CHAPTER 50 PANCREATIC INJURIES
The pancreas is relatively protected deep within the confines of the retroperitoneum. As such, injuries to the pancreas are uncommon, but not rare, and can present a diagnostic dilemma. In fact, despite advances in modern trauma care, there remains significant morbidity and mortality, with mortality rates ranging from 9%–34%.1 Frequent complications are also common following pancreatic injuries, occurring in 30%–60% of patients. The high complication rate associated with these injuries is primarily secondary to diagnostic delays and missed injuries. When identified early, the treatment of most pancreatic injuries is straightforward. It is the delayed recognition and/or treatment of these injuries that can result in devastating outcomes.
There are few well-documented historical accounts about the management of pancreatic injuries. The first documented case of pancreatic trauma was an autopsy report from St. Thomas Hospital in London in 1827 in which a patient struck by the wheel of a stagecoach suffered a complete pancreatic body transection.2 Over the next several decades, reports of pancreatic injuries were scattered. In 1903, after extensive review of the literature, only 45 cases of pancreatic trauma, 21 resulting from penetrating injuries and 24 from blunt trauma could be identified.3 The occurrence of complications following pancreatic injury was also noted early. In 1905, Korte4 reported a case of an isolated pancreatic transection with resultant pancreatic fistula. The fistula closed spontaneously and the patient survived.
ANATOMY
A complete understanding of pancreatic relational anatomy is essential for providing appropriate treatment and understanding the potential for associated injuries. The pancreas is about 15–20 cm in length, 3.1 cm wide, and 1–1.5 cm thick. The average mass is 90 g (ranging from 40 to 180 g).5 The inferior vena cava, aorta, left kidney, both renal veins, and right renal artery lie posterior to the pancreas. The head of the pancreas is nestled in the duodenal sweep, with the body crossing the spine and the tail resting within the hilum of the spleen. The splenic artery and vein can be found along the superior border of the pancreas. The superior mesenteric artery and vein reside just behind the neck of the pancreas and are enclosed posteriorly by the uncinate process. This process can be absent or can almost completely encircle the superior mesenteric artery and vein.
PHYSIOLOGY
The pancreas is a compound tubuloalveolar gland with both endocrine (insulin, glucagon, somatostatin) and exocrine (digestive enzyme precursors, bicarbonate) function. The endocrine cells are separated histologically into nests of cells known as the islets of Langerhans. There are three predominant subtypes of islet cells: alpha cells (which produce glucagon), beta cells (which produce insulin), and delta cells (which produce somatostatin). Although these cells are distributed throughout the substance of the pancreas, most reside primarily within the tail. Consequently, it would seem that a distal pancreatectomy would be poorly tolerated in terms of endocrine function. However, it is well known that resection of more than 90% of the pancreas must occur before endocrine insufficiency develops, provided the remainder of the gland is normal. In fact, partial resection induces hypertrophy and increased activity of the residual islet cells. In animal studies, Dragstedt6 was the first to show that removal of 80% of the pancreas did not significantly alter carbohydrate or fat metabolism or the digestion and/or absorption of food, provided that the remaining gland is normal and that pancreatic secretions still have access to the upper digestive tract via the ductal system.
DIAGNOSIS
It is important to remember that whenever there is trauma to the pancreas, particular attention must be given to the possibility of a major ductal injury for this is the single most important determinant of outcome after pancreatic injury. In fact, this concept was first recognized as early as 1962.7 Subsequent investigators have confirmed and reemphasized the necessity of determining the status of the pancreatic duct. In fact, Heitsch et al.8 found that distal resection of ductal injuries significantly lowered postoperative morbidity and mortality when compared with drainage alone. This finding was confirmed over a decade later when investigators documented a drop in mortality rate from 19%–3% after pancreatic resection proximal to the site of ductal injury.9
Elevated serum amylase is not a reliable indicator of pancreatic trauma. In fact, the use of amylase as a screening tool in blunt trauma carries a negative predictive value of 95%.10 Measurement of the pancreatic isoamylase fraction has failed to substantially improve both the sensitivity and specificity of this value as a marker of pancreatic injury.
Asymptomatic patients with elevated serum pancreatic isoamylase require observation and repeat amylase determination. Persistently elevated serum amylase or the development of abdominal symptomatology warrants further investigation and may include computed tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP), or operative exploration. Abdominal CT scans have a reported sensitivity and specificity as high as 80% in diagnosing pancreatic injury.11 Patton and colleagues12 reported that in 26 patients that sustained blunt pancreatic trauma, early CT scan was suspicious for injury in 15. CT failed to demonstrate injury in four patients (21%), resulting in a delay in operative intervention (mean, 3.8 days). The remaining patients had other indications for exploration.
Endoscopic retrograde cholangiopancreatography can be useful in the diagnosis of pancreatic duct rupture. In addition, it can aid in the diagnosis of and occasionally the management of the complications of missed pancreatic injuries. A report from the University of Louisville documents ERCP as a useful diagnostic tool in the evaluation of the pancreatic duct in the early postinjury period in hemodynamically stable patients with elevated amylase levels, persistent abdominal pain, and abnormal or questionable abdominal CT findings.13 ERCP is also extremely helpful in the evaluation of patients in whom the diagnosis of pancreatic injury was missed during the initial evaluation. It is in these patients that ERCP can aid in diagnosing the injury, planning the surgical approach if necessary, determining internal transpancreatic stent placement, and transductal drainage of a pancreatic abscess. However, ERCP may not always be available and should not delay operation in patients with progressive clinical deterioration.
Magnetic resonance (MR) imaging, specifically MRCP (magnetic resonance cholangiopancreatography), has emerged as an alternative technique for evaluating the pancreatic duct. Although primarily used in elective circumstances, MRCP has been reported as a viable option for evaluating the status of the duct in those patients with pancreatic injuries.14 However, it frequently is not practical for use in trauma patients.
Once again, it must be stressed that, if possible, it is important to determine the status of the duct at the time of exploration. Most of these injuries can be diagnosed by local exploration. Injuries to the duct occur in approximately 15% of pancreatic trauma and are generally the result of penetrating injury.15 Blunt injury can also result in transection of the major duct with or without complete transection of the gland. Minor contusions and/or lacerations of the pancreatic parenchyma usually do not require further evaluation of the duct. However, an intact pancreatic capsule does not eliminate the possibility of complete transection of the pancreatic duct.9