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Management of pancreatic trauma in adults

Management of pancreatic trauma in adults
Literature review current through: Jan 2024.
This topic last updated: Jan 11, 2024.

INTRODUCTION — Injury to the pancreas is infrequent. The retroperitoneal location of the pancreas makes signs and symptoms typical of intra-abdominal injuries less obvious, and the diagnosis and management can be challenging. Most injuries to the pancreas are low grade and can be managed with minimal intervention; however, complex injuries require timely surgical management. Pancreatic injuries are frequently associated with other injuries, and as a result, the rate of complications and mortality associated with pancreatic injuries is overall high.

The mechanisms, associated injuries, diagnosis, and management of pancreatic injury in adults are reviewed here. Duodenal injury often accompanies pancreatic injury and is reviewed separately. (See "Management of duodenal trauma in adults".)

The general approach to blunt and penetrating abdominal trauma is reviewed separately. (See "Initial management of trauma in adults" and "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults".)

PANCREATIC ANATOMY — The pancreas is a compound exocrine and endocrine gland located in the retroperitoneum at the level of the second lumbar vertebrae (figure 1). Exocrine pancreatic secretion is composed of enzymes, water, electrolytes, and bicarbonate, which are delivered to the duodenum via the pancreatic duct of Wirsung and aid with digestion. Insulin, glucagon, and somatostatin are secreted by the islets of Langerhans, A cells, and D cells, respectively. Removal of 90 percent of the mass of the pancreas can generally be performed without resulting in endocrine or exocrine deficiency.

The pancreas is divided into five parts, including the head, uncinate process, neck, body, and tail. The head of the pancreas lies to the right of the superior mesenteric artery. The uncinate process is a variable posterolateral extension of the head that passes behind the retropancreatic vessels and lies anterior to the inferior vena cava and aorta. The neck is defined as the portion of the gland overlying the superior mesenteric vessels. The body and tail lie to the left of the mesenteric vessels; there is no meaningful anatomic division between the body and tail.

The pancreatic duct joins the common bile duct to drain into the duodenum via the major papilla (ampulla of Vater) (figure 2 and picture 1). The anatomy of these ducts can vary. In 85 percent of individuals, both the pancreatic duct and the common bile duct enter the duodenum through a common channel. In 5 percent of patients, both ducts enter the duodenum through the same ampulla but via separate channels. In the remaining 10 percent of patients, each duct enters the duodenum through a separate ampulla [1]. The entry of the common bile duct into the pancreatic tissue posteriorly can also vary (figure 3).

The arterial supply pancreas (figure 4) is derived from the celiac artery providing the superior pancreaticoduodenal arteries (anterior and posterior branches) and the superior mesenteric artery providing the inferior pancreaticoduodenal arteries (anterior and posterior branches). The splenic artery supplies primarily the body and tail of the pancreas. The venous drainage (figure 5) follows the arteries to provide tributaries to the splenic vein and superior mesenteric vein, which drain into the portal vein.

The pancreas is innervated by sympathetic fibers from the splanchnic nerves (figure 6) and parasympathetic fibers from the vagus, both of which give rise to intrapancreatic periacinar nerve plexuses. The parasympathetic fibers stimulate exocrine and endocrine function, whereas the sympathetic fibers have an inhibitory effect.

TRAUMA EVALUATION — The initial resuscitation, diagnostic evaluation, and management of the patient with blunt or penetrating injury are based on protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma.

In the setting of acute trauma, many patients cannot relate their symptoms or medical history due to altered mental status (eg, neurologic injury, intoxication) or because they are intubated and sedated. Every attempt should be made to identify preexisting medical conditions. The presence of significant medical comorbidities and medical conditions requiring antiplatelet therapy or anticoagulation should be determined. (See "Overview of inpatient management of the adult trauma patient", section on 'Patient assessment'.)

Although Focused Assessment with Sonography in Trauma (FAST) is a useful, validated test for detecting hemoperitoneum in the setting of blunt trauma, it is not reliable as a screening test for pancreatic injury. Approximately one-third of patients with retroperitoneal injuries including injuries of pancreas will have normal FAST examinations [2,3]. (See "Emergency ultrasound in adults with abdominal and thoracic trauma".)

Because of these issues, hemodynamically stable patients with concern for the pancreatic injury require computed tomography (CT) imaging. Patients who are hemodynamically unstable due to ongoing hemorrhage will have these injuries diagnosed at the time of operation. (See 'Pancreatic imaging' below and 'Abdominal exploration' below.)

Risk for injury — Pancreatic injuries are uncommon, occurring in <1 percent of trauma admissions [4-6] and accounting for <5 percent of traumatic abdominal injuries [7,8].

Injury mechanism — Blunt pancreatic injury more commonly presents to the trauma center compared with penetrating injury [4,5]. This may be due, in part, to the overall higher incidence of blunt trauma in the United States and the high lethality of penetrating injuries to this region of the body. In a review of pancreatic injuries from the National Trauma Data Bank in the US, 61 percent had blunt injuries and 39 percent had penetrating injuries [4].

Approximately 80 percent of blunt injuries to the pancreas are caused by motor vehicle collisions. The mechanism is typically due to crushing of the pancreas between the vertebral column and seatbelt or steering wheel. The remainder of blunt pancreatic injuries result from falls, assaults, or direct abdominal impact. Blunt pancreatic injury can also be due to any focal impact to the abdomen, such as motorcycle or bicycle crashes that crush the pancreas between the spinal column and handlebar [9-11]. Other mechanisms that cause abdominal crush injury can also cause pancreatic injury (eg, earthquake-related injuries [12], trampling, being kicked or butted by an animal [13]). (See "Severe crush injury in adults".)

Any implement or missile that penetrates the abdominal wall can injure the pancreas. Abdominal gunshot or shotgun wounds are more likely to result in severe injury compared with stab wounds because of their high energy. However, depending upon the girth of the victim and force applied, even a short knife, other implement, or impaling object that penetrates the abdominal wall can cause pancreatic injury.

Associated injuries — The scope of injuries associated with pancreatic trauma is illustrated in the following retrospective reviews.

In a review of 3465 injuries involving the pancreas, there were 7526 associated injuries [7]. The liver was the most injured organ, accounting for 19 percent of associated injuries. Other organs injured along with the pancreas included the stomach (16 percent), spleen (11 percent), colon (8 percent), and duodenum (8 percent).

Among 777 patients with penetrating pancreatic trauma from the National Trauma Data Bank (NTDB) from 2010 and 2014, associated injuries occurred in approximately 50 percent of patients and included injuries to the liver, stomach, and major abdominal vasculature [14].

Because of the proximity of the major vascular structures (figure 7), including the aorta, vena cava, portal vein and mesenteric veins, injury to the pancreas associated with vascular injury can lead to exsanguinating hemorrhage. Penetrating pancreatic injury is more likely to result in vascular injury [15,16]. One review documented that 37 percent of patients with penetrating pancreatic injury had major vascular injuries [15]. (See "Abdominal vascular injury".)

CLINICAL EVALUATION

History and physical evaluation — A history of any blow, crushing mechanism, or missile/implement trajectory to the mid-to-upper abdomen should raise suspicion for pancreatic injury. (See 'Injury mechanism' above.)

Abdominal tenderness and peritoneal signs on initial evaluation may indicate the presence of intra-abdominal injury but are not specific for pancreatic injury. A physical exam finding of abdominal wall ecchymosis may be a sign that a crush injury has occurred. In a study of 117 blunt abdominal injuries due to motor vehicle crashes, significantly more patients who presented with abdominal wall ecchymosis or the "seatbelt sign" had intra-abdominal injuries requiring surgery compared with those who did not have ecchymosis (36 versus 4 percent) [17].

The thoracic and lumbar spine should be carefully palpated for spinal tenderness, which may indicate the presence of a spine fracture (image 1). Approximately one-third of patients with transverse vertebral body fractures (ie, Chance fracture) of the low thoracic or lumbar spine have intra-abdominal injuries [18].

Clinical symptoms and signs that may suggest an undiagnosed injury in patients who are being conservatively managed are reviewed below. (See 'Role of conservative management' below.)

Laboratory studies — While an elevated serum amylase or lipase may be associated with a pancreatic injury, these laboratory studies are not specific enough to establish or exclude the diagnosis. When elevated amylase occurs in association with pancreatic injury, higher enzyme levels are not necessarily associated with higher grades of pancreatic injury. An elevated amylase or lipase can be present in patients with blunt abdominal trauma who do not have pancreatic injury [19-24]. Alterations in serum amylase can also be due to a variety of conditions not associated with trauma, many of which do not involve the pancreas (table 1), and many drugs can affect serum amylase values (table 2). (See "Approach to the patient with elevated serum amylase or lipase".)

DIAGNOSIS — Injury to the pancreas may be suspected based on the mechanism of injury or identification of injury to organs in close proximity to the pancreas (figure 7). History and physical examination are nonspecific and are not reliable for detecting pancreatic injury. A definitive diagnosis of pancreatic injury is made by pancreatic imaging studies, typically computed tomography (CT) of the abdomen or identification of the injury during exploratory laparotomy, as indicated by the clinical scenario.

Pancreatic imaging — The imaging diagnosis of blunt pancreatic injury relies primarily on CT of the abdomen. If abdominal CT demonstrates the injury, but the integrity of the pancreatic duct cannot be established with CT, cholangiopancreatography (magnetic resonance or endoscopic) can be performed.

The injured pancreas can appear normal on the initial CT, especially within 12 hours after the injury. If initial imaging does not show a pancreatic injury, but the ongoing clinical situation suggests that pancreatic injury may be present, repeat CT imaging with thin sections through the pancreas may demonstrate the injury [25]. The development of complications related to diagnosed or undiagnosed pancreatic injury may also require further imaging or even abdominal exploration. (See 'Complications of pancreatic injury' below.)

Computed tomography — Abdominal CT findings of pancreatic injury include both direct and indirect findings [6,26-36]. Direct injuries are seen on contrast-enhanced CT, while noncontrast CT can show indirect signs [37]. Indirect findings are generally nonspecific as these can be seen with other organ injuries. However, the indirect CT finding of peripancreatic fluid is highly sensitive (67 to 85 percent) for pancreatic injury [38].

Direct CT findings (seen on contrast-enhanced CT):

Pancreatic swelling or enlargement

Pancreatic laceration

Pancreatic transection

Pancreatic hematoma or active bleeding

Heterogenous enhancement

Indirect CT findings (seen on noncontrast CT):

Infiltration of peripancreatic fat

Thickening of anterior pararenal fascia

Fluid in the lesser sac

Peripancreatic fluid, especially fluid between splenic vein and pancreas

Intra- or extraperitoneal fluid

Associated injuries (eg, duodenal, hepatobiliary, splenic)

On CT, highly specific findings for pancreatic injury include active hemorrhage and pancreatic laceration involving >50 percent of the parenchymal width [38]. However, in spite of higher-resolution CT technology, missed injury (blunt) to the pancreas continues to be a problem with between 5 and 10 percent of pancreatic ductal injuries missed with abdominal CT [39,40]. In addition, because the integrity of the pancreatic duct determines the course of treatment for injury to the pancreas, imaging the duct with an imaging study that has high specificity is desirable. In a multicenter study of 206 patients, specificities for 16 channel and 64 channel CT scanners were 94.8 and 90.3 percent, respectively, while sensitivities were 54.0 and 52.4 percent, respectively [36]. If the integrity of the pancreatic duct cannot be established with CT, cholangiopancreatography can be performed. (See 'Magnetic resonance cholangiopancreatography' below and 'Endoscopic retrograde cholangiopancreatography' below.)

If there is high suspicion for blunt pancreatic injury, but no clear injury on abdominal CT, the patient should be admitted for monitoring and repeat lipase/amylase every 6 to 12 hours. If symptoms worsen or findings on serial abdominal examination progress or enzymes elevate, a repeat CT scan should be obtained with fine cuts through the pancreas. Abdominal CT obtained several hours after the event may be more sensitive due to the changes associated with progressive inflammation around the pancreas.

Magnetic resonance cholangiopancreatography — Magnetic resonance cholangiopancreatography (MRCP) is sensitive for detecting pancreatic ductal injury, and it can also demonstrate pancreatic parenchymal and peripancreatic abnormalities, such as pancreatic laceration, hematoma, contusion, and peripancreatic fluid [29,40-42]. Standard MRCP can also be augmented as a dynamic secretin-stimulated MRCP, which can demonstrate main pancreatic ductal injury as well as continued leakage [43].

Compared with endoscopic retrograde cholangiopancreatography (ERCP), MRI/MRCP demonstrates the duct beyond the laceration and is noninvasive. However, it may be difficult to differentiate pancreatic duct compression due to hematoma from signal loss due to pancreatic ductal injury. Other disadvantages of MRCP for the diagnosis of pancreatic injury include that it is time consuming, monitoring the injured patient while the test is being performed can be difficult, there is no opportunity for treatment, and it is not widely available. For equivocal findings on MRCP, proceeding to ERCP may be reasonable.

Endoscopic retrograde cholangiopancreatography — ERCP is the most accurate imaging technique to detect and localize pancreatic ductal injury [44-47]. However, it is an invasive procedure and should only be performed in those with firm indications and should not be performed when duodenal perforation is suspected.

For patients with traumatic injuries, ERCP is indicated for hemodynamically stable patients with CT of the abdomen that is inconclusive for pancreatic ductal injury, suspected pancreatic ductal injury based upon clinical findings during a period of observation or postoperatively, and operative findings that are suspicious for pancreatic ductal injury when an intraoperative contrast study cannot be performed [45]. Compared with MRCP, ERCP can be used for stent placement in the presence of main pancreatic ductal injury. (See 'Evaluating ductal anatomy' below.)

Some ductal injuries identified with ERCP may be conducive to management with percutaneous or endoscopic techniques (eg, biliary stent, pancreatic stent). (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

Diagnosis at laparotomy — For trauma patients with indications for emergency laparotomy, injuries to the pancreas should be actively sought during abdominal exploration. Techniques for exposing the pancreas and their intraoperative evaluation are discussed below; the evaluation of other retroperitoneal organs is reviewed separately. (See 'Abdominal exploration' below and "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Damage control laparotomy'.)

PANCREAS INJURY GRADING — A widely used pancreatic injury classification system is from the American Association for the Surgery of Trauma (AAST), which classifies the severity of pancreatic injury based on the injury type, injury location, and presence of absence of the main pancreatic duct injury (table 3) [48]. Although injury management does not correlate exactly with grade, this injury scale provides a practical means by which to communicate the severity of injury [48]. The initial severity of pancreatic injury is estimated based upon findings of computed tomography or more definitively during operative exploration.

Grade I – Minor contusion without duct injury or superficial laceration without duct injury.

Grade II – Major contusion without duct injury or tissue loss, or major laceration without duct injury or tissue loss.

Grade III – Distal transection (through-and-through laceration) or deep parenchymal injury with ductal injury.

Grade IV – Proximal pancreatic transection (through-and-through laceration) or deep parenchymal injury involving ampulla.

Grade V – Massive disruption of the pancreatic head.

MANAGEMENT

Role of conservative management — Conservative management of low-grade blunt (grade I or grade II pancreatic injury [ie, contusion or superficial laceration without pancreatic ductal injury]) is safe and can be suggested if the grade of injury is determined with certainty by imaging studies and if the patient is hemodynamically stable without other indications for a laparotomy [49-58]. Nonoperative management is not recommended for penetrating mechanisms.

Patients with ductal injury identified on computed tomography or MRI-cholangiopancreatography are generally not candidates for nonoperative management, although endoscopic management using pancreatic stenting may considered in select cases. (See 'Role of endoscopic management' below.)

Conservative management consists of gastrointestinal decompression and nutrition support, as indicated. For patients with concurrent duodenal hematoma, a nasogastric tube is typically placed for decompression. (See "Management of duodenal trauma in adults", section on 'Role of conservative management'.)

Careful monitoring is essential to monitor for complications that indicate the need for intervention or surgical exploration. Patients with pancreatic injuries who develop peripancreatic fluid collections or pseudocysts may require percutaneous drainage if clearly infected, which may result in prolonged hospitalized care. A retrospective multicenter study evaluated the outcomes of 230 patients with blunt pancreaticoduodenal injury [39]. Of the 97 patients managed nonoperatively, 10 patients (6 pancreatic) failed nonoperative management and required surgery.

When patients are being observed following trauma, the following clinical symptoms and signs may suggest an undiagnosed pancreatic injury [59,60]:

Increasing abdominal pain

Increasing abdominal tenderness

Persistent emesis or inability to tolerate oral diet

Unexplained hypotension

Increasing leukocytosis

Increasing serum amylase or lipase

Nutrition support and enteral access — Early enteral nutrition is preferred over parenteral nutrition for most injured patients [61-68]. However, placing and maintaining enteral access in patients with blunt pancreatic injury who are managed nonoperatively can be challenging. Postpyloric placement of a nasoenteric feeding is preferred, if possible, to allow enteral feeding and avoid the complications of parenteral nutrition. (See "Overview of perioperative nutrition support", section on 'Indications' and "Inpatient placement and management of nasogastric and nasoenteric tubes in adults".)

Patients undergoing exploratory laparotomy and operative management of pancreatic injuries can have a nasal-jejunal tube or surgical jejunostomy placed prior to abdominal closure [66]. There are insufficient data to recommend routine jejunostomy in all cases of operative pancreatic injury given that approximately 4 percent of trauma patients will have complications related to a surgical jejunostomy (eg, soft tissue infection, leak, enteric fistula, bowel obstruction) [69,70].

Abdominal exploration — Evaluation of the pancreas is mandatory for injured patients who undergo exploratory laparotomy for other indications. A significant number of patients with other abdominal injuries will be diagnosed with pancreatic injury at the time of exploratory laparotomy [71-74].

Following control of abdominal hemorrhage or gastrointestinal contamination, the visible areas of the retroperitoneum should be inspected for hematoma, bile staining, and peripancreatic hematomas or fluid. Retroperitoneal hematomas in the setting of penetrating trauma should be explored. (See "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Exploration of retroperitoneal hematoma'.)

If there is a high suspicion of pancreatic injury due to a missile or highly associated injuries, each of the steps described below should be performed to mobilize and examine the retroperitoneum.

Perform a Kocher maneuver (figure 8) by dissecting the lateral peritoneal attachments of the duodenum to expose the head and neck of the pancreas.

Divide the gastrocolic ligament to allow entry into the lesser sac and inspection of the anterior surface of the pancreas.

Divide the retroperitoneum inferior to the pancreas to inspect the posterior pancreas after mobilizing and lifting the inferior edge of the pancreas.

Expose the third portion of the duodenum with a right medial visceral rotation.

Mobilize the ligament of Treitz to expose the tail of the pancreas.

Because the pancreas is highly vascular, transections and major lacerations of the pancreas are easily identified as a peripancreatic hematoma during visual inspection of the retroperitoneum. All peripancreatic hematomas should be explored. Once the hematoma is decompressed, the pancreas is examined for several minutes, possibly with loupe magnification, if needed, to identify any leakage of clear pancreatic fluid consistent with pancreatic ductal injury [75].

If pancreatic ductal injury is suspected but is not immediately apparent, a dose of secretin (1 unit/kg intravenously) can be given to stimulate pancreatic secretion [76]. Intraoperative ultrasound can also be used to detect pancreatic parenchymal or pancreatic ductal injury [77]. If a suspected pancreatic ductal injury cannot be confirmed, cholangiopancreatography via the gallbladder is an option [78]. However, in the presence of an intact duodenum and no apparent main duct injury to the pancreatic head, drainage alone is an option without intraoperative cholangiogram. If the postoperative lipase/amylase drain output is high, then ERCP is advised with the goal of stenting any main duct injury.

Evaluating ductal anatomy — When injury to the pancreas is identified during abdominal exploration, the integrity of the main pancreatic duct should be evaluated and the location of the injury (proximal versus distal) (algorithm 1) need to be determined.

Findings consistent with pancreatic ductal injury include direct observation of the injured duct, complete transection of the pancreas, laceration of >50 percent of the pancreas, central perforation, and severe pancreatic maceration [79-81]. In indeterminate cases, intraoperative cholangiopancreatography can often determine the presence of ductal injury but can be technically difficult to accomplish.

Intraoperative cholangiopancreatography during trauma exploration can be performed through an existing duodenal wound or via the gallbladder. A catheter is directed into the ampulla of Vater or pancreatic duct injecting 2 to 5 mL of soluble contrast into the duct while imaging using fluoroscopy or shooting a plain film. Injection of contrast via the gallbladder with retrograde filling of the pancreatic duct has also been reported with a 79 percent success rate [82]. In general, duodenotomy for ductography is not advised.

Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) can also provide the necessary imaging but can be logistically challenging.

An alternative approach is to use damage control techniques with wide pancreatic drainage and obtain a postoperative study (ERCP or magnetic resonance cholangiopancreatogram [MRCP]) to evaluate the ductal anatomy. However, positive findings may indicate the need to return to the operating room to manage the identified injuries. (See 'Damage control' below.)

Damage control — Damage control surgery involves immediate control of bleeding sites (including those associated with pancreatic injury) and gastrointestinal contamination with delayed management of injuries that are not immediately life-threatening, including pancreatic injuries. Intraperitoneal packing and temporary abdominal closure are followed by fluid resuscitation, patient warming, and correction of coagulation deficits in the intensive care unit [83-85]. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury" and "Management of the open abdomen in adults".)

Bleeding from the pancreas distal to the head of the pancreas can usually be controlled with packing; however, high-grade injuries to the head of the pancreas are often associated with bleeding that cannot be controlled by packing, and, thus, resection without immediate reconstruction may be needed.

For suspected pancreatic ductal injuries, wide drainage is used, but if the injury is distal, a distal pancreatectomy is advised. (See 'Operative management of pancreatic injury' below.)

Bleeding from high-grade pancreaticoduodenal injuries often cannot be controlled by packing, and thus resection without immediate reconstruction may be needed. The pylorus, pancreatic neck, and proximal jejunum are stapled across and transected, the common bile duct is ligated, and the biliary tract is drained using tube cholecystostomy [86]. Closed-suction drains are placed to control duodenal and pancreatic secretions. Following resuscitation and stabilization, definitive resection and reconstruction (Whipple) can be performed. (See 'Combined pancreaticoduodenal injuries' below.)

Operative management of pancreatic injury — Generally accepted principles of operative management of pancreatic injuries include control of bleeding, wide drainage to control potential pancreatic fistula, avoiding pancreaticoenteric anastomoses, and limiting the extent of procedures in the setting of damage control surgery. (See 'Damage control' above.)

Perhaps the only consensus among trauma surgeons is that wide closed-suction drainage should be performed, as discussed below [56,73,87]. When drains are placed, we prefer to use closed-suction drains rather than sump drainage, which has been associated with a greater incidence of septic pancreatic complications [88]. Drains should be placed transversely, adjacent to the gland. When treating pancreatic injuries, a minimum of two drains should be placed, one superior to the pancreas and one inferior to the pancreas. While there has been considerable effort characterizing pancreatic drain output following elective pancreatic surgery, less attention has been directed to drain output following traumatic injury. Nonetheless, standard definitions of high- and low-volume output and drain to serum amylase ratios should be used to describe postoperative drain output [89].

Parenchymal injury without ductal injury — Based upon injury grade, the operative management of parenchymal injuries that are not associated with ductal injury is as follows:

Grade I injuries are minor contusions associated with small hematomas, minor capsular injury, and traumatic pancreatitis. When minor contusions are identified in the operating room, no specific intervention is needed (not even drainage) [39].

Grade II injuries are pancreatic lacerations that do not involve the main pancreatic duct. Bleeding from the parenchyma is often apparent. Grade II injuries are treated with limited debridement and closed-suction drainage [76]. Several procedures, including suture repair of the capsule, omental plug, bipolar cautery, and tissue sealant, have been advocated to decrease pancreatic fistula formation from minor pancreatic ductal injury, but there is no evidence to support these methods.

Low-grade pancreatic injuries still carry a significant rate of pancreatic complications (4 to 42 percent), so careful monitoring is required. Nonresectional treatment remains the norm [90].

Pancreatic ductal injuries — Higher-grade injuries include distal (grade III) and proximal (grade IV, grade V) pancreatic ductal injuries, which are often associated with duodenal injury. Multiple other traumatic injuries are often associated, necessitating a damage control approach. (See 'Damage control' above and 'Combined pancreaticoduodenal injuries' below.)

Surgical management of pancreatic ductal injuries depends upon whether the main pancreatic duct is injured to the left or the right of the superior mesenteric vein.

Pancreatic transection or parenchymal injury to the left of the superior mesenteric vein is most commonly managed with distal pancreatectomy (figure 9). Distal pancreatic resection can be accomplished without significantly prolonging operative time or sacrificing the spleen (figure 10) and should be considered in hemodynamically stable patients with isolated pancreatic injury [91-94]. To salvage the spleen, the splenic artery branches, and venous tributaries draining the posterior surface of the pancreas are isolated and ligated, working from distal to proximal, followed by division of the pancreas (figure 10). The technical aspects of resecting the body and tail of the pancreas are discussed elsewhere. (See "Surgical resection of lesions of the body and tail of the pancreas", section on 'Distal pancreatectomy'.)

There is significant controversy about the management of pancreatic traumatic injuries between adult and pediatric surgeons. In general, pediatric surgeons are more likely to adopt a watchful waiting approach to a pancreatic injury seen on imaging. A multicenter study (from 1995 to 2012) examined the management and outcome of 167 patients under the age of 18 with grade II and III blunt pancreatic injury (57 treated with distal resection; 95 managed nonoperatively) [95]. The authors concluded that distal pancreatectomy was superior to nonoperative management with more rapid resumption of diet, fewer repeat interventions, and a shorter period to complete resolution. When the main duct was involved, the benefits of operative resection also included lower morbidity and shorter hospitalization. This assessment that operative management of grade III injuries (pancreatic duct injured) with distal resection is supported in other reports as well, noting that 26 percent of grade II to V injuries managed nonoperatively failed nonoperative approach with longer length of stay and higher incidence of pseudocysts, drainage procedures, and persistent pancreatitis [96].

Management of pancreatic ductal injury to the right of the superior mesenteric vessels depends upon the presence and extent of pancreatic tissue devitalization and whether there is concomitant duodenal injury. Options include selective debridement of frankly necrotic tissue and wide suction drainage, extended distal pancreatectomy with division of the pancreas to the right of the superior mesenteric vessels, and pancreaticoduodenectomy (ie, Whipple procedure). In a review of 134 patients with blunt pancreatic ductal injury, 34 patients with proximal injuries (not grade V) were treated with closed-suction drainage alone [97]. Complication rates were no different compared with more aggressive approaches. Favorable results have also been reported for proximal duct injury due to gunshot wounds using debridement, suture repair, and closed-suction drainage [98]. There is substantial debate among experienced trauma surgeons as to the role of resection versus wide drainage with possible stenting of the pancreatic duct in high-grade injuries, particularly when the main pancreatic duct status is not clear on initial explorations [99]. (See 'Combined pancreaticoduodenal injuries' below and "Surgical resection of lesions of the head of the pancreas".)

Main pancreatic duct injuries with extensive injury to the pancreatic head can also be managed with central pancreatectomy (ie, Roux-en-Y pancreaticojejunostomy for internal drainage with oversewing of the proximal segment (figure 11)), provided sufficient parenchyma is preserved [100]. Some authors have advocated this technique due to the high incidence of endocrine insufficiency and diabetes when >90 percent of the pancreas is removed. For these types of injuries, central pancreatectomy has an advantage over distal or subtotal pancreatectomy in preserving the tail of the pancreas and its endocrine and exocrine function, as well as the spleen [101]. However, this procedure has been associated with a high incidence of pancreatic leak and abscess formation, and some argue that a more conservative approach should be used. These considerations and the complexity of the procedure make central pancreatectomy unsuitable for many patients, particularly multiply injured patients. The technical aspects of central pancreatectomy are discussed elsewhere. (See "Surgical resection of lesions of the body and tail of the pancreas", section on 'Central pancreatectomy'.)

An alternative to pancreatic-enteric anastomosis in patients who will not tolerate an extended procedure is pancreatic duct ligation and drainage [102]. The resulting pancreatic fistula is managed accordingly. (See 'Pancreatic fistula' below.)

Role of endoscopic management — Pancreatic ductal injury is mostly managed surgically; however, as endoscopic skills, techniques, and equipment have improved, many centers are considering the role of endoscopic stenting of isolated pancreatic duct injuries rather than pursuing surgical management [6,97,98,103-108]. Endoscopic management has been perhaps more widely applied in children, as well as in more proximal injuries, but stenting more distal pancreatic duct injuries has been reported. A 2018 review of 22 pediatric trauma centers identified the use of ERCP in 14 centers and 26 patients [109]. The authors concluded that ERCP can be useful to diagnose duct injury and for management of late complications such as stricture and fistula. However, early endoscopic intervention for pancreatic duct disruption may not improve outcome or expedite recovery .

This approach should be considered with caution, as optimal patient selection and long-term results are unknown.

Combined pancreaticoduodenal injuries — Combined pancreatoduodenal injuries are associated with a high risk for morbidity and mortality. In some patients with combined pancreatoduodenal injuries, the duodenal injury and pancreatic injury can be approached separately using relatively simple procedures. (See "Management of duodenal trauma in adults", section on 'Low grade' and 'Parenchymal injury without ductal injury' above.)

When combined pancreatoduodenal injuries are more extensive, the risk of postoperative pancreatic and/or duodenal fistula is high. Adjunctive procedures should be considered to decrease the volume of secretions in the duodenum, such as pyloric exclusion or tube decompression. Of these, pyloric exclusion is the most expedient and least complex option. (See "Management of duodenal trauma in adults", section on 'Adjunctive surgical techniques'.)

For patients with severe, combined pancreatoduodenal injury, such as when the ampulla of Vater or intrapancreatic common bile duct has been destroyed or the head of the pancreas has been devitalized, reconstruction is not possible and resection is needed. Fortunately, this rarely occurs. A damage control approach is often needed due to other associated injuries, which necessitates a staged procedure [75,84,86,110-114]. The head of the pancreas and proximal duodenum can usually be resected quickly (pancreaticoduodenectomy), and drainage established. (See 'Damage control' above.)

Once stabilized, the patient is brought back to the operating room for reconstruction (figure 12 and figure 13). (See "Surgical resection of lesions of the head of the pancreas", section on 'Gastrointestinal reconstruction'.)

POSTOPERATIVE CARE AND FOLLOW-UP — The necessary postoperative care and follow-up depends on the extent of surgery and the presence of any postoperative complications. Patients with multiple injuries may have initial damage control surgery and thus will require second-look laparotomy and open abdominal management, which is reviewed separately. (See "Management of the open abdomen in adults".)

Peripancreatic drains should be monitored for rate of output and amylase or lipase levels to evaluate progression of the pancreatic leak.

Postpyloric enteral feeding is preferred for nutrition support, and so placement of a nasal jejunal feeding tube or feeding jejunostomy should be considered at the time of surgery for patients with severe injury. (See 'Nutrition support and enteral access' above.).

Postoperative care and follow-up of patients who have undergone pancreatic resection is reviewed separately, but a key area is the evaluation for endocrine and exocrine pancreatic dysfunction. (See "Surgical resection of lesions of the head of the pancreas", section on 'Postoperative care and follow-up' and "Surgical resection of lesions of the body and tail of the pancreas", section on 'Postoperative care and follow-up'.)

MORBIDITY AND MORTALITY — For pancreatic trauma, approximately half of deaths occur early in the course related to bleeding and hemorrhagic shock, and approximately half of deaths occur late and are related to complications such as pancreatic fistula formation, sepsis, and multiorgan failure [7]. Morbidity and mortality increases with increasing grade of injury [4,8,14,16,39,52,104,115-121]. The rate of late infectious complications is high even when the injury is identified early.

In a review of 76 case series describing nearly 5000 patients, the mortality rate attributed to pancreatic injuries was 20 percent for penetrating injury and 19 percent for blunt injury [7]. In a later review of pancreatic injuries from the National Trauma Data Bank, mortality rates were also similar at 21.2 percent [4]. Independent predictors of death included age ≥70 years, injury severity score ≥15, Glasgow Coma Scale motor <6, gunshot wound, and presence of associated injuries.

Complications of pancreatic injury — Complication rates for pancreatic injuries range from 24 to 50 percent [15,71,78,122-125]. Complications include pancreatic fistula, pancreatic pseudocyst, intra-abdominal abscess, and post-traumatic pancreatitis, often due to missed or delayed diagnosis of main pancreatic ductal injury. Postresection pancreatic insufficiency can develop with more than 90 percent of the pancreas removed. (See "Surgical resection of lesions of the body and tail of the pancreas", section on 'Perioperative morbidity and mortality' and "Surgical resection of lesions of the head of the pancreas", section on 'Perioperative morbidity and mortality'.)

In addition, erosion of adjacent tissue by pancreatic enzymes can result in pseudoaneurysms, and rarely, massive spontaneous bleeding from splenic, gastroduodenal, and hepatic arteries. (See "Overview of visceral artery aneurysm and pseudoaneurysm" and "Treatment of visceral artery aneurysm and pseudoaneurysm".)

The impact of a missed diagnosis of pancreatic injury on morbidity and mortality is difficult to determine because injuries not initially apparent on computed tomography (CT) are often diagnosed subsequently at exploratory laparotomy performed for other indications [115,126-128]. In addition, missed blunt pancreatic injuries tend to occur in patients who have other severe injuries, from which the patient often succumbs.

Pancreatic fistula — Pancreatic fistula is the most common complication of a pancreatic injury. The incidence ranges from 5 to 37 percent of patients [15,45,78,93,124]. Pancreatic fistulas can be demonstrated with CT or cholangiopancreatography (endoscopic retrograde cholangiopancreatography [ERCP] or magnetic resonance cholangiopancreatography) (image 2). Nonoperative management includes initial bowel rest and parenteral nutrition. Enteral nutrition can be initiated in patients with low-output fistulas provided the fistula output does not increase. Octreotide administration does not increase the rate of healing, but it does decrease the amount of fistula output, which may be useful in patients with high-output fistulas with hypovolemia and electrolyte abnormalities [15]. Patients with persistent fistulas may require reexploration [76].

Pancreatic pseudocyst — The incidence of pancreatic pseudocyst formation is approximately 30 percent following blunt pancreatic injury [129]. Early management consists of percutaneous drainage of fluid collections and treatment of infectious complications. Late management is like that of nontraumatic pseudocysts. Options include endoscopic retrograde cholangiopancreatography with pancreatic duct stenting [129,130], internal drainage, external drainage, and resection [76,129]. If pancreatic pseudocyst occurs and is not infected or not clinically debilitating in causing obstruction, delaying intervention (external drainage) is recommended, as the majority resolve. (See "Approach to walled-off pancreatic fluid collections in adults" and "Endoscopic interventions for walled-off pancreatic fluid collections".)

Intra-abdominal abscess — Intra-abdominal abscess occurs in 7 to 18 percent of patients with pancreatic injuries [61,71,124]. Most post-traumatic intra-abdominal abscesses can be treated with percutaneous drainage. The need for open surgical drainage is uncommon. (See "Antimicrobial approach to intra-abdominal infections in adults".)

Post-resection pancreatic insufficiency — In general, a healthy pancreatic gland can be resected at the mesenteric vessels (ie, pancreatic head resection or pancreatic tail resection) with low risk of developing diabetes [131-133]. Resection of greater than 90 percent of the pancreatic gland will result in both insulin-insufficiency as well as digestive enzyme insufficiency. The risk of diabetes is directly proportional to the amount of gland resected, but also depends on the patients' natural tendency towards diabetes, including age, body mass index, and pre-injury hemoglobin A1c level [134]. Postoperative glucose control and postdischarge monitoring is required. (See "Total pancreatectomy", section on 'Endocrine replacement' and "Total pancreatectomy", section on 'Exocrine replacement'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Traumatic abdominal and non-genitourinary retroperitoneal injury".)

SUMMARY AND RECOMMENDATIONS

Incidence and risk – Traumatic injury to the pancreas is infrequent, occurring in <1 percent of all trauma patients and <5 percent of patients with abdominal injury. Blunt injuries, which are typically caused by motor vehicle crashes, are more common among patients who present to a trauma center in the United States, but penetrating injuries may be more common overall. The pancreas is rarely injured in isolation. (See 'Injury mechanism' above and 'Associated injuries' above.)

Clinical features and diagnosis – Suspicion for pancreatic injury should be increased with any direct blow or crushing impact to the abdomen or any implement that traverses the mid- to upper abdomen. The diagnosis of pancreatic injury can be challenging; low-grade injuries and pancreatic ductal injuries can be missed on initial abdominal computed tomography (CT), and repeat imaging may be necessary. Cholangiopancreatography (endoscopic or magnetic resonance) may be required when pancreatic ductal injury is suspected. For patients with indications for abdominal exploration, retroperitoneal bile staining or peripancreatic fluid/hematoma indicate the need to explore the pancreas. (See 'Clinical evaluation' above and 'Pancreatic imaging' above and 'Abdominal exploration' above.)

Pancreatic injury grading – The American Association for the Surgery of Trauma (AAST) pancreas injury scale is commonly used to classify pancreatic injury (table 3). The severity of injury is estimated based upon findings of abdominal CT or more definitively during operative exploration and correlates with the presence of associated injuries and increasing rates of morbidity and mortality. (See 'Pancreas Injury grading' above.)

Conservative management – For hemodynamically stable patients with low-grade (I or II) blunt pancreatic injury (ie, contusion/laceration without pancreatic ductal injury) determined with certainty by imaging studies and with no other indications for abdominal exploration, we suggest initial conservative management, rather than pancreatic intervention or repair (Grade 2C). Conservative management includes bowel rest and nutrition support (enteral preferred). Most low-grade blunt pancreatic parenchymal injuries heal without surgical intervention. Conservative management is not advised for penetrating mechanisms. (See 'Role of conservative management' above.)

Operative management

Parenchymal injury – When parenchymal pancreatic injuries require operative intervention, relatively simple surgical techniques are often all that is needed. These include debridement of devitalized tissue, local repair of lacerations, and closed-suction drainage. (See 'Parenchymal injury without ductal injury' above.)

Pancreatic ductal injury – The surgical management of pancreatic ductal injuries depends on the location of the injury. Injury to the distal main pancreatic duct (ie, to the left of the superior mesenteric vein [SMV]) is managed with distal pancreatectomy. Injury to the proximal main pancreatic duct (ie, to the right of the SMV) can often be managed with selective debridement and extensive drainage; however, more complex techniques may be necessary, particularly if the duodenum is also injured. (See 'Pancreatic ductal injuries' above.)

Complex injury – High-grade injuries to the pancreatic head or severe combined injuries of the duodenum and pancreas are managed with staged resection (pancreaticoduodenectomy) and reconstruction. After an interval during which the patient is resuscitated, the patient is returned to the operating room for reconstruction (Whipple procedure). (See 'Combined pancreaticoduodenal injuries' above.)

Complications and mortality – Mortality is related to the severity of the pancreatic injury and associated injuries (liver, major abdominal vasculature). Complications are common and include pancreatic fistula, pancreatic pseudocyst, and intra-abdominal abscess. These complications can usually be managed without the need to return to the operating room. The incidence of late infectious complications is high even when pancreatic injury is diagnosed and treated in a timely fashion. Post-resection pancreatic insufficiency can occur following resection of greater than 90 percent of the pancreas. (See 'Morbidity and mortality' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Ronald Jou, MD, Susan I Brundage, MD, Paul M Maggio, MD, MBA, FACS, and Damon Clark, MD, who contributed to earlier versions of this topic review.

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Topic 116260 Version 9.0

References

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