Pancreatic trauma
Traumatic injury to the pancreas is rare and difficult to diagnose. In contrast, traumatic injuries to the liver, spleen and kidney are common and are usually identified with ease by imaging modalities. Pancreatic injuries are usually subtle to identify.
Pancreatic trauma occurs in approximately 4% of all patients sustaining abdominal injuries. The pancreas has an intimate relationship with the major upper abdominal vessels, and there is significant morbidity and mortality associated with severe pancreatic injury. Immediate resuscitation and investigations are essential to delineate the nature of the injury, and to plan further management.
- Abdominal pain that may be widespread or in the upper middle part of the abdomen. Your abdomen may also be tender and hard.
- Bruising, swelling, or scratches over the injured area.
- Fever, nausea (upset stomach), or vomiting (throwing up).
- Trouble breathing.
- Signs of shock, including a fast pulse (heartbeat), low blood pressure, and pale, sweaty skin.
The diagnosis of pancreatic trauma requires a high index of suspicion and detailed imaging studies. Grading pancreatic injury is important to guide operative management. The most important prognostic factor is pancreatic duct disruption and in these cases, experienced hepatopancreaticobiliary (HPB) surgeons should be involved. Complications following pancreatic trauma are common and the majority can be managed without further surgery.
The first priority in pancreatic trauma is to control hemorrhage and to contain bacterial contamination. The other main management priority is the identification of specific pancreatic injury with special attention to the integrity of the ductal system.
Ductal injury is the single most important factor in late morbidity and mortality. Most pancreatic injuries can be managed with closed external drainage. Débridement of devitalized pancreatic tissue adjacent to the fracture site is essential in severe pancreatic injuries. It is important, however, to preserve at least 20% to 50% of functional pancreatic tissue whenever possible. Resection should be accompanied by drainage and duodenal diversion for concurrent pancreatic head and duodenal injuries. If there is only a contusion or laceration without evidence of major duct disruption, suture closure and external drainage usually suffice. Severe injuries of the pancreatic head can be managed according to their appearance on intraoperative pancreatography. If the duct is intact, wide-bore drainage should suffice. If duct injury is demonstrated, a Roux-en-Y diversion may be considered.
However, increased complication rates of up to 60% have been reported in patients with high-grade injuries treated with pancreaticojejunostomy, suggesting that distal pancreatectomy, when feasible, is a superior operative treatment for these patients.
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