bubble_chart Overview

The pancreas is located in the upper abdomen behind the peritoneum and is well-protected, so the chance of injury is relatively low, accounting for only 2-5% of abdominal injuries. However, there has been a recent increasing trend, with complications occurring in 19-55% of cases and a mortality rate of approximately 20-35%.

bubble_chart Etiology

Pancreatic injuries are divided into two types: open and closed, often caused by blunt force such as car accidents. Northrup proposed the mechanism of blunt pancreatic injury as follows: ① When the force comes from the right side of the vertebral body, it compresses the pancreatic head, leading to pancreatic head contusion, often accompanied by liver, common bile duct, and duodenal injuries. ② A force applied to the upper abdomen directly over the vertebral body often causes a transverse fracture of the pancreatic body. ③ A force from the left side frequently results in pancreatic tail injury, which may be combined with splenic rupture.

Open, or penetrating, pancreatic injuries are mostly caused by gunshots or sharp objects. There are significant regional differences in the incidence of closed and open pancreatic injuries. Iatrogenic injuries are often caused by surgeries such as gastrectomy, duodenectomy, and splenectomy, and occasionally by endoscopic retrograde cholangiopancreatography (ERCP). Based on the location of pancreatic injuries, injuries to the pancreatic head account for about 40%, the pancreatic body 15%, the pancreatic tail 30%, and multiple injuries 16%.

bubble_chart Clinical Manifestations

The main clinical manifestations of pancreatic trauma are internal bleeding and pancreatic ascites, especially in cases of severe pancreatic injury or main pancreatic duct rupture. Patients may experience severe upper abdominal pain radiating to the shoulders and back, accompanied by nausea, vomiting, abdominal distension and fullness, weakened or absent bowel sounds. Shock may occur due to internal bleeding and massive fluid loss. Periumbilical skin discoloration (Cullen's sign) may also be present.

bubble_chart Diagnosis

The diagnosis of open pancreatic injury is not difficult. Gunshot wounds in the upper abdomen or near the umbilicus must consider the possibility of pancreatic injury. During exploratory laparotomy, the site of injury is easily identified. The diagnosis of closed pancreatic injury is very challenging, with fewer than half of cases correctly diagnosed preoperatively. The main reasons are: ① The pancreas is deeply located, giving a false sense of security, so pancreatic injury is rarely considered; ② Pancreatic injury is often accompanied by concurrent injuries to abdominal organs and major blood vessels, and its manifestations can be easily overshadowed; ③ In the early stages of pancreatic injury, bleeding and pancreatic fluid leakage are often confined behind the peritoneal membrane, with mild and nonspecific symptoms and signs. A few cases are only diagnosed after the formation of a pseudocyst. Therefore, any upper abdominal injury, even a minor one, should be closely monitored to rule out pancreatic injury.

Peritoneal puncture or lavage: In the short term after injury, peritoneal fluid is minimal, and puncture results are often negative. Only when the main pancreatic duct is severed can positive results be obtained. Measuring amylase in peritoneal fluid has some diagnostic value.

Pancreatic amylase measurement: In patients with pancreatic injury, about half exhibit elevated serum amylase levels, but the degree of elevation does not correlate with the severity of pancreatic injury. Twenty percent of patients with pancreatic transection have normal serum amylase levels, indicating that serum amylase testing is not highly sensitive.

Special examinations: Abdominal X-ray plain films may show retroperitoneal masses, widening of the duodenal loop, and abnormal displacement of the stomach and transverse colon. Other tests, such as B-mode ultrasound, CT scans, selective abdominal angiography, retrograde cholangiopancreatography, and pancreatic isotope scanning, can confirm pancreatic parenchymal injury, intra-abdominal vascular rupture, pancreatic duct injury, and pseudocyst formation. However, these are difficult and unnecessary in emergency situations.

Exploratory laparotomy is the simplest method for early diagnosis. Any intra-abdominal bleeding or peritonitis is an indication for laparotomy. Intraoperative exploration to confirm pancreatic injury is crucial, as missed diagnosis can lead to serious consequences. During surgery, if saponified ecchymosis on the peritoneum, retroperitoneal hematoma in the upper abdominal region, or hematoma at the root of the transverse mesocolon are found, the gastrocolic ligament should be incised to explore the pancreas. A Kocher incision should be used to expose the pancreatic head and the first and second parts of the duodenum, followed by exposure of the pancreatic body and tail. If the spleen is injured, examination of the pancreatic tail should not be overlooked; if the duodenum is injured, concurrent injury to the pancreatic head should also be considered.

After determining the location and extent of pancreatic injury during surgery, it is also necessary to accurately assess whether the pancreatic duct is injured. Central penetrating injuries, severe crushing, and deep lacerations of the pancreas often involve the pancreatic duct. If pancreatic duct injury cannot be confirmed in cases of pancreatic head injury, injecting contrast or dye through the duodenal papilla after incising the duodenum is a simple and practical method to detect pancreatic duct injury.

bubble_chart Treatment Measures

The treatment of pancreatic injury primarily depends on the location and severity of the injury, particularly the integrity of the main pancreatic duct and the presence of associated injuries to the duodenum or other organs.

The main principles of treating pancreatic injury include thorough hemostasis, management of associated organ injuries, removal of necrotic pancreatic tissue, and adequate drainage. Specific treatments are as follows:

For superficial pancreatic contusions, lacerations without pancreatic duct injury, simple repair and adequate drainage are sufficient, with silicone double-lumen tubes being the best drainage option.

For transection injuries of the pancreatic body or tail, or severe lacerations involving the pancreatic duct, resection of the distal pancreas may be performed. The pancreatic duct is ligated, the stump is closed with a double-layer suture, and the area is wrapped with the greater omentum, followed by double-lumen drainage of the pancreatic bed. The postoperative complication rate is 7%, with a mortality rate of 14%. Resection of up to 80% of pancreatic tissue does not lead to endocrine or exocrine insufficiency. However, if severe injury to the mid-pancreas requires resection of over 90% of the tissue, postoperative pancreatic insufficiency may occur. In such cases, after debridement, a pancreaticojejunostomy may be performed at both ends of the pancreas, though the procedure is somewhat complex. Pancreatic duct repair is technically challenging and has a high postoperative stricture rate, making it unsuitable.

The simplest approach for severe pancreatic tail injury is distal pancreatectomy. If combined with splenic rupture, splenectomy may also be performed.

Management of pancreatic head lacerations involving the main pancreatic duct or severe combined pancreaticoduodenal injuries is the most challenging, often requiring pancreaticoduodenectomy, with a mortality rate as high as 45%. In cases of combined pancreatic head and duodenal injuries where the duodenum remains viable, a duodenal diverticulization procedure may be considered. This technique, proposed by Berne et al. (1968), includes repair of the duodenal injury, antrectomy, antecolic gastrojejunostomy, vagotomy, duodenostomy, T-tube drainage of the common bile duct, and double-lumen drainage of the injured area. Jordan later refined the procedure by simply incising the gastric antrum and using absorbable sutures to close the pylorus internally, followed by a side-to-side gastrojejunostomy, significantly reducing operative time. The pyloric sutures dissolve after several weeks, restoring gastroduodenal continuity. For extensive pancreatic head and duodenal injuries, or cases involving uncontrolled bleeding from the common bile duct or ampulla, pancreaticoduodenectomy is necessary, but the mortality rate can reach 60%.

It is important to note that in surgeries involving multiple organ injuries, pancreatic injuries should be addressed last. Drainage of the pancreatic bed is the most critical measure.

Postoperative complications of pancreatic injury are common, with pancreatic fistula being the most frequent. Most fistulas heal spontaneously within 6–8 weeks, though some may persist for months. Approximately 10% of fistulas require reoperation. Other common complications include pancreatic abscess, pancreatitis, and pseudopancreatic cysts.