Injuries to the
pancreas
External
injury (Fig. 55.23)
Presentation
and management
The most frequent presentation of blunt pancreatic trauma is epigastric
pain which may be minor at first, with the progressive development of more
severe pain due to the sequelae of leakage of pancreatic fluid into the
surrounding tissues. A rise in pancreatic amylase occurs in 90 per cent of
cases. A CT scan of the pancreas or ultrasound scan will delineate the damage
that has occurred to the pancreas. Persisting abdominal pain with signs of
peritonitis require careful assessment of the patient, and support by
intravenous fluids and a nil oral regime should be instituted. Immediate
operation is contra-indicated because the bruising associated with the retroperitoneal
damage will prevent clear visualisation of the pancreas. It is preferable to
manage conservatively, investigate with ultrasound and, once the damage is
ascertained, undertake appropriate action. Operation is only indicated if there
is disruption of the main pancreatic duct; almost all other patients will
resolve with conservative management unless duct stricturing develops leading to recurrent episodes of pancreatitis, in which
case the appropriate treatment is resection of the tail of the pancreas up to
the site of duct disruption. If the damage is purely confined to the head of the
pancreas simple drainage is normally effective; should this fail, however, then
a pancreatoduodenectomy may be necessary.
A pancreatic pseudocyst may develop (Fig.
55.24). If the main duct is intact, the cyst should be drained percutaneously. It is now rarely necessary to undertake a cystgastrostomy (Fig. 55.25).
If the cyst develops in the presence of complete disruption of the pancreas,
there is no alternative but to undertake a distal resection.
Prognosis
The most common cause of death in the immediate period is bleeding, but once the acute phase has passed the mortality and morbidity should be minimal with a complete return to normal activity. The mortality rate of penetrating injury to the pancreas with associated injuries to the surrounding viscera approaches 50 per cent.
latrogenic
injury
This can occur in four ways.
• Injury to the tail of the pancreas during splenectomy resulting
in a pancreatic fistula.
• Injury to the accessory pancreatic duct (Santorini) which is
the main duct in 7 per cent of patients during Billroth II gastrectomy. A
pancreatogram performed by cannulating the duct at the time of discovery of such
an injury will demonstrate whether it is safe to ligate and divide the duct. If
no alternative drainage duct can be demonstrated then the duct should be
reanastomosed to the duodenum.
• Attempts at enucleation of islet cell tumours of the pancreas
can result in fistulae.
• Duodenal or ampullary bleeding following sphincterotomy. This
injury may require duodenotomy to control the bleeding.
Pancreatic
fistula
This usually follows operative trauma to the gland, or may occur as a
complication of acute or chronic pancreatitis. Management is to define the site
of the fistula, the epithelial structure to which it communicates (e.g. external
to skin or internal to bowel), and to correct metabolic and electrolyte
disturbances. The danger of a pancreatic fistula is that there is digestion of
surrounding structures by activated pancreatic enzymes causing local damage,
perforation, bleeding and digestion of the skin. Immediate control of the
fistula can be obtained by a nil by mouth regime, the use of octreotide and
adequate drainage of the fistula with protection of the skin. Investigation of
the cause of the fistula is required and, usually, once the cause is determined
appropriate remedies can be introduced. Frequently the cause is related to
obstruction within the pancreatic duct which can be overcome by the insertion
of a stent or catheter endoscopically into the pancreatic duct, and waiting for
closure of the fistula while supporting the patient by a conservative regime
with parenteral nutritional support and good nursing. As a principle, in the
management of any fistula, the underlying cause for the fistula must be treated
before closure will be effective.