Operative Choice and Technique Following Pancreatic Injury Anane-Sefah, MD;

John

Lawrence W.

Norton, MD; Ben Eiseman,

During a five-year period, 50 patients were operated on for pancreinjury. Forty had open trauma and ten closed. Half of each group were treated by drainage alone. Overall mortality was 14%, with all deaths following open injuries due to gunshots. Deaths were more frequent after drainage than after resection. Substantial complications occurred in 70%, with more frequent and more serious morbidity in drained patients. Sump drainage was associated with less morbidity than Penrose drainage. Guidelines for management of pancreatic trauma are (1) resection of sinistral gland for perforating injuries of the body or tail; (2) drainage of perforations of the pancreatic head when the major duct is intact; (3) resection of duodenum and pancreatic head for devitalizing injury of both structures. atic

and operative skill are required to maximum benefit with minimum risk follow¬ pancreatic injury. Trade-off values in each direction

judgment Bothachieve

ing are

inordinately important.

This is

a review of treatment principles based on a fiveexperience at the Denver General Hospital with 50 patients who required laparotomy for pancreatic injury. It emphasizes the value of aggressiveness in managing seri¬ ous wounds of both proximal and distal segments of the

year

MD

lives are saved by immediate laparotomy, salvaging many patients with major wounds of the aorta and vena cava who might otherwise bleed to death while obtaining the benefits of precise angiographie localization of their upper abdominal injury. At lap¬ arotomy, the entire pancreas is visualized through the divided gastrocolic ligament and the lesser sac. more

Site of

pancreas.

Table 1.—Site and Type of Pancreatic Injury in 50 Patients*

CLINICAL EXPERIENCE All

patients requiring operative intervention for injury of the

Head

pancreas between July 1968 and July 1973 were reviewed. There were 50 such patients during the 60 months. Forty (80%) were penetrating wounds and ten (20%) followed blunt trauma. Of the 40 open wounds, 35 were gunshot wounds and five stab

wounds. Stabbings gradually are decreasing in frequency, as gun¬ shot injuries increase in this hospital population. Average time in¬ terval between open injury and hospitalization in our Emergency Department was 28 minutes, an important factor in management of large vessel injuries and a tribute to Denver's Emergency Med¬ ical System. Thirty-six of the 40 patients with penetrating injuries were male, with an average age of 35 years. Of the ten patients requir¬ ing operation for blunt trauma, nine were injured in vehicular ac¬ cidents. Average age of these patients was 37 years. Mean time between injury and beginning of laparotomy was one hour and 40 minutes. During this time the usual resuscitative routines, including roentgenographic and pyelographic studies, were performed. With our hospital practically on the edge of the Denver combat zone, we seldom resort to diagnostic angiography in open or closed abdominal injuries. Experience dictates that far

Accepted

for publication Aug 8, 1974. From the Department of Surgery, Denver General Hospital and Univerof Colorado School of Medicine, Denver. sity Reprint requests to Department of Surgery, Denver General Hospital, Denver, CO 80204 (Dr. Norton).

Injury

Open Injuries.—The head of the pancreas was injured in 17 pa¬ tients (42%), the body in seven (18%), the tail in 12 (30%), and mul¬ tiple sites in four (10%). Types of injury are itemized according to site in Table 1. The gland was perforated, lacerated, or fractured in 85% of patients with open injuries. The majority of patients had substantial injuries of other or¬ gans, as shown in Table 2. Three quarters had hemorrhage from major (named) vessels, including the aorta and vena cava, at the time of laparotomy. The liver was injured in 59%, the spleen in 38%, and the stomach in 41%. Each of the pancreatic visceral neighbors, including kidney and spinal cord, were variously in¬ volved. Forty-one percent of the open wounds penetrated the dia¬ phragm.

Open injuries v

„,

'

....

Closed injuries

J Contusion

| Perforation

j Contusion < ,

I Perforation 0

..

Body

2 2 15 5 10" 2 2

Tail

Multiple

2 0 10 4 01 r , 3 1

_

*

Majority of open (85%) and closed (80%) injuries involved perforation, laceration, or fracture of gland. Table

2.—Injuries Associated With Pancreatic Trauma* Pancreatic _

Associated Injury

Major vessel Liver Stomach

Diaphragm Spleen Small intestine Colon Duodenum

Kidney/ureter Biliary tract Spinal cord

Open 77 59 41 41 38

Injury, %

_

Closed 10 40

50

28 28 18 18 8 10

20 20 10

* In majority of patients with either open or closed pancreatic in¬ jury, substantial injury of nearby abdominal structure occurred.

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Table

3.—Operative Treatment of Pancreatic Injuries Drainage

Site

13 4 2

Head

Body

Open injuries

Tail

Multiple

1

Resection 4 3 10 3

Table

Incidence, %

Complication Sepsis Pancreatitis

Head

Pseudocyst

Body

Closed injuries

6.—Complications After Closed Pancreatic Injury* Overall 50 40 20

After

Drainage After Resection 80 80 40

20

40

40

Fistula

Tail

Hemorrhage

Multiple

Other

40

*

Table 4.—Deaths Patient

Table

Following Open Pancreatic Injury

Site of Injury Head Head Head Head Head Body and tail Tail

Cause of Death

Operation Drainage Drainage Drainage Drainage Drainage

Sepsis Sepsis Sepsis Sepsis Sepsis Hemorrhage Respiratory distress

Resection Resection

5.—Complications

Open Pancreatic Injury*

After

Incidence, %

Complication Sepsis

Overall 55

Hemorrhage

18

Fistula Pancreatitis

13 13

Pseudocyst Other

10

After

Drainage After Resection 60 15 15 10 15

50 10 10 10

Twenty-seven of 40 patients had serious morbidity following open pancreatic trauma. Incidence of such complications was quite similar in patients treated by resection and by drainage, although severity of sepsis was generally greater among the latter. *

Injuries.—The head of the pancreas was the primary site in three patients. Seven others with closed pancreatic trauma had wounds of the body or tail (Table 1). The gland was fractured in eight patients and severely contused in two. Eight of the ten patients (80%) had injury to organs adjacent to the pan¬ creas (Table 2). The spleen was ruptured in five (50%) and the liver in four (40%). Only one patient had major vessel damage, in con¬ trast to the open injury group. Closed

of

injury

Operative Treatment Open Injuries.-Among

40 patients with open pancreas trauma, treated by drainage alone and 20 by resection and drain¬ age (Table 3). Six of the 20 (30%) patients who were drained had sump drains in place for seven to ten days. The others were drained with soft rubber (Penrose) drains that were removed be¬ tween ten and 14 days postoperatively. Drainage was used exclu¬ sively in managing 13 of 17 (76%) injuries of the head of the pan¬ creas and in only two of 12 (17%) injuries of the tail. Four (57%) wounds of the body were drained, and one of the four patients with multiple sites of damage had drainage alone. In 16 of the 20 resected patients, pancreas to the left of the por¬ tal vein was excised. The others had pancreaticoduodenectomy. Drainage after resection utilized sumps in seven and Penrose drains alone in 13 patients.

20

were

Eight of ten patients had substantial morbidity after closed pan¬ creatic injury. Incidence of sepsis, pancreatitis, and pseudocyst was greater after drainage than after resection.

equal number of patients with blunt pancre¬ by drainage alone (five) and by resection (five) (Table 3). Drainage was the sole treatment in four of seven patients with mid- or distal pancreatic injury and in one of the three patients with closed injury of the head. Sump drains were used in all but one of the patients who were drained. Resection was used for distal disease in three and for injury of the head in two patients, each of whom underwent pancreaticoduodenectomy. Closed Injuries.—An

atic trauma were treated

Mortality Open Injuries.—Of the 40 patients with open injuries, seven died (mortality, 18%). All deaths followed gunshot wounds. Table 4 summarizes details of the injuries that resulted in death and the operative techniques employed. Five deaths followed wounds of the head of the pancreas, all of which were drained. The other two deaths were from open injury to the body and tail, both of which were resected. The patient who died following resection of the body and tail of the pancreas had several other organs injured and did not die as a result of his pancreatic injury alone. The cause of death was sepsis in those who underwent only drainage. Closed Injuries.—Of ten patients operated on for blunt pancre¬ atic injury, none died postoperatively.

Morbidity Only 17 (34%) of the entire group of 50 patients had a complica¬ tion-free hospital stay. Open Injuries.-Twenty-seven of the 40 patients had at least one major complication (morbidity, 68%) (Table 5). Sepsis was the most frequent complication (50%). One patient died suddenly of massive hemorrhage during the early postoperative period. Six others bled briefly from drain sites but required no transfusion. Pancreatitis was diagnosed in five patients, fistula in an equal number, and pseudocyst in two patients. Morbidity unrelated to the pancreas included delirium tremens (three) and wound dehis¬ cence (one). The incidence of complication was similar in patients who had undergone drainage and resection, although the severity of sepsis was generally greater among those who had only under¬

gone drainage. Closed Injuries.—Only two of ten (20%) patients with blunt pan¬ creatic trauma had no postoperative complication. Each of these two patients underwent resection of distal gland. Complications among both patients who had been resected and those who had been drained with closed wounds are listed in Table 6 and include sepsis, pancreatitis, pseudocyst, phlebitis, and delirium tremens. One patient who had been drained required evacuation of a sub¬ phrenic abscess. Since operative treatment depends mainly on the extent and

pancreatic injury, cordingly. site of

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our

clinical

experience is analyzed

ac¬

Open Injury of Head Without Duodenal Injury

Open Injury to

4

0 Resected

9 Drained Died 3

Complication

9

/ \ Complication

Died

Fig 1.—Nine patients had open injury of head of pancreas without duodenal involvement. All underwent drainage and had postopera¬ tive complications; three died.

Repaired and Drained

Died 2

Complication

Open.—Fifteen

of the 17 open injuries to the head of the pan¬ caused by gunshots. In 14 patients, either the aorta, vena cava, or superior mesenteric vessels were lacerated and in 12 the liver was injured. The duodenum was damaged in eight pa¬ tients and the biliary tract in three. Open wounds of the pancreatic head were treated by drainage primarily (13) or by resection with drainage (four). Perforation of the head of the gland with associated injury of the duodenum was drained in four patients and resected by means of pancre¬ aticoduodenectomy in four others. All contusions, lacerations, and fractures of the head of the pancreas were drained with (two) or without (seven) tube duodenostomy. Results of drainage versus resection in open injuries of the head of the pancreas are shown in Fig 1 and 2. All resected patients survived with minimal morbidity and no long-term evidence of pancreatic endocrine or exocrine deficiency. By contrast, among the 13 patients considered to have less severe injury not requiring resection, mortality was 39% (five patients) and morbidity was 100%, including pancreatic fistula and pseudocyst formation. Closed-Three of ten patients with blunt abdominal trauma had injury of the head of the pancreas (Fig 3). In two, the second por¬ tion of the duodenum was virtually destroyed, necessitating pan¬ creaticoduodenectomy. The third had less severe damage to the pancreas and no duodenal wound. Treatment in this case was by drainage alone. All three patients survived closed injury to the pancreatic head. The patient who underwent drainage developed a pseudocyst that was drained internally four weeks after trauma surgery. He sub¬ sequently had transient leakage of pancreatic juice through the abdominal wound. It appears from this brief experience that closed injuries of the head of the gland are well treated by resection as opposed to creas were

drainage.

4 Resected

Died 0

(Whipple

Complication

1

Fig 2.—Among patients with combined open injury of duodenum and head of pancreas, four underwent drainage (two deaths) and four resection (no deaths).

Injuries Injuries of the Head

4

Head and Duodenum

of the

Body

and Tail

Open.—Figure 4 illustrates operative results in 23 patients who had open injuries of the body or tail. All of the pancreas to the left of the injury was resected in 16 patients. Of these, two died and four (25%) had major postoperative complications ascribable to the pancreatic injury. One death, however, was due primarily to respiratory distress. The other, caused by massive hemorrhage within 24 hours, was attributable to resection. In contrast, seven patients with less severe penetrating injuries were treated by drainage only. None of these died, but all had a major complication ascribable to the pancreatic injury. This suggests that major penetrating injuries of the body and tail of the pancreas are best treated by resection and not by drain¬ age alone in terms of lessening postoperative morbidity. None of the patients resected to the left of the superior mesenteric vein had endocrine or exocrine pancreatic insufficiency. Nothing was lost by excising superfluous gland. On the other hand, failure to resect damaged pancreas led to serious complication in several patients.

Closed.—There were seven patients with blunt injury of the body and tail of the pancreas. Of these, three were treated by re¬ section and four by drainage only. None of these patients died, but complications in patients who had undergone drainage were more frequent and severe than in those who had undergone resection (Fig 5). It appears, then, that injuries of the body and tail, whether from blunt or open injury, are best treated by sinis¬ trai resection.

Overall Results

patients who underwent exploratory surgery for closed pancreatic injury, seven (14%) died postop¬ open eratively and 35 (70%) developed major complications. Mortality was greater among patients treated by drain¬ age (20%) than among patients treated by resection (8%). Similarly, more patients treated by drainage (90%) had complications than patients treated by resection (48%). Of 50 or

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Closed

Injury to Head

Injury

Closed

and Duodenum

to

Body and Tail

3 Resected

4 Drained

\

/ Died 0

/

Complications

Died 0

Few

¿/

1 Drained

2 Resected

/ \ Died 0 Complication 1

/ \ Died 0

Complication

0

Fig 3.—Three patients survived after blunt trauma to head of pan¬ Associated duodenal injury in two necessitated pancre¬ aticoduodenectomy. to

Numerous

Fig 5.—Of seven patients with closed injury of body and tail, three treated by resection and four by drainage alone. Complications

were

creas.

Open Injury

\ Complications

Body and Tail

were more common

among the latter.

nal column. Frequently when the pancreas is injured, so too is a visceral neighbor. In such a crowded anatomic ghetto, the surgeon seldom finds an isolated injury of the pancreas and seldom can resect the gland without sacri¬

repairing

important adjacent structure. complicated by the inordi¬ nately expensive endocrinologie cost of removing the whole pancreas. Finally, if pancreatic juice once gets loose in the peritoneal cavity following injury, complications such as abscess, fistula, and hemorrhage become dreadful possibilities. There is no wonder that surgeons plot an operative course that will minimize subsequent mortality and mor¬ bidity for a patient with open or closed pancreatic trauma. Despite such efforts, published mortalities range from 20% ficing

or

some

Pancreatic surgery is further

to 16 Resected

Died 2 Complication 4

7 Drained

/ \ Complication

Died 0

7

Fig 4.—Open injuries of body or tail of pancreas were treated by drainage alone in seven patients and by resection in 16. All patients treated by drainage had at least one major complication; two pa¬ tients treated by resection died. The morbidity after sump drainage (36%) was less than after Penrose drainage (64%) in those patients who were

treated

only by drainage.

COMMENT

The pancreas is anatomically well protected, as befits an organ whose juices are so corrosive. Unfortunately, it is surrounded in its retroperitoneal recess by organs of a vi¬ tal nature, such as the aorta, vena cava, bile duct, and spi-

39%, and serious morbidity from 25% to 75%. Diagnosis of Pancreatic Injury We explore all penetrating wounds of the abdomen, '-4

not

relying do somer-7 on the possibility of a fortuitously benign missile track. The philosophy to be adopted must take into account the nature of the practice and such fac¬ tors as the reliability of not being involved in another op¬ erative emergency when the signs of intraperitoneal vis¬ ceral damage declare themselves. Missiles entering the back are at least as dangerous as are those entering anteriorly, a dictum well known by sur¬ geons dealing with war injuries8 but often forgotten by those not practicing in high-volume trauma centers. The pancreas tucked in the retroperitoneal space is partic¬ ularly vulnerable to penetrating injuries from the flank. Following blunt trauma, the diagnosis of pancreatic in¬ jury occasionally will depend on serum or peritoneal fluid amylase concentrations. Recently we observed a patient in whom the only signal for laparotomy following blunt trauma from an automobile accident was an abrupt rise in as

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Drain

Contusion

^^-

Laparotomy Perforation

Drain

Resect

Pancreatic Injury

Transection

No

Resect

Perforation

Operation

Debride and Drain

Duct Intact Perforation Duct

Child Procedure Drain Body Into Roux-en-Y

Destroyed

Destroyed

Whipple

Procedure

Roux-en-Y Drainage Perforation *·

Duct Intact Duodenum

Damaged

Duct Intact

Duodenum and Pancreas

Destroyed

Fig 6.—Decisions in operative management of open or closed pancreatic trauma are based on site and type of injury. Generally, resection is advised for injuries to left of portal vein and drainage

for those to

the serum amylase level. Results of diagnostic paracen¬ tesis were normal. The abdomen was soft, except for slight tenderness along the area of the abdomen covered by the seat belt. At laparotomy the pancreas was com¬ pletely transected over the vertebra. The posterior peri¬ toneum was intact, explaining the paucity of intraperito¬ neal signs. Possible pancreatic (and duodenal) injury is but one of several reasons why a posttraumatic retroperitoneal hematoma should be explored. Bile staining, the telltale signal of duodenal or biliary tract rupture, is easy to pick up in the early hours of postinjury, but may be masked by clotted blood or pus thereafter. Delay in diagnosing both pancreatic and duodenal perforation increases mortality

presence of acute

astonishingly."

Assessment of Pancreatic

Injury

Because simple pancreatic contusion can be left unmo¬ lested (or at most be provided with an adjacent drain site through the flank), the surgeon's first duty is to assess the severity of the pancreatic lesion. This is a judgment call, unless there is obvious major duct interruption. Seldom is there need to resort to operative pancreatography in the

Duodenostomy Diverticulize Duodenum

Whipple

Procedure

right, except when duodenum or pancreatic head verely damaged.

are se¬

injury to settle the issue. If the injury is body or tail and is sufficiently deep to raise the pos¬ sibility of ductal damage, the sinistrai gland should be re¬ sected. If there is only superficial contusion, the injury can be ignored or drained through the flank for a few days. The occasional cutaneous fistula following such injury will close spontaneously if there is no proximal duct obstruc¬ in the

tion.

Midpancreas Injury Over

the Vertebra

When pinched between a seat belt and the vertebral col¬ umn, the pancreas can be totally severed, leaving good gland both to the right and to the left. Often there is an associated duodenal or jejunal blowout. Operative options are (1) resection of the gland to the left of the injury; (2) implantation of the duct of the left-hand remnant into a loop of gut; or (3) reanastomosis of the pancreatic duct. The lattermost has nothing to recommend it. It is difficult in a small-caliber, normal-size duct; it is needless because of the reserve function of the intact head; and it is hazard¬ ous because of danger of postoperative extravasation of pancreatic juice. With little detriment and maximum ben¬ efit, resection of the body and tail is the preferred tech-

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on the and exocrine support.

nique, relying

remaining head

Head

for both endocrine

tents, the stump

be turned in and a gastrojejunos¬ et al"1 have termed this "diverticularization" of the injured duodenum. If the common duct is crushed or severed simultaneous with the pancreatic injury, it should be replanted into the duodenum or jejunum. This was performed without inci¬ dent in one of the cases in this series along with repair of the perforated vena cava and closure of holes in the duode¬ num, stomach, and colon. As thus didactically stated, our operative philosophy can be summarized as being extirpatively radical to the left of the superior mesenteric vein but more conservative in management of injuries to the pancreatic head and duode¬ num. This approach is illustrated in the form of a decision tree in Fig 6. can

tomy performed. Berne Injury

Alone

A simple drill-hole, low-velocity missile perforation of the pancreatic head without adjacent organ damage can be treated by conservative debridement and drainage if the pancreatic duct is not involved. There may very likely be drainage of pancreatic juice for days or even weeks, but if there is not proximal obstruction it will cease. Rarely, the patient will return with recurrent discomfort weeks or months later. When the drainage tract is re¬ opened, pancreatic fluid pours out. If a pancreaticogram or visualization of the pancreatic duct through a duodenoscope shows no obstruction proximal to the fistula, the drainage tract will close, even though the patient and sur¬ geon may endure three or more recurrences of premature closure. If serious obstruction proximal to the fistula per¬ sists beyond the period of acute edema, then resection and reimplantation must be considered, but not before a long trial of conservative therapy. Our clinical experience dramatizes the unfortunate de¬ gree of morbidity that follows simple drainage treatment for perforating injuries of the head of the pancreas. This complication rate is somewhat balanced by the advan¬ tages of preserving duodenum and pancreas. Perhaps more attention should be given to resection of the head with preservation of duodenum and distal pancreas im¬ plantation into jejunum in such patients.

Drainage

Method

Anderson et al," Stone et al,12 and Baker et al" report that the use of combined sump drainage and Penrose drainage is clearly superior to Penrose drainage alone in decreasing postoperative complications of pancreatic in¬ jury. Our experience confirms this, and we recommend that sumps placed through flank incisions be used along with Penrose drains in both open and closed trauma. A soft sump drain is maintained for at least one week, while rubber drains remain until ten to 14 days postoperation. This investigation GM20309.

was

supported by National Institutes of Health grant

Smashed Pancreatic Head

When the pancreatic head is widely macerated by either blunt or penetrating trauma, there is, of course, no re¬ course but to resect. Our experience, however, dictates conservatism in interpreting the severity of such damage. If resection is required, decision evolves to either (1) leav¬ ing the duodenal vasculature and the duodenum as in a Child operation or (2) resecting the duodenum as in a Whipple procedure. In either case, the pancreatic body and tail, if intact, should be implanted into a loop of jeju¬ num. In normal pancreas the duct is small and a mucosato-mucosa anastomosis is difficult. The head of the gland should simply be invaginated into an open limb of gut. Pancreatic Head Plus Duodenum

Severe or

damage to the pancreatic head, whether by blunt penetrating trauma, often involves the duodenum or

the common bile duct or both. When the duodenum cannot function as an intestinal or biliary conduit, it obviously should be resected in the manner of pancreaticoduoden¬ ectomy. We treated three patients during the past 24 months who had bullet wounds of the duodenum where closure over a duodenostomy tube permitted preservation of the duodenum. If, after closing the debrided duodenum, it seems hopelessly narrow for transport of stomach con-

References 1. Fogelman MJ, Robinson LJ: Wounds of the pancreas. Am J Surg 101:698-706, 1961. 2. Wilson RG, Tagett JP, Pucelik JP, et al: Pancreatic trauma.

J Trauma 7:643-651, 1967. 3. Werschky LR, Jordan GL Jr: Surgical management of traumatic injury to the pancreas. Am J Surg 116:768-772, 1968. 4. Anderson CB, Weisz D, Rodger MR, et al: Combined pancreaticoduodenal trauma. Am J Surg 125:530-534, 1973. 5. Mason JH: The expectant management of abdominal stab wounds. J Trauma 4:210-218, 1964. 6. Wilder JR, Habermann ER, Schachmer SJ: Selective surgical intervention for stab wounds of the abdomen. Surgery 61:231-235, 1967. 7. Ryzoff RI, Shaftan GW, Herbsman H: Selective conservatism in penetrating abdominal trauma. Surgery 59:650-653, 1966. 8. Poole HL: Wounds of the pancreas (62 casualties), in Coates JB Jr (ed): Surgery in World War II. US Army Medical Department, 1955, vol 11, pp 285-290. 9. Jones RC, Shires GT: The management of pancreatic injuries. Arch Surg 90:502-508, 1965. 10. Berne CJ, Donovan AJ, White EJ, et al: Duodenal "diverticulization" for duodenal and pancreatic injuries. Am J Surg 127:503-507, 1974. 11. Anderson CB, Connors JP, Mejia DC, et al: Drainage methods in treatment of pancreatic injuries. Surg Gynecol Obstet 138:587-590, 1974. 12. Stone HH, Stowers KB, Shippey SH: Injuries to the pancreas. Arch Surg 85:525-530, 1962. 13. Baker RJ, Dippel WF, Freeark RJ, et al: The surgical significance of trauma to the pancreas. Arch Surg 86:1038-1044, 1963.

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Operative choice and technique following pancreatic injury.

During a five-year period, 50 patients were operated on for pancreatic injury. Forty had open trauma and ten closed. Half of each group were treated b...
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