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Blunt pancreatic injury: two case reports and a review of the literature
Injury
(1985) 16,391-392
Printedin
Great Britain
391
Blunt pancreatic injury: two case reports and a review of the literature P. J. Friend, N. V. Jamieson and R. MacFarlane Department
of Surgery, Addenbrooke’s
Hospital, Cambridge
Two cases are reported of patients who sustained transection of the pancreas without damage to any other intra-abdominal organ. Surgical management included distal pancreatectomy and splenectomy. The incidence and management of pancreatic injury are discussed.
INTRODUCTION of the pancreas is an uncommon of blunt abdominal injury. The pancreas is damaged in l-2 per cent of cases of abdominal injury but of these the majority (90 per cent) are associated with some other visceral injury, which is usually responsible for the initial symptoms. The cases reported here illustrate how isolated damage after moderate injury may present relatively late and without specific signs. ISOLATED
injury
complication
CASE REPORTS Case
1
A 27-year-old woman was admitted as an emergency case 9 hours after falling from a horse. She had landed on her left side, injuring her chest, knee and nose. At the time, it did not appear to be a major injury; she fell onto hard, rutted ground but was not kicked or trampled by the horse. She was well enough to drive herself home but developed increasing, left-sided abdominal pain. On admission she was noted to be tender in the left hypochondrium but the abdomen was not distended and she had normal bowel sounds. She was warm and pink with normal blood pressure and pulse. There were no external signs of injury of her chest or abdomen. Investigations at this stage included a haemoglobin of 11.1 g per cent and white cell count of 20x109/1. Radiographs of the abdomen and chest were normal. In the hour after admission her condition deteriorated, with increasing abdominal pain; she became clinically ‘shocked’. Diagnostic peritoneal lavage confirmed the presence of free intra-peritoneal blood and she underwent urgent laparotomy after resuscitation. At operation, 2 I of free blood were removed. There was a large retroperitoneal haematoma in the floor of the lesser sac, extending into the transverse mesocolon. The spleen was intact. The haematoma was evacuated and the source of the bleeding found to be branches of the splenic artery in the vicinity of a complete transection of the pancreas between the body and tail of the gland. No other intra-abdominal injury was found. The spleen and distal fragment of pancreas were removed. The transected end of the pancreas was overrun with prolene;
large tube drains were placed in the lesser sac and left subphrenic space. After this she made an uncomplicated recovery. Her serum amylase on the day after the operation was 340 units but consistently below this level thereafter. She was discharged 10 days after admission. Case 2 A 27-year-old woman was admitted following a road traffic accident in which she was the driver of a car involved in a low speed collision with a bus. She was not wearing a seat belt and had sustained injuries of the upper abdomen and the chin. On admission she was noted to be pale; there was some bruising over the left costal margin and a small cut on the chin. She was tender in the left hypochondrium but her abdomen was not distended and she had normal bowel sounds; blood pressure and pulse were normal. During observation in the Accident Department her condition deteriorated; her blood pressure fell to 70/40 mmHg and her pulse rose to llO/min. She was treated with an intravenous infusion and her pulse and blood pressure returned to normal. Over the next 3 days her condition remained satisfactory but her haemoglobin fell from 10.9 to 6.3 g per cent. At this stage the left hypochondria1 tenderness was more marked and her abdomen was slightly distended, although bowel sounds were still normal. A diagnostic peritoneal tap was carried out, confirming the presence of intraperitoneal blood. At operation free blood was found in the peritoneal cavity, with a large amount in the lesser sac. There was a large retroperitoneal haematoma around the duodenum and pancreas, extending into the transverse mesocolon. The liver and spleen were intact and no other intra-abdominal injury was found. The haematoma was evacuated; there was a complete transection of the pancreas exposing the superior and inferior mesenteric and splenic veins, although none of these vessels was apparently damaged. The distal part of the pancreas and the spleen were removed. The pancreatic duct was identified in the transected end of the gland and was ligated; the transected surface was oversewn with silk. A sump drain was placed in the lesser sac and a corrugated drain in the left subphrenic space. Her postoperative course was initially uneventful but was complicated by right-sided pulmonary embolism after 9 days; she was anticoagulated and made a good recovery. Her serum amylase immediately after the operation was 330 units and subsequently it was lower than this. She was discharged 7 weeks after admission.
DISCUSSION Approximately 20 per cent of pancreatic injuries follow blunt injury to the abdomen (Stone et al., 1981).
392
Ninety per cent of such injuries are associated with some other visceral damage, most frequently to the liver, spleen, small bowel or colon. Pancreatic injury is found to complicate l-2 per cent of cases of blunt abdominal injury (Heyse-Moore, 1976). The majority of such cases follow road traffic accidents (HeyseMoore, 1976). The manner of presentation of pancreatic injury is variable; there is often cardiovascular shock and increasing peritonism over a period of several hours (Robey et al., 1982). This is particularly likely if it is associated with some other visceral injury. Late presentation is relatively common up to 6 weeks after injury and may lead to pseudocyst formation (HeyseMoore, 1976; Henarejos et al., 1983). Investigation of a suspected pancreatic injury may be fruitless. Serum amylase is elevated in Xl-90 per cent of cases (British Medical Journal, 1975; Sims et al., 1984), but false positives occur in about 30 per cent of cases (Cameron and Wellwood, 1983). A full blood count may reveal a leucocytosis or increased haematocrit. Abdominal radiographs are usually unhelpful. Peritoneal lavage usually demonstrates free blood and the effluent is likely to show a high amylase content. In cases which are seen late, ultrasonography and computerized tomography are useful investigations. Pancreatic injuries may be classified simply: 1. Simple contusion. 2. Capsular tear without disruption of the duct. 3. Major disruption of the duct. 4. Combined pancreatico-duodenal injury. Non-operative management of pancreatic injuries is not recommended, being associated with a high incidence of complications and a mortality rate rising to 50 per cent (Heyse-Moore, 1976). However, this figure is misleading because a substantial number of minor, isolated pancreatic injuries are undoubtedly overlooked following blunt injury. Operative treatment has three fundamental objectives: (1) to define precisely the nature of the injury; (2) to control haemorrhage, which may be profuse because of both the vascular nature of the gland and the proximity of major vessels; (3) to provide adequate drainage and carry out resection when appropriate. The first two categories of pancreatic injurycontusion and laceration-are usually best treated by external drainage alone; sump drains are preferable. If the gland is disruptetiategories 3 and 4-a more radical surgical approach is needed. If the injury is to the left of the superior mesenteric vessels distal pancreatectomy, combined with external drainage, is the safest procedure. Some surgeons advocate preservation of the spleen if it is not injured as there is evidence that a high incidence of postoperative sepsis is associated with splenectomy (Robey et al., 1982). If the injury involves the proximal part of the gland and it is likely that major damage of the duct has occurred, some form of internal drainage may be employed. This can be achieved with a Roux loop
Injury: the British Journal of Accident Surgery (1985) Vol. 16/No. 6 Table 1. Complications 1. 2. 3. 4. 5. 6.
of pancreatic
injury
Pancreatic pseudocyst Pancreatic abscess Pancreatic fistula Pancreatitis Subphrenic abscess Wound infection
anastomosed to the pancreatic capsule at the site of the injury. There is, however, a very high risk of leakage
and a mortality of 38 per cent has been reported using this form of management (Stone et al., 1981). Injuries which involve both the head of the pancreas and the duodenum may be managed by partial pancreatico-duodenectomy (Whipple’s procedure), but such injuries are associated with a very high mortality20-30 per cent (Stone et al., 1981). If major damage extends to the body of the gland, total pancreatectomy should be considered. Many complications are associated with pancreatic injury (Table r). Complications occur in more than 50 per cent of cases (Sims et al., 1984), depending on the nature of the injury. Pancreatic injury must be considered in all cases of abdominal injury. Although a relatively uncommon complication of blunt injury, it may manifest itself in a large variety of ways. Prompt diagnosis and treatment are essential to prevent the development of serious complications. Acknowledgements
With thanks to Professor R. Y. Calne, FKCS and Mr B. H. Hand, MS, FRCS for permission to report on patients under their care, and Miss V. J. Hubert and Miss T. J. Mayes for typing the manuscript.
REFERENCES British Medical Journal (1975) Blunt pancreatic injury. Br. Med. J. 2, 4. Cameron A. E. and Wellwood J. M. (1983) Blunt injury of the pancreas. Br. J. Clin. Pratt. Feb., 34. Henarejos A., Cohen D. M. and Moosa A. R. (1983) Management of pancreatic trauma. Ann. R. Coil. Surg. 65, 297.
Heyse-Moore G. H. (1976) Blunt pancreatic and pancreaticoduodenal trauma. Br. J. Surg. 63, 226. Robey E., Mullen J. T,. and Schwab C. W. (1982) Biunt transection of the pancreas treated by distal pancreatectomy, spfenic salvage and hyperahmentation. Ann. Surg. 196, 695.
Sims E. H., Mandal A. K., Schlater T. et al. (1984) Factors affecting the outcome in pancreatic trauma. J. Trauma 24, 125.
Stone H. H., Fabian T. C., Satiani B. et al. (1981) Experiences in the management of pancreatic trauma. J. Trauma 21, 257.
Paper accepted
10 September
1984.
Requesrsfur reprinrs should be addressed to: P. J. Friend, FFKS, Department of Surgery, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ.
(1985) 16,391-392
Printedin
Great Britain
391
Blunt pancreatic injury: two case reports and a review of the literature P. J. Friend, N. V. Jamieson and R. MacFarlane Department
of Surgery, Addenbrooke’s
Hospital, Cambridge
Two cases are reported of patients who sustained transection of the pancreas without damage to any other intra-abdominal organ. Surgical management included distal pancreatectomy and splenectomy. The incidence and management of pancreatic injury are discussed.
INTRODUCTION of the pancreas is an uncommon of blunt abdominal injury. The pancreas is damaged in l-2 per cent of cases of abdominal injury but of these the majority (90 per cent) are associated with some other visceral injury, which is usually responsible for the initial symptoms. The cases reported here illustrate how isolated damage after moderate injury may present relatively late and without specific signs. ISOLATED
injury
complication
CASE REPORTS Case
1
A 27-year-old woman was admitted as an emergency case 9 hours after falling from a horse. She had landed on her left side, injuring her chest, knee and nose. At the time, it did not appear to be a major injury; she fell onto hard, rutted ground but was not kicked or trampled by the horse. She was well enough to drive herself home but developed increasing, left-sided abdominal pain. On admission she was noted to be tender in the left hypochondrium but the abdomen was not distended and she had normal bowel sounds. She was warm and pink with normal blood pressure and pulse. There were no external signs of injury of her chest or abdomen. Investigations at this stage included a haemoglobin of 11.1 g per cent and white cell count of 20x109/1. Radiographs of the abdomen and chest were normal. In the hour after admission her condition deteriorated, with increasing abdominal pain; she became clinically ‘shocked’. Diagnostic peritoneal lavage confirmed the presence of free intra-peritoneal blood and she underwent urgent laparotomy after resuscitation. At operation, 2 I of free blood were removed. There was a large retroperitoneal haematoma in the floor of the lesser sac, extending into the transverse mesocolon. The spleen was intact. The haematoma was evacuated and the source of the bleeding found to be branches of the splenic artery in the vicinity of a complete transection of the pancreas between the body and tail of the gland. No other intra-abdominal injury was found. The spleen and distal fragment of pancreas were removed. The transected end of the pancreas was overrun with prolene;
large tube drains were placed in the lesser sac and left subphrenic space. After this she made an uncomplicated recovery. Her serum amylase on the day after the operation was 340 units but consistently below this level thereafter. She was discharged 10 days after admission. Case 2 A 27-year-old woman was admitted following a road traffic accident in which she was the driver of a car involved in a low speed collision with a bus. She was not wearing a seat belt and had sustained injuries of the upper abdomen and the chin. On admission she was noted to be pale; there was some bruising over the left costal margin and a small cut on the chin. She was tender in the left hypochondrium but her abdomen was not distended and she had normal bowel sounds; blood pressure and pulse were normal. During observation in the Accident Department her condition deteriorated; her blood pressure fell to 70/40 mmHg and her pulse rose to llO/min. She was treated with an intravenous infusion and her pulse and blood pressure returned to normal. Over the next 3 days her condition remained satisfactory but her haemoglobin fell from 10.9 to 6.3 g per cent. At this stage the left hypochondria1 tenderness was more marked and her abdomen was slightly distended, although bowel sounds were still normal. A diagnostic peritoneal tap was carried out, confirming the presence of intraperitoneal blood. At operation free blood was found in the peritoneal cavity, with a large amount in the lesser sac. There was a large retroperitoneal haematoma around the duodenum and pancreas, extending into the transverse mesocolon. The liver and spleen were intact and no other intra-abdominal injury was found. The haematoma was evacuated; there was a complete transection of the pancreas exposing the superior and inferior mesenteric and splenic veins, although none of these vessels was apparently damaged. The distal part of the pancreas and the spleen were removed. The pancreatic duct was identified in the transected end of the gland and was ligated; the transected surface was oversewn with silk. A sump drain was placed in the lesser sac and a corrugated drain in the left subphrenic space. Her postoperative course was initially uneventful but was complicated by right-sided pulmonary embolism after 9 days; she was anticoagulated and made a good recovery. Her serum amylase immediately after the operation was 330 units and subsequently it was lower than this. She was discharged 7 weeks after admission.
DISCUSSION Approximately 20 per cent of pancreatic injuries follow blunt injury to the abdomen (Stone et al., 1981).
392
Ninety per cent of such injuries are associated with some other visceral damage, most frequently to the liver, spleen, small bowel or colon. Pancreatic injury is found to complicate l-2 per cent of cases of blunt abdominal injury (Heyse-Moore, 1976). The majority of such cases follow road traffic accidents (HeyseMoore, 1976). The manner of presentation of pancreatic injury is variable; there is often cardiovascular shock and increasing peritonism over a period of several hours (Robey et al., 1982). This is particularly likely if it is associated with some other visceral injury. Late presentation is relatively common up to 6 weeks after injury and may lead to pseudocyst formation (HeyseMoore, 1976; Henarejos et al., 1983). Investigation of a suspected pancreatic injury may be fruitless. Serum amylase is elevated in Xl-90 per cent of cases (British Medical Journal, 1975; Sims et al., 1984), but false positives occur in about 30 per cent of cases (Cameron and Wellwood, 1983). A full blood count may reveal a leucocytosis or increased haematocrit. Abdominal radiographs are usually unhelpful. Peritoneal lavage usually demonstrates free blood and the effluent is likely to show a high amylase content. In cases which are seen late, ultrasonography and computerized tomography are useful investigations. Pancreatic injuries may be classified simply: 1. Simple contusion. 2. Capsular tear without disruption of the duct. 3. Major disruption of the duct. 4. Combined pancreatico-duodenal injury. Non-operative management of pancreatic injuries is not recommended, being associated with a high incidence of complications and a mortality rate rising to 50 per cent (Heyse-Moore, 1976). However, this figure is misleading because a substantial number of minor, isolated pancreatic injuries are undoubtedly overlooked following blunt injury. Operative treatment has three fundamental objectives: (1) to define precisely the nature of the injury; (2) to control haemorrhage, which may be profuse because of both the vascular nature of the gland and the proximity of major vessels; (3) to provide adequate drainage and carry out resection when appropriate. The first two categories of pancreatic injurycontusion and laceration-are usually best treated by external drainage alone; sump drains are preferable. If the gland is disruptetiategories 3 and 4-a more radical surgical approach is needed. If the injury is to the left of the superior mesenteric vessels distal pancreatectomy, combined with external drainage, is the safest procedure. Some surgeons advocate preservation of the spleen if it is not injured as there is evidence that a high incidence of postoperative sepsis is associated with splenectomy (Robey et al., 1982). If the injury involves the proximal part of the gland and it is likely that major damage of the duct has occurred, some form of internal drainage may be employed. This can be achieved with a Roux loop
Injury: the British Journal of Accident Surgery (1985) Vol. 16/No. 6 Table 1. Complications 1. 2. 3. 4. 5. 6.
of pancreatic
injury
Pancreatic pseudocyst Pancreatic abscess Pancreatic fistula Pancreatitis Subphrenic abscess Wound infection
anastomosed to the pancreatic capsule at the site of the injury. There is, however, a very high risk of leakage
and a mortality of 38 per cent has been reported using this form of management (Stone et al., 1981). Injuries which involve both the head of the pancreas and the duodenum may be managed by partial pancreatico-duodenectomy (Whipple’s procedure), but such injuries are associated with a very high mortality20-30 per cent (Stone et al., 1981). If major damage extends to the body of the gland, total pancreatectomy should be considered. Many complications are associated with pancreatic injury (Table r). Complications occur in more than 50 per cent of cases (Sims et al., 1984), depending on the nature of the injury. Pancreatic injury must be considered in all cases of abdominal injury. Although a relatively uncommon complication of blunt injury, it may manifest itself in a large variety of ways. Prompt diagnosis and treatment are essential to prevent the development of serious complications. Acknowledgements
With thanks to Professor R. Y. Calne, FKCS and Mr B. H. Hand, MS, FRCS for permission to report on patients under their care, and Miss V. J. Hubert and Miss T. J. Mayes for typing the manuscript.
REFERENCES British Medical Journal (1975) Blunt pancreatic injury. Br. Med. J. 2, 4. Cameron A. E. and Wellwood J. M. (1983) Blunt injury of the pancreas. Br. J. Clin. Pratt. Feb., 34. Henarejos A., Cohen D. M. and Moosa A. R. (1983) Management of pancreatic trauma. Ann. R. Coil. Surg. 65, 297.
Heyse-Moore G. H. (1976) Blunt pancreatic and pancreaticoduodenal trauma. Br. J. Surg. 63, 226. Robey E., Mullen J. T,. and Schwab C. W. (1982) Biunt transection of the pancreas treated by distal pancreatectomy, spfenic salvage and hyperahmentation. Ann. Surg. 196, 695.
Sims E. H., Mandal A. K., Schlater T. et al. (1984) Factors affecting the outcome in pancreatic trauma. J. Trauma 24, 125.
Stone H. H., Fabian T. C., Satiani B. et al. (1981) Experiences in the management of pancreatic trauma. J. Trauma 21, 257.
Paper accepted
10 September
1984.
Requesrsfur reprinrs should be addressed to: P. J. Friend, FFKS, Department of Surgery, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ.