADE - II


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GRADE - III

Crushing or transection of the head Duodenum intact


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GRADEGRADE -- IIIIII


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GRADEGRADE -- IIIIII


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GRADE - IVCrushing or transection of Pancreatic head and

duodenum injury


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GRADEGRADE -- IVIV


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GRADEGRADE -- IVIV


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GRADEGRADE -- IVIV


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MANAGEMENT OFMANAGEMENT OF

PANCREATIC TRAUMAPANCREATIC TRAUMA

Depends upon location of injuryDepends upon location of injury[ BY CT ][ BY CT ]

Whether or not pancreatic duct is injuredWhether or not pancreatic duct is injured


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DIAGNOSING PANCREATICDIAGNOSING PANCREATIC

DUCT INJURYDUCT INJURY NO IDEAL METHOD EXISTS FORNO IDEAL METHOD EXISTS FOR

IDENTIFYINGDUCCTAL INURIESIDENTIFYINGDUCCTAL INURIES

Operative pancreatography throughOperative pancreatography through

duodenotomy or following resection of tail ofduodenotomy or following resection of tail of

pancreaspancreas

Passing of Coronary artery dilator into duct viaPassing of Coronary artery dilator into duct via

papillapapilla

ERPERP


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LOCATION OF PANCREATICLOCATION OF PANCREATIC

INJURYINJURYTAILTAIL

BODYBODY

NECKNECK

HEADHEAD


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TAIL,BODY AND NECK INJURIESTAIL,BODY AND NECK INJURIES

WITH DUCT TRANSECTEDWITH DUCT TRANSECTED

Distal pancreatectomy with splenectomyDistal pancreatectomy with splenectomy

Distal pancreatectomy with spleen perservationDistal pancreatectomy with spleen perservation

Conserving distal pancreas and spleen with RouxConserving distal pancreas and spleen with Roux--enen--Y LimbY Limb


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Pancreatic head andduct injuryPancreatic head andduct injury


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RouxRoux--enen--YY panreatojejunostomypanreatojejunostomy


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GRADEGRADE IV INJURYIV INJURY

HEAD OF PANCREAS AND DUODENALHEAD OF PANCREAS AND DUODENAL

INJURYINJURY


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GASTROJEJUNOSTOMY WITHGASTROJEJUNOSTOMY WITH

DUODENUM REPAIR AND FEEDINGDUODENUM REPAIR AND FEEDING

JEJUNOSTOMYJEJUNOSTOMY


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WHIPPLES PROCEEDUREWHIPPLES PROCEEDURE

INDICATIONS OF WHIPPLES ININDICATIONS OF WHIPPLES IN

PANCREA TIC TRAUMAPANCREA TIC TRAUMA

Injury to CBD and pancreatic duct in head ofInjury to CBD and pancreatic duct in head of

pancreaspancreas

A

vulsion of papilla of vater from duodenumA

vulsion of papilla of vater from duodenum Destruction of entire 2Destruction of entire 2ndnd part of duodenumpart of duodenum


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INDICATIONS OF WHIPPLES ININDICATIONS OF WHIPPLES IN

MALIGNANCIESMALIGNANCIES

Malignant tumors affecting duodenumMalignant tumors affecting duodenum

Head of pancreasHead of pancreasDistal part of bile ductDistal part of bile duct


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WHIPPLE[ BEFORE ]WHIPPLE[ BEFORE ]


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WHIPPLE [ AFTER ]WHIPPLE [ AFTER ]


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COMLICATIONSCOMLICATIONS

NecrosisNecrosis

HaemorrhageHaemorrhage

AbscessAbscess PseudocystPseudocyst

FistulaFistula

Diabetes mellitusDiabetes mellitus Pancreatic insufficiencyPancreatic insufficiency

PSEUDOCYSTPSEUDOCYST


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PSEUDOCYSTPSEUDOCYST

WALLED OF COLLECTIONWALLED OF COLLECTIONOF SECRETIONSOF SECRETIONS


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CONCLUSIONCONCLUSION

Signs on admission CT may be easily overlookedSigns on admission CT may be easily overlooked

CT tends to under stage pancreatic injuriesCT tends to under stage pancreatic injuries Pancreatic duct disruption not well seen on CTPancreatic duct disruption not well seen on CT

Delayed diagnosis has worse prognosisDelayed diagnosis has worse prognosis

Surgery indicated for majorSurgery indicated for major splspl pancreatic headpancreatic headtraumatrauma

MRCP and ERCP useful to assess ductMRCP and ERCP useful to assess duct


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Pancreatic Injuries