Mechanisms of liver injury

Blunt and penetrating trauma are the two principal mechanisms of liver injury. Road traffic accidents account for the majority of blunt injuries, whereas knife and gunshot wounds constitute the major cause of penetrating injuries. In the UK, blunt trauma predominates by a ratio of approximately 2:1 as documented in a large Scottish epidemiological study.¹ Whilst this is typical for other European centres,² it differs from the experience in South Africa, where penetrating injuries account for 66% of liver trauma,³ and in North America, where up to 86% of liver injuries are penetrating wounds.^4,5

Two types of blunt liver trauma have been described – deceleration (shearing) trauma and crush injury. Deceleration injuries occur in road traffic accidents and in falls from a height where there is movement of the liver relative to its diaphragmatic attachments.⁶ Crush injuries are caused by direct trauma to the liver area. The two types of injury may coexist but tend to produce somewhat different types of liver injury. Deceleration or shearing injuries create lacerations in the hepatic parenchyma, typically between the right posterior section (segments 6 and 7) and the right anterior section (segments 5 and 8), which can extend to involve major vessels. In contrast, a direct blow to the abdomen may lead to a crush injury, with damage to the central portion of the liver (segments 4, 5 and 8). Compression between the right lower ribs and the spine may also cause bleeding from the caudate lobe (segment 1). Blunt trauma can rupture Glisson’s capsule and can also lead to subcapsular or intraparenchymal haematoma formation. Penetrating injuries are usually associated with gunshot or stab wounds, with the former usually resulting in more tissue damage due to the cavitation effect as the bullet traverses the liver substance.

Injury to the hepatic veins and juxtahepatic vena cava can occur as a result of shearing stress in blunt trauma. It is worth noting that there may not be initial exsanguinating haemorrhage as the weight of the liver may provide some compression.

Classification of liver injury

The severity of liver trauma ranges from a minor capsular tear, with or without parenchymal injury, to extensive disruption involving both lobes of the liver with associated hepatic vein or vena caval injury. The American Association for the Surgery of Trauma has adopted for general use the classification of liver injury described initially in 1989 by Moore and colleagues, and revised subsequently in 1994⁷ (Table 17.1). The hepatic injury grade is calculated from assessment of the liver injury using information derived from radiological study, operative findings or autopsy report. Where there are multiple injuries to the liver, the grade is advanced by one stage. Grade I or II injuries are considered minor; they represent 80–90% of all cases and usually require minimal or no operative treatment. Grade III–V injuries are generally considered severe and may require surgical intervention, while grade VI lesions are regarded as incompatible with survival. Schweizer et al. have described a protocol-based liver trauma management system employing this classification system that permits lesser injuries to be treated non-operatively and allows more appropriate selection of patients for operative treatment.⁸

The initial assessment and management of an injured patient should proceed according to the Advanced Trauma Life Support (ATLS) guidelines of the American College of Surgeons Committee on Trauma. The initial focus of attention is on the patient’s airway, breathing and circulation. The airway is secured, intravenous access established and fluid resuscitation commenced.

The role of ‘aggressive’ high-volume fluid replacement in trauma victims has been questioned, with evidence suggesting that excessive fluid replacement is associated with adverse outcome.⁹ As this evidence came from an American series that included a large proportion of relatively young, previously fit adults suffering from penetrating trauma to the torso, with ready access to trauma centres, the results may not necessarily be applicable to practice in other countries.

Diagnosis of liver injury

In penetrating abdominal trauma, hepatic injury should be considered in any patient with a wound to the abdomen. Hepatic injury should also be considered in patients with penetrating low thoracic wounds and also in posterior penetrating wounds below a coronal plane at the tips of the scapulae.

Patients with major hepatic injury may present with profound clinical shock and abdominal distension. Hypotension resistant to fluid resuscitation combined with gross abdominal distension is an indication for immediate laparotomy. The operative management options for patients in this situation will be discussed in detail subsequently. Emergency room thoracotomy with cross-clamping of the descending thoracic aorta is a dramatic intervention, but even in centres where this technique is advocated the outcome is poor.

In Feliciano et al.’s series of 1000 patients with liver trauma treated during a 5-year period, 45 patients underwent emergency room thoracotomy for control of haemorrhage related to their liver injury and all died.⁴ Similarly, in an 11-year review of 783 patients who sustained liver trauma in Scotland, 11 patients underwent an unsuccessful laparotomy or thoraco-laparotomy in the emergency room.¹

In less dramatic situations, with a patient who is haemodynamically stable or responds to fluid resuscitation, appropriate investigations can be employed to obtain more information regarding the liver injury and to ascertain whether there is coexisting intra-abdominal visceral injury. During the initial survey a detailed clinical history is taken. Particular attention is paid to the mechanism of a road traffic accident, with supplemental information from ambulance crew, witnesses or police being used to piece together a picture of the accident. Speed of vehicle, position of occupant in vehicle, use of seatbelts, employment of airbag restraint systems and a history of ejection of the patient from the vehicle are important items of information. Conscious patients may complain of abdominal pain. Shoulder tip pain may arise from blood in the subdiaphragmatic space causing phrenic nerve irritation.

As resuscitation proceeds, a detailed physical examination is carried out. On inspection, attention is paid to the presence of anterior abdominal wall bruising, which may indicate compression from a seatbelt, and flank bruising, which may indicate retroperitoneal extravasation of blood. Signs of localised or generalised peritonitis are recorded in the conscious patient. In this context it should be noted that although there is evidence that the use of opiate analgesia will not significantly obscure physical signs in patients with acute abdominal pain, these findings have not been confirmed in abdominal trauma patients where the situation may be complicated by head injury, alcohol intoxication or the requirement for assisted ventilation.

Baseline investigations consist of a full blood count (for haemoglobin and haematocrit), serum urea and electrolytes, serum amylase, a coagulation screen, and blood for crossmatching. An erect chest radiograph and a plain abdominal film can be taken if the patient is sufficiently stable. In the context of diagnosing liver injury, features that may be of relevance include fractures of the lower ribs, elevation of the right hemidiaphragm and loss of the psoas shadow suggesting retroperitoneal bleeding. Retroperitoneal perforation of the duodenum may give rise to soft tissue shadowing in the right upper quadrant, loss of the psoas shadow and occasionally extraluminal gas may be noted.

Following initial assessment, patients who are conscious but have haemodynamic instability resistant to fluid resuscitation and with clinical signs of peritonitis should undergo laparotomy. In patients who are haemodynamically stable and have suspected liver injury, further diagnostic tests may be undertaken at this stage to define the nature of the injuries. An ideal test will establish the presence and extent of any liver injury together with providing information on concomitant visceral injury.

Formerly, diagnostic peritoneal lavage (DPL) was the procedure of choice for the quick diagnosis of haemoperitoneum, particularly in patients with an impaired level of consciousness and equivocal physical signs. However, DPL is invasive and a positive result for blood provides no information regarding either the site or the nature of the injury, and in the context of liver injury may lead to patients undergoing surgery where they may be better treated non-operatively.

An alternative investigation that has been advocated in initial trauma evaluation is focused assessment with sonography for trauma (FAST).¹⁰ This involves ultrasonographic assessment of the pericardium, right upper quadrant including Morrison’s pouch, left upper quadrant and pelvis. This evaluation is not designed to identify the degree of organ injury, but rather the presence of blood. A large meta-analysis of the use of emergency ultrasonography for blunt abdominal trauma reported sensitivity rates ranging from 28% to 97% and specificity rates close to 100%.¹¹

Rozycki et al. demonstrated a significant correlation between haemoperitoneum in the right upper quadrant and injury to the liver, and suggested that adherence to a pre-agreed protocol increased the reliability of ultrasound assessment of abdominal trauma.¹² Other centres have also reported that ultrasound is a reliable ‘first’ test for the assessment of a patient with suspected liver trauma.¹³ However, an important cautionary note comes from the study carried out by Richards et al.¹⁴ In a series of 1686 abdominal ultrasound scans for trauma, 71 patients had bowel or mesenteric injury and 30 patients had a negative ultrasound scan (43% false-negative rate). Limitations of FAST include operator dependence, poor assessment of the retroperitoneum, unreliable detection of pneumoperitoneum and difficulty in scanning obese patients or those with overlying wounds.

Computed tomography (CT) is the ‘gold standard’ investigation for the evaluation of a patient with suspected liver trauma (Fig. 17.1). The use of intravenous contrast may help in the detection of non-viable parenchyma. CT has high sensitivity and specificity for detecting liver injuries; these attributes increase as the time between injury and scanning increases, as haematomas and lacerations become better defined. Specific CT features of liver trauma have been reported by a number of authors. Fang et al. described intraparenchymal ‘pooling’ of intravenous contrast that correlated strongly to the presence of ongoing haemorrhage.¹⁵ Yokota and Sugimoto documented ‘periportal tracking’ to consist of a circumferential area of low attenuation around the portal triad.¹⁶ Periportal tracking is thought to represent blood or fluid within the condensation of the Glissonian sheath around the portal structures and indicates the presence of injury to structures in the portal triad. If the sign is present in the periphery of the liver it may alert the clinician to the presence of a peripheral bile duct injury that in turn may present as a bile leak. Addition of oral contrast does not appear to add to the diagnostic yield of CT in the assessment of liver injury.¹⁷

In order to maintain a balanced perspective, it is worthwhile considering some of the limitations of CT in the assessment of liver trauma. The CT-defined grade of injury may differ from the grade of liver injury found at operation, with the predominant tendency being to overdiagnose the grade of injury on CT as compared with subsequent operative findings. Croce et al. concluded that CT should not be used in isolation to estimate blood loss and that CT may not provide an accurate assessment of the extent of a liver laceration in some areas of the liver – specifically in the vicinity of the falciform ligament.¹⁸

Bearing the above limitations in mind, CT will help define the extent of the liver injury and will be of value in the detection of injury to other intra-abdominal viscera, in particular pancreatic injury. CT will allow the liver injury to be graded and thus will provide objective information that is mandatory if non-operative treatment is to be contemplated. Further refinements now permit accurate three-dimensional image reconstruction, and technical modifications such as helical CT combined with intravenous contrast allow demonstration of the biliary tree (CT cholangiography) or vascular anatomy (CT angiography).

Some authors recommend performing a whole-body CT as the standard diagnostic tool during the early phase for patients with polytrauma, advocating that this will alter treatment in up to 34% of patients with blunt trauma.¹⁹ A 30% reduction in mortality using this approach has also been reported.²⁰ Other arguments in favour of an imaging survey are the reduction in time from admission to intervention and consistency in managing haemodynamically unstable patients.²¹ However, at present the logistics of such an approach are not universally applicable as it requires a CT scanner in, or very close to, the emergency department.

Management of liver injury: selection of patients for non-operative management

The feasibility of non-operative management of patients with intra-abdominal solid-organ injury was first established in paediatric surgery but was subsequently extended to adult practice. Richie and Fonkalsrud described successful conservative management of four patients with liver injury in an era before the availability of CT.²⁶ Further indirect evidence for the feasibility of a non-operative approach came from a report published by White and Cleveland²⁷ in the same year. They reported a consecutive series of 126 patients with liver trauma, all of whom underwent laparotomy. Interestingly, 67 patients in this series (53%) had placement of a drain to the subhepatic space as their only liver-related surgical intervention at laparotomy. Subsequent studies have recognised that 50–80% of liver injuries stop bleeding spontaneously and this has led to a non-operative approach for blunt liver trauma in selected patients.

Non-operative management of liver trauma is now a well-established treatment option. Trunkey’s group in Portland, Oregon, first defined in 1985 the following criteria for the selection of patients for non-operative management:

Farnell et al. extended the threshold of haemoperitoneum to 250 mL and described specific liver injuries suitable for non-operative management.²⁹ Feliciano suggested subsequently that any blunt hepatic injury, regardless of its magnitude, should be managed without operation if the patient was haemodynamically stable and had a haemoperitoneum of less than 500 mL.³⁰ The degree of liver injury amenable to successful non-operative management has gradually extended over recent years, and most authors now believe that the ultimate decisive factor in favour of non-operative management is haemodynamic stability of the patient at presentation or after initial resuscitation, irrespective of the grade of liver injury on CT or the amount of haemoperitoneum.^31,32

A 22-month prospective study from Memphis of the initial non-operative treatment of haemodynamically stable blunt hepatic trauma patients compared outcome to a matched cohort of blunt hepatic trauma patients treated operatively.³³ The study reported that of 136 patients with blunt trauma, 24 (18%) underwent emergency surgery. Of the remaining 112 patients, 12 (11%) failed conservative management (for causes not related to the liver injury in seven) and the remaining 100 patients were treated successfully without operation. Of these, 30% had minor injuries (grades I and II) but 70% had major injuries (grades III–V). This study concluded that non-operative management was safe for haemodynamically stable patients and that this was independent of the CT-delineated grade of the liver injury. The blood transfusion requirement and the incidence of abdominal complications were lower in the non-operatively treated group.

Reporting a single institutional experience, Boone et al. stated that 46 (36%) of 128 consecutive patients with blunt liver trauma were successfully treated non-operatively, including 23 patients with grade III and IV injuries.³¹ A review of 495 patients from the published literature noted a success rate for non-operative treatment of 94%.³⁴ This was accomplished with a mean transfusion rate of 1.9 units, a complication rate of 6% and a mean hospital stay of 13 days. There were no liver-related deaths, nor were there any missed enteric injuries.

The current consensus view is that successful selection of patients for conservative treatment after blunt abdominal trauma cannot be carried out by CT alone, but that an overall assessment of suitability for such an approach must take into account the findings of careful repeated clinical examination and the results of close monitoring of haemodynamic and haematological parameters. If non-operative management is selected, haemodynamic instability is the predominant indication for intervention early in the clinical course whilst intervention (often radiological or endoscopic) may be required later for management of bile leak or intrahepatic collections.

If a non-operative strategy is selected it should be borne in mind that the risk of hollow-organ injury increases in proportion to the number of solid organs injured³⁵ and that there is a small but significant risk of delayed haemorrhage. However, it appears that the natural course of liver injuries is more analogous to that of lung or kidney injuries, rather than splenic injuries, in that any deterioration is usually gradual, with a fall in haemoglobin level or an increase in fluid requirement, rather than acute haemodynamic decompensation. Therefore, with close supervision, patients who fail with an initial non-operative approach can be detected early and treated appropriately.

Although non-operative management of haemodynamically stable patients with liver trauma has become the standard of care over the past decade, the role of in-hospital follow-up CT to monitor the injury remains controversial. Demetriades et al. reported that follow-up CT at a mean of 10 days after surgical intervention showed a 49% incidence of liver-related complications, most of which required subsequent intervention.³⁶ However, other authors suggest there is little evidence that follow-up CT provides additional information and rarely changes management.³⁷ In the author’s practice, in-hospital follow-up scan is not employed routinely unless the patient develops relevant symptoms or signs, but a follow-up scan 4–6 weeks later is undertaken to ensure resolution of the injury.

The management policy for abdominal gunshot injuries in most centres continues to be a mandatory laparotomy, regardless of the clinical presentation;³⁸ however, several studies have reported successful non-operative management of selected liver gunshot injuries.^39,40 In the study by Omoshoro-Jones et al., 26.6% of patients who presented with liver gunshot injuries were managed non-operatively, with an overall success rate of 94% and a morbidity rate of 36%, of which 3% were liver related.³⁹ This approach is associated with the risk of failure to detect concomitant intra-abdominal visceral injury and therefore should only be considered in specialist centres with experience in management of liver trauma and appropriate facilities to deal with any complications that arise.

Operative management of liver injury

Complications of liver trauma

Outcome after liver injury

The outcome after liver trauma is related not only to the severity of the injury but also to the severity of any associated injury. Most series report mortality rates of approximately 10–15%; however, the large variation in case mix between different centres makes comparison difficult. In a large series of 1000 cases of liver trauma from Houston, an overall mortality of 10.5% was reported.⁴ White and Cleveland documented a similar mortality rate, with eight deaths occurring in a consecutive series of 126 patients (6.3%).²⁷ The results in the series reported by Schweizer et al. recorded an overall mortality rate of 12% (21 deaths in 175 patients), with a progressively higher mortality rate associated with an increasing grade of liver injury.⁸ In a series of 337 patients, Kozar et al. reported 37 hepatic-related complications in 25 patients; 63% (5 of 8) of patients with grade V injuries developed complications, 21% (19 of 92) of patients had grade IV injuries, but only 1% (1 of 130) of patients had grade III injuries.⁵⁶ The mechanism of injury has an important bearing on the mortality rate, with blunt trauma carrying a higher mortality rate (10–30%) than penetrating liver trauma (0–10%). While most early deaths seem to be due to uncontrolled haemorrhage and associated injuries, most late deaths result from head injuries and sepsis with multiple organ failure.

Incidence of biliary injury

The reported incidence of injury to the extrahepatic biliary system varies between 1% and 5% of patients who sustain abdominal trauma.⁵⁷ In a review of 5070 patients who sustained blunt and penetrating abdominal trauma, Penn reported a 1.9% incidence of gallbladder injury.⁵⁸ Soderstrom et al. identified 31 patients (2.1%) with gallbladder injury in a group of 1449 patients who sustained blunt abdominal trauma and underwent exploratory laparotomy.⁵⁹ In a further review of 949 patients undergoing laparotomy for acute trauma, there were 32 injuries to the gallbladder (3.4%) and five to the common bile duct (0.5%).⁶⁰ Burgess and Fulton reported that, over a 5-year period, 24 of 184 patients with abdominal trauma had extrahepatic bile duct or gallbladder injury as well as liver injury.⁶¹ They reported that this injury was often seen with severe hepatic trauma and in association with multiple organ injury. Dawson et al. reviewed the results of treatment of all patients with porta hepatis injuries presenting to a level I trauma centre in Seattle over an 11-year period.⁶² A total of 21 patients (0.21% of 10 500 admissions) had injuries to the portal triad, of whom 11 (52%) died. Isolated extrahepatic bile duct injury occurred in four of these patients. Injuries to the portal vein or hepatic artery, either in isolation or in association with extrahepatic bile duct injury, were associated with the worst prognosis. Of note is the fact that in none of the 21 cases was the diagnosis of the injury made preoperatively. The male to female ratio is usually reported as approximately 5:1.⁶³ However, Bade et al. reported a male to female ratio of 25:1, which may reflect the higher number of injuries from stab wounds seen in a South African population.⁶⁴ Most series report a median age of approximately 30 years and there are many reports in children.

Classification of biliary injury

The gallbladder is the most frequently injured part of the extrahepatic biliary tract. The largest reported series of extrahepatic biliary tract injuries consists of 53 patients, of whom 45 (85%) sustained injury to the gallbladder and eight (15%) had an injury to the bile duct.⁶⁴ Kitahama et al. reported the gallbladder to be involved in 32 (80%) of 40 patients, while ductal injury occurred in 12 (30%), some patients having multiple injuries.⁶³

Injury to the gallbladder resulting from blunt trauma can be classified as contusion, avulsion or perforation. In addition to these three main types of injury, Penn added traumatic cholecystitis as a pathological entity.⁵⁸ The most common type of gallbladder injury is perforation. Avulsion of the gallbladder may refer to the organ being partially or completely torn from the liver bed while still attached to the bile duct, or it may signify complete separation from all attachments with the organ lying free in the abdomen. Contusion is probably under-reported, as it will be recognised only if laparotomy is performed. The natural course of an untreated gallbladder contusion is not known, although it is likely that the majority resolve without further complication. It has been speculated that an intramural haematoma might result in necrosis of the gallbladder wall and result in a subsequent perforation. There have been a number of reports of delayed rupture of the gallbladder, and it is plausible that unrecognised contusion of the gallbladder might lead to such a delayed presentation.

Bile duct injury is classified according to the site of injury and according to whether the transection is partial or complete. Partial duct injuries are often referred to as ‘tangential’ wounds. Penetrating injuries can affect any part of the extrahepatic biliary system; however, the commonest sites of injury due to blunt trauma are at the point where the common bile duct enters the pancreas and where the biliary confluence exits from the liver. These sites are at points of maximum fixation, which accounts for their propensity to injury.

Isolated injury to the extrahepatic biliary tract is very uncommon. The liver is the organ most commonly injured in association with biliary tract trauma (approximately 80% of cases), with the duodenum, stomach, colon and pancreas being the next most frequently reported. Associated vascular injuries are relatively rare; however, inferior vena cava and portal vein injuries are more commonly reported than those to the hepatic artery, renal vessels or aorta.

Presentation and diagnosis of biliary injury

Clinical presentation of the vast majority of bile duct injuries can be divided into two broad categories. The first contains patients in whom clinical signs or associated injury lead to laparotomy with early diagnosis and surgical management (early presentation); these patients generally present with hypovolaemic shock or signs of an acute abdomen. The second category of patient has a delay (greater than 24 h) in diagnosis and definitive therapy (delayed presentation). These patients comprised over half the cases (53.2%) in a review of combined series.⁶⁵ In addition, a third category of patient, representing a very small proportion of those who sustain a bile duct injury, may present with obstructive jaundice months or even years after the initial trauma (late presentation). In these patients, the bile duct injury is always isolated. Compromise of the blood supply to the duct may occur either at the time of the primary injury or at operation during the Pringle manoeuvre, and this may contribute to the development of a late biliary stricture. Bourque et al. reported that the delay between clinical presentation and surgical intervention for isolated bile duct injury averaged 18 days, with a range from several hours to 60 days.⁶⁶ Michelassi and Ranson reported that biliary injury was not recognised at initial operation in 11 (12%) of 91 patients with extrahepatic biliary tract trauma,⁶⁵ whereas Dawson and Jurkovich reported that 41% of bile duct injuries were missed at initial laparotomy.⁶⁷

If a non-operative course of management for abdominal trauma is adopted, suspicion of an extrahepatic bile duct injury may be raised by CT evidence of a central liver injury involving the porta hepatis or the head of the pancreas, the presence of fluid collections in the subhepatic space, or evidence of periportal tracking of haematoma.¹⁶ The diagnostic procedure of choice is ERCP, and if a duct injury is identified this may be treated by endoscopic stenting.⁶⁸

Intraoperative recognition of biliary tract injury requires a high index of suspicion. The presence of free bile in the peritoneal cavity, or the presence of bile staining in the hepatoduodenal ligament or retroperitoneum, is a sign of injury to the extrahepatic bilary tract. Biliary tract injury must also be suspected if there is profuse bleeding from the hepatic artery or portal vein, particularly following blunt trauma, as the bile duct is also likely to be injured. Penetrating wounds near the porta hepatis require careful examination. If routine dissection does not reveal the location of the injury, fine-needle intraoperative cholangiography via the gallbladder or common bile duct may identify the site. Cystic duct cholangiography should be considered after cholecystectomy for traumatic gallbladder injury to avoid missing an associated bile duct injury.

It is possible for a patient who has sustained blunt abdominal trauma to be discharged from hospital only to return days or weeks later with a combination of symptoms and signs, including jaundice, abdominal distension, nausea, vomiting, anorexia, abdominal pain, low-grade fever or weight loss – a clinical picture similar to that seen in patients with intraperitoneal bile leakage following cholecystectomy. When jaundice develops after abdominal trauma, missed extrahepatic biliary injury must be considered.

Operative management of biliary injury

Many patients with extrahepatic biliary tract injury present in shock due to associated haemorrhage, and the priority at laparotomy is to identify and control haemorrhage. The report of Dawson et al. demonstrates that these patients are at risk of exsanguinating on the operating table.⁶² Injuries to the gallbladder are best treated by cholecystectomy.⁶⁹ Primary repair of a clean and simple partial or complete transection of the common duct using absorbable sutures such as 4/0 polydioxanone over a T-tube inserted through a separate choledochotomy has been described. However, this type of repair is not appropriate if there is any evidence of duct contusion, loss of ductal tissue or possible injury to the hepatic artery as this may increase the risk of late development of an ischaemic stricture. In general, it is therefore safer to recommend that most injuries should be managed by fashioning a Roux-en-Y hepatico-jejunostomy as in the management of iatrogenic bile duct injuries.

Outcome after biliary injury

Injuries of this nature are associated with a mortality rate of 10% from concomitant injuries.⁶³ Septic complications and bile leakage account for most of the early morbidity and may require operative intervention. Late morbidity after repair of a traumatic biliary tract injury is unusual; however, jaundice or episodes of ascending cholangitis suggest a stricture of the ductal system.

Mechanisms of pancreatic injury

Deceleration injury and direct blunt trauma are major mechanisms of pancreatic trauma, with the neck of the gland being at risk of transection across the vertebral column. The deep location of the pancreas means that considerable force is needed to cause an injury and this level of force may often be sufficient to damage other organs.

Diagnosis of pancreatic injury

Pancreatic injury should be suspected in any patient with penetrating trauma to the trunk, particularly if the entry site is between the nipples and the iliac crest, and in any patient with blunt compression trauma of the upper abdomen.

In an early study, Moretz et al. found that there was no reliable correlation between serum amylase and pancreatic injury.⁷¹ In a later report, Takashima et al. retrospectively studied admission serum amylase values in a series of 73 patients with blunt pancreatic trauma treated in a single institution over a 16-year period.⁷² Sixty-one (84%) of these patients had a raised serum amylase level. Of interest, the serum amylase level was found to be abnormal in all patients admitted more than 3 hours after trauma.

Bearing in mind the practicality that patients with pancreatic injury will simultaneously be undergoing evaluation to exclude concomitant intra-abdominal visceral injury, contrast-enhanced CT has been the investigation of choice (Fig. 17.7). Reported CT features of pancreatic injury include free intraperitoneal fluid, localised fluid in the lesser sac, retroperitoneal fluid, pancreatic oedema or swelling and changes in the peripancreatic fat. The presence of fluid in the lesser sac between the pancreas and the splenic vein is reported by Lane et al. to be a reliable sign in blunt pancreatic injury.⁷³ However, Sivit and Eichelberger reported that this radiological sign was rarely the only abnormal CT finding in pancreatic injury.⁷⁴ It should be borne in mind that many of these CT features are also seen in acute pancreatitis (and furthermore that acute pancreatitis may occur as a result of blunt abdominal trauma). There is also evidence that CT tends to underdiagnose pancreatic injury. Akhrass et al. evaluated the clinical course of 72 patients with pancreatic injury admitted over a 10-year period.⁷⁵ Seventeen of these patients underwent CT as part of their initial assessment and this was reported as normal in nine. Eight of these patients underwent laparotomy (principally for suspected associated splenic injury) and three were found to have pancreatic injury requiring distal pancreatectomy. Newer, non-invasive imaging modalities such as magnetic resonance pancreatography have been reported in the assessment of patients with suspected pancreatic trauma.⁷⁶ Increased sophistication with the use of this technique may allow for accurate assessment of pancreatic ductal integrity.

Classification of pancreatic injury

Of the various proposed classification schemes, Lucas suggested in an early report that appropriate treatment be formulated according to the type of injury.⁷⁷ This classification system divides pancreatic injuries into three groups:

A more complex system of classification taking into account the frequent coexistence of duodenal and pancreatic injuries was proposed by Frey and Wardell⁷⁸ (Table 17.2). The most common site of injury is the neck of the pancreas. The relative frequency of pancreatic injuries reported in collected reviews is represented in Fig. 17.9.

Initial management of pancreatic injury

In a major retrospective clinical casenote review of pancreatic trauma from six hospitals, Bradley et al. demonstrated a significant association between pancreas-related morbidity and injury to the main pancreatic duct.⁷⁹ Delayed intervention (due to delay in recognition of main pancreatic duct injury) was associated with high morbidity. CT was unreliable for the assessment of main pancreatic ductal integrity and an accurate assessment required ERCP.

Operative management of pancreatic injury

The mainstay of treatment remains operative as pancreatic injuries are usually diagnosed at laparotomy. The important principles at operation are to gain good access to allow thorough inspection of the gland. Access to the lesser sac is best done by creating a window in the gastrocolic omentum outside the gastroepiploic arcade to allow examination of the body of the pancreas. A Kocher manoeuvre is necessary to permit palpation of the head of the pancreas between the thumb and fingers. A thorough inspection of the base of the transverse mesocolon is also undertaken. Injury to the pancreas is suspected if retroperitoneal haemorrhage can be seen through the base of the mesocolon or the lesser omentum. Absence of any sign of haemorrhage over the pancreas and duodenum makes injury unlikely.

Experience of patients with pancreatic injury from Durban led to the recommendation for operative treatment of patients with penetrating or gunshot injury and signs of peritoneal irritation.⁸⁰ In this large series of 152 patients with pancreatic trauma presenting during a 5-year period, 63 patients had been shot, 66 stabbed and 23 had blunt trauma. The mainstay of treatment was exploratory laparotomy followed by drainage of the pancreatic injury site. Large-bore soft silastic drains were used to minimise the risk of drain erosion into a major vessel. The mortality rates in these groups were 8% after gunshot injury, 2% after stab wounds and 10% after blunt trauma. The majority of these deaths were attributed to damage of other organs. The proportions of patients that developed pancreatic fistulas in the three groups were 14%, 9% and 13%, respectively. The authors concluded that ‘conservative’ surgical drainage (avoiding pancreatic resection) was justified after pancreatic injury. This large series lends weight to the treatment plan proposed by Lucas for grade I injuries, which consists of passive closed drainage using a wide-bore drain.

Simplified management guidelines based on the treatment protocols developed during the treatment of 124 pancreatic injuries at the University of Tennessee⁸¹ also advocate simple drainage alone for proximal pancreatic injuries. There were 37 (30%) patients with proximal injuries. The ‘pancreas-related’ morbidity was 11% – principally the sequelae of pancreatic fistulas. Of 87 distal pancreatic injuries, the integrity of the main pancreatic duct was not established in 54 (62%). Patients thought to have a high probability of duct transection were treated by distal pancreatectomy. A concern with simple drainage for injuries in the head of the pancreas is persistent pancreatic fistula, and thus a surgical alternative is to drain the head of the pancreas into a Roux-en-Y limb of jejunum.

Moncure and Goins described their experience over a 6-year period with a consecutive series of 44 patients with pancreatic injury,⁸² of which penetrating abdominal trauma accounted for the majority of cases. Class I pancreatic injuries occurred in 55% of patients and the majority were managed by simple drainage. Grade II injuries occurred in 18% and grade III injuries in 21%. Coexistent duodenal injuries were treated by primary closure in 21% and more complex duodenal exclusion techniques were used in 20%. The most frequent complications were intra-abdominal abscesses (31%) and pancreatic fistulas (16%).

Krige et al. reported on a series of 110 patients with pancreatic injuries after blunt trauma.⁸³ One hundred and one patients underwent a total of 123 operations, including drainage of the pancreatic injury (n = 73), distal pancreatectomy (n = 39) and Whipple resection (n = 5). The overall complication rate was 74.5% and the mortality rate was 16.4%. Only two of the 18 deaths were attributable to the pancreatic injury. Mortality increased exponentially as the number of associated injuries increased.

Severe Lucas grade III injuries involving the head of the pancreas, duodenum and distal bile duct represent a major challenge, but fortunately are relatively rare, occurring in approximately 5% of all duodenal injuries.⁸⁴ The principles of treatment are to ensure that haemorrhage from concomitant injuries is dealt with first, as this is likely to be the major source of mortality. Similarly a prolonged operative procedure should be avoided in a potentially unstable patient and the involvement of an experienced pancreatic surgeon is desirable. Duodenal injuries can be closed primarily or drained into a Roux loop. Bile duct injuries may be repaired primarily over a T-tube or drained into a Roux limb of jejunum. The large variety of operative procedures described for these complex injuries suggests that treatment has to be tailored to the individual injury complex and that no single procedure is likely to be uniformly applicable or successful. Very rarely, pancreatico-duodenectomy may be required for complex, severe pancreatic injuries with concomitant duodenal and distal bile duct injuries. Clearly, this sort of resection should not be undertaken lightly in an individual suffering from shock and its sequelae, but rather like liver transplantation for trauma it is useful to have an index of awareness of the available therapeutic options.

Complications of pancreatic injury

The most common post-traumatic complications include necrotising pancreatitis, pseudocyst formation, pancreatic abscesses and pancreatic fistula. Cerwenka et al. reported the incidence of these complications to be 15%, 9%, 6% and 4%, respectively.⁸⁵ The principles regarding management are similar to those for treating these complications when they arise as a result of pancreatitis or pancreatic surgery. Inflammation of the pancreas after trauma behaves in much the same way as acute biliary or acute alcohol-induced pancreatitis, with the possible exception that there is a higher incidence of development of local complications such as pseudocyst – possibly relating to the nature of duct disruption in trauma. The Cape Town group reported that, of a series of 64 patients with pancreatic trauma, pseudocysts developed in 15 patients (23%), of whom eight had a duct injury demonstrated by endoscopic retrograde pancreatography.⁸⁶ Patients with pseudocysts related to distal duct injury were treated successfully by percutaneous aspiration. Three patients with duct injuries in the neck/body region underwent distal pancreatectomy. Pseudocysts related to ductal injury in the head of the pancreas were drained internally by Roux-en-Y cyst-jejunostomy. The authors concluded that traumatic pancreatic pseudocysts associated with a peripheral duct injury may resolve spontaneously, whereas those associated with injuries to the proximal duct would more likely require surgical intervention. Alternative treatment strategies include endoscopic transpapillary or transmural drainage of the pseudocyst.

The incidence of pancreatic fistula after surgery for trauma is dependent on the type of procedure, with some evidence that the fistula rate is higher after drainage procedures than after resection. Successful insertion of pancreatic duct stents has been reported for management of major pancreatic duct disruption; however, the incidence of long-term ductal stricture is high and therefore the role of pancreatic duct stenting needs to be further defined.⁸⁷

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