Presentation on theme: "Pancreatic Injury Dr HK Leung Queen Elizabeth Hospital"— Presentation transcript:
1 Pancreatic Injury Dr HK Leung Queen Elizabeth Hospital Joint Hospital Surgical Grand Round
2 Pancreas Retroperitoneal organ Divided into uncinate process, head, neck, body and tail with respect to SMA and SMVTip of tail extends to splenic hilum
3 Pancreatic injury 6 – 7 % of blunt trauma Overall mortality of 20% Commonly associated with multiple injuriesCompounds an already high mortality rateLess common because of its retroperitoneal location, but with subtle symptom and sign, diagnosis and management often delayedErosion of adjacent vascular and visceral structureAssociated injury: duodenum and vascular structure
4 Mechanism of injury Blunt injury Penetrating injury Direct force across the upper abdomenSeat belt, steering wheel and handlebar of bicycle / motorcyclePenetrating injuryStab and gunshot woundBlunt trauma: Part of pancreas injured at left of PV / SMV, associated injuries1/3 blunt injury
5 Diagnostic challenge Before the era of CT scan Physical examination USG or peritoneal diagnostic lavageSerum amylaseJones reported one third of the 400 pancreatic injuries had normal serum amylase level1Progressive rise over 24 to 48 hours strongly suggest injury and mandates further investigation1.) Management of pancreatic trauma. Ann Surg, May 1978AXR: Fracture lumbar spine, retroperitoneal air bubbles along psoas / kidney; displacement of stomach and T colon, generalized ground glass appearanceLimitation of PDL fluid to lesser sacPancreatic lesion missed on USG due to retroperitoneal location and overlying T colon, gastric bubble and duodenum, obesity, subcutaneous emphysemaAkhrass: pancreatic trauma: a ten year multi institutional experience: 400 cases, 82% with raised amylase (1997)Bradley: all patient had raised amylase after 3 hours in pancreatic trauma (1998)Isolated brain injury can also cause increased serum amylase level, also in duodenal, small, bowel, hepatic trauma lung injury, rupture of stomach, alcohol intoxication, acute renal failureDelay = increased mortality90% of injury would ultimately develop increased serum amylase levelLevel not in proportion to severity of injury
6 Investigation To identify main pancreatic duct injury Computed tomographyERCP / MRCPExploratory laparotomyCT: extraperitoneal fluid; fluid in lesser sac, arterial pararenal space, between splenic vein and pancreatic parenchymal space, pancreatic edema, hematoma, fracture and thickening of anterior renal fasciaNormal initial findings does not exclude pancreatic injuryERCP + non contrast CT for extravasation
7 Computed tomography 3 weeks after injury 2 months after injury M/23 RTA victimLUQ: swollen hypo enhancing ill - defined pancreatic headLLQ: Lacerated pancreatic head – uncinate process regionF/26, go kart injury, treated with drainageRight: hypodense non – enhancing area at pancreatic neck with surrounding hypodense peripancreatic fluid with subsequent CT: linear hypodensity corresponding to previous laceration3 weeks after injury2 months after injury
8 Computed tomography Pancreatic fracture, edema or hematoma Fluid between splenic vein and pancreatic parenchymaIncreased attenuation of fat around pancreasExtraperitoneal or lesser sac fluidThickening of anterior renal fasciaFluid in pararenal space, transverse mesocolon, lesser sac and around SMAHemorrhage into peripancreatic fat, mesocolon and mesentryDuodenal hematoma / lacerationLeft kidney / adrenal gland / spleen injuryChance fracturePancreatic ductal dilation and pseudocyst formation
9 ERCP / MRCPERCPLocalize ductal injury by contrast extravasation or cutoffTherapeutic role of stentingLimit to stable cases without associated injuryMRCPNon invasiveNot therapeuticERCP has been used more frequently to assist in diagnosisIf CT scan is equivocal or a small parenchymal laceration is present, ERCP is the most reliable method to define continuity of the main pancreatic duct accuratelySuggested in all patient treated conservatively and with delayed presentationLocalize the injury to plan treatmentComplicates pancreatitis, cholangitis, sepsis, GIT injuryMRCP for patient who had pancreatic fistula complicated drainage or pancreatic fistula who had pyloric exclusion, unreliable early after injury, but good for chronic stage
10 Exploratory laparotomy Establish the continuity of the main pancreatic ductComplete visualization with hematoma exploredDuctal injuryDuctal injury unlikely in the absence of parenchymal disruptionExtensive fat necrosis in lesser sacIntraoperative ERCP / USGAdministration of secretin to observe clear fluid from injured ductTaken emergently to the operating room for abdominal trauma (unstable, stab injury)Secretin (1 unit / kg)Head and neck of pancreas - Kocher maneuverBody of pancreas - Gastrocolic omentum & retroperitoneumTail of pancreas - Gastrocolic omentum & spleenLesser sac fluid collection, retroperitoneal bile staining, overlying hematomaIntraoperative criteria of main pancreatic duct injury: complete transection, laceration of more than half, central perforation, severe macerationOther than integrity of duct, presence of devitalised pancreatic head or duodenum, extent of duodenal injury, integrity of ampulla and bile duct, concomitant vascular injuryIntra operative cholangiogram via cystic duct, CBD or duodenum
11 Management Surgical intervention Conservative management Role of ERCP Presence or absence of main pancreatic duct injuryLocation and severityCo - existing abdominal injury (inc. concomitant duodenal injury)Hemodynamic status (damage control surgery)Conservative managementSerial physical examination and investigationChange of condition mandates further managementRole of ERCPOctreotide: some studies report that it can prevent pancreatic complication; mainly use as to treat fistula
12 Management Indication for surgery Damage control surgery Peritonitis HypotensionEvidence of disruption of the pancreatic ductDamage control surgeryControl of bleeding and bowel contaminationComplex procedure after patient stabilized (e.g. anastomosis)hypothermic, acidotic, or coagulopathic,
13 American Association of the Surgery of Trauma Pancreas Injury ScaleGrade Type of Injury Description of Injury I Hematoma Minor contusion without duct injury Laceration Superficial laceration without duct injury II Hematoma Major contusion without duct injury or tissue lossLaceration Major laceration without duct injury or tissue lossIII Laceration Distal transection or parenchymal injury with duct involvementIV Laceration Proximal transection or parenchymal injury involving ampulla(Proximal pancreas is to the patients’ right of the SMV)V Laceration Massive disruption of pancreatic head*Advance one grade for multiple injuries up to grade III
14 Grade I and II External drainage Repair of laceration with tacking of viable omentum or suturingLaceration oversewn often result in necrosis leading to fistulaClosure of capsule laceration might complicate pseudocystDrainage and debridementSuspected ductal injuryOpen duodenum, retrograde pancreatogram or omental pedicle with closed suction system
15 Grade I and IIJuan et al reported 35 cases of pancreatic injury managed conservativelyExclude initial emergency laparotomy due to unstable hemodynamic status, evidence of peritonitis or associated injuryGrade I – 12 patients; Grade II – 23 patientsFailure of conservative management defined as subsequent exploratory laparotomy or development of pancreatic complication1 out of 12 in Grade I (Missed bowel injury)4 out of 23 in Grade II (3 pancreatic abscess and 1 liver injury)Mortality2 patients died of pulmonary embolism and myocardial infarct (both in conservative management group)Selective nonoperative management of low-grade blunt pancreatic injury: are we there yet? J Trauma. July 2008 USA.Especially in case which initial laparotomy is not performedNon operative management of solid organ injuries is the recommended treatment in hemodynamically stable patientsAt least a ERCP to rule out ductal injury
16 Grade III Hemodynamically stable patient, especially in children Distal pancreatectomy with splenic salvageHemodynamically unstable patientDistal pancreatectomy with splenectomy
17 Grade IV External drainage Roux-en-Y distal pancreatojejunostomy Hemodynamically stableTransection of the pancreas at the neck or just to the right of the mesentericAnterior Roux-en-Y PancreatojejunostomyIn the rare patient, a penetrating wound through the pancreatic duct at the head of the pancreas preserves the parenchyma posterior to the transected duct.In these cases, several investigators have recommended performance of an anterior Roux-en-Y pancreatojejunostomy.
18 Grade IV ERCP + stenting Hemodynamically stable patients with isolated proximal ductal injuriesLin et al reported 6 case of ductal injury13 cases of Grade III and 3 cases of Grade IV1 died after distal pancreatectomy4 recovered with ductal stricture1 stent dislodged and defaulted follow up1.) Long-term results of endoscopic stent in the management of blunt major pancreatic duct injury Surg Endosc. Oct 2006 OctDuctal stricture required prolonged stenting
19 Grade V Pancreatoduodenectomy 2 stage procedure with anastomosis at reoperation within 48 hourStomach, jejunum, pancreatic stump and CBD ligated and drained
20 Combined pancreaticoduodenal injury Complete exposure of duodenum and pancreas with hematoma and bile staining area exploredIntegrity of Common bile duct, pancreatic duct, ampulla and duodenumVaries from simple repair and drainage to complex surgical proceduresDamage control surgery and diversion proceduresChoice of procedure based on the extent of the pancreatic and duodenal injuries, the hemodynamic status of the patient, and the expertise of the surgeon.Complex repairThe pancreatic injury can be treated with the omental pancreatorrhaphy, distal pancreatectomy, or a Roux-en-Y distal pancreatojejunostomy.A duodenal injury may require a transverse duodenorrhaphy, resection with end-to-end anastomosis, or Roux-en-Y jejunal limb to repair (mucosa-to-mucosa) a large defect in the wall of the duodenum.In approximately 25% of the patients with combined pancreatoduodenal injuries, small duodenal injuries can be repaired primarily and moderate injuries to the pancreas can be widely drained
21 Complication Intra-abdominal abscess Pancreatic fistula Pseudocyst PancreatitisDuctal stricture (after stenting)Peripancreatic / parenchymal abscessHemorrhage secondary to infected retroperitoneal autodigestion, embolisation or OTPancreatic fistula: (low < 200ml per day/ high > 500ml per day) leakage of pancreatic fluid over 2 weeks in duration, usually resolve with drainage, or else ERCP and stenting, then operationPseudocyst: main determinant as integrity of duct; internal stent or OTPancreatitis: upstream secondary to fibrous formation or post – traumatic;
22 Take home messageThe integrity of the main pancreatic duct is key in the management and outcome of patients with pancreatic trauma.ERCP has been used more frequently to assist in diagnosis and, on occasion, for definitive management of ductal discontinuity in patients with contraindications to laparotomy.Early operative intervention is warranted in most patients with confirmed or suspected ductal injury.The integrity of the main pancreatic duct is key in the management and outcome of patients with pancreatic trauma.Simple external drainage and distal pancreatectomy are commonly performed operative procedures and have a favorable outcome most of the time.Pancreatoduodenectomy is indicated in those select patients with extensive combined pancreatoduodenal injuries who are hemodynamically stable with few associated injuries.Post-operative complications after repair of major pancreatic injuries include intra-abdominal abscesses, postoperative fistulas, and an occasional pancreatic pseudocyst. Many of these complications may be treated successfully without re-operation.
25 Classification of pancreatic injuries by ERCP GradeDescriptionINormal main pancreatic duct on ERCPIIaInjury to branches of main pancreatic duct on ERCP with contrast extravasation inside the parenchymaIIbInjury to branches of main pancreatic duct on ERCP with contrast extravasation into the retroperitoneal spaceIIIaInjury to the main pancreatic duct on ERCP at the body or tail of the pancreasIIIbInjury to the main pancreatic duct on ERCP at the head the pancreasData from Takishima T, Hirat M, Kataoka Y, et al. Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas. J Trauma 2000;48:745–52.
26 Diversion procedure Pyloric exclusion with gastrojejunostomy Duodenal diverticulization“Triple-tube” approach
27 Pyloric exclusion with gastrojejunostomy The pyloric muscle ring is closed with a number 1 polypropylene suture through a dependent gastrotomy.Antecolic gastrojejunostomy is then performed using this gastrotomy.
28 Duodenal diverticulization Truncal vagotomyAntrectomy with gastrojejunostomyDuodenal closureTube duodenostomyDrainage of the CBDExternal drainage
29 “Triple-tube” approach Placement of a gastrostomy tube for proximal decompressionRetrograde duodenostomy tube inserted by way of the jejunum for decompression of the repaired duodenumAntegrade jejunostomy tube for enteral feeding