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Pancreatic injuries due to non-penetrating abdominal trauma
Pancreatic
Injuries Due to Non-penetrating Abdominal Trauma W. KINNAIRD,
DAVID
M.D., Louisville,
From the Department of Surgery, University of Louisville
condition. Other bIows, as from a policeman’s biIIy, bicycle handIebars and basebalI bats, are causative. Accident victims that are thrown from, run over, or crushed by automobiIes are particularly prone to injury of the pancreas. It is significant that even trivial bIows may be foIIowed months Iater by symptoms referabIe to the pancreas3 The widespread use of alcohol, with its attendant stimulation of the pancreas,12 may predispose the victim’s injured pancreas to inflammation. Pathology. Injuries to the pancreas can be convenientIy divided into three types as fol10~s: (I) simpIe contusion with edema, (2) hematoma or hemorrhage, and (3) varying degrees of Iacerations to compIete transection of the pancreas.3 The typica inffammatory response to injury occurs, and in addition, acinar Ieakage of pancreatic ferments with activation may result. The exact mechanism of activation is not cIear (various theories relate it to necrotic tissue, bite, ischemia or bacteria). The enzyme Iipase speeds the breakdown of fat to glycerin and fatty acids. CaIcium then combines with the fatty acids to produce typical findings of fat necrosis, which is a process of saponification. Activated trypsin may break down ceIluIar and in so doing open up damaged protein, bIood vessels, Ieading to further delayed hemorrhage. Amylase is apparentIy absorbed from the damaged organ, and a resultant rise in serum amyIase occurs. If the damage is sufbcient, an outpouring of these secretions and an attempt by the body to Iocalize this process wiI1 resuIt. This gives rise to the characteristic pseudocyst which may graduaIIy enIarge if there is continued Ieakage of secretions particuIarIy when there is obstruction or damage to the proxima1 duct system. Likewise, enzymatic breakdown of hematoma may resuIt in pseudocyst formation. If the inffammation subsides spontaneousIy, fibrosis (or caIcif?cation) of the pancreas may resuIt which may be
School of Medicine and the Louisville Veterans Administration Hospital, Louisville, Kentucky. ANCREATIC
injuries due to trauma are of etiologic types: operative, penetrating 7 SurgicaI trauma is by and non-penetrating. far the most common of these? Penetrating wounds of the pancreas, not commonly encountered in civiIian hospitals, are best considered under the genera1 problem of abdominal penetrations. BIunt injuries of this organ occur more frequentIy5J5 than generaIIy recognized (TabIe I), and for this reason deserve further emphasis. Mechanism. The pancreas, whiIe Iying in the dorsal region of the abdomen, has the disadvantage of fixation over the first Iumbar vertebra. This anatomic situation lends itseIf readiIy to the cIassic contrecoup type of injury folIowing bIows to the upper abdomen. In the day of super horsepower automobiles the steering whee1 injury is often responsibIe for this
P three
TABLE I FREQUENCY OF BLUNT TRAUMA TO PANCREAS
-
-
Acute HospitaI
j Years
Pan-
Blunt rrauma
FFE
,creas 1ilone
atitis
I
I San Francisco Hospital. . .‘1942-1950 St. Luke’s HospitaI, Bethlehem, Pa.. 1935-195 I Los AngeIes County HospitaI.. 1939-195 I Charity HospitaI of Louisiana. 1944-1954 Ohio State HospitaI 1948-1954 HarIem Hospital.. 1936-1946 Georgetown University HospitaI . 1946-195 I LouisviIIe Veterans Administration HospitaI.. . 1946-1954 American
Journal
of Surgery,
,_
I‘71
9
5
4
3
1,328
18
14
109
6
75
5 4
I35
4
155
-I
Volume gr. April,
4 rgr;b
Kentucky
I 552
Injuries
Pancreatic severe enough disturbances.
to produce
diabetes
tained. This procedure has been employed in a number of instances at the LouisviIle Veterans Administration Hospital, and so far as we kno\\, there has been no morbidity or mortality. Lahorator\-. Elevation of the serum am~lase is a definite aid in diagnosis. This test is quickI?- and easil)- run, and most laboratories report results in Somogyi units, the normal being from 60 to 200 (varies with hospitals). Characteristically, the amylase level ma\ fall to normal within forty-eight hours. It is 1~~ no means infallible, as high amvlase may result from upper intestinal perforation or following use of morphine SO, with production of spasm of the sphincter of Oddi. A rising amvlase is, of course, more diagnostic than an isolated elevated reading. The white blood count most often is elevated to 10,000 to 12^,000. The red f,lood count and hemoglobin are within normal limits in the early phase unless there has been massive hemorrhage, but falI in the red cell mass as well as plasma volume can be anticipated. As fat necrosis is not often extensive in comparison to non-traumatic pancreatitis, the level of serum calcium is usually normal. Scout x-ray films of the abdomen often reveal some degree of localized ileus, the so-called “sentinel loop.” ~Ffanagement. The following are general principles of management applied to injuries to the pancreas alone. These should not be construed as a conservative regimen; rather they are the basis of active treatment in both operative and non-operative cases. I. Reduction of pancreatic secretion, ;iccomplished b?;: ia) Absolute starvation to diminish gastric secretory activity and hence humoral (secretin) stimulation of the pancreas. (b) Nasogastric indwelling tube with removal of stomach contents, which has dual purpose of decreasing pancreatic secretions and relieving distressing ileus. (c) Parasympatholytic drugs which fjlock the neurogenic (vagal) control of pancreatic function. Atropine is effective although pro-banthine@ is the drug of choice. Pro-banthine is given in doses of 50 mg. intravenousl,v, four times a day, until tablets can be substituted. These drugs, in addition. reduce gastric hydrochloric acid formation. 2. Reduction of pain I~\- the use of: (a) DemeroI,@ IOO mg. every three to four hours. Morphine sulfate is contraindicated as it tends
or digestive
Clinicul Picture. When the pancreas alone is injured, the symptoms and physical findings vary depending on the severity. There is often a delay of twenty-four to seventy-two hours in onset of the complaints.2,7 Pam is always present and ma)- be mild to excruciating. It is usually upper abdominal (left, right or epigastric), not necessarily fjand-like, and frequentIS is diffuse. Radiation to back and shoulders occurs at times. Nausea and vomiting may be pronounced. Shock, contrar?; to most books, is rare’ except with complete transection where major vessels are severed. Physical Iindings are tenderness lvith guarding or rigidity, and rebound of the upper abdomen, although occasionally these signs may be more diffuse. A low grade temperature elevation is most often present. In approximatelv 50 per cent of cases, there are important associated intraand extraabdominal injuries which may mask the pancreatic injury. Head injuries, rib, long bone and spinal fractures are common, and too much stress cannot be placed upon diligent observations for the deveIopment of abdominal symptoms in these unfortunate accident victims. Lacerations of the liver, spleen and kidne?; are the most frequently” associated intra-abdominal injuries. The signs and symptoms following injuries to these solid viscera or to the hollow\\- viscera may overshadow pancreatic trauma. A not too common, but grave, associated injury is retroperitoneal laceration of the duodenum.3,x Occasionally, this suspected injur!, may be diagnosed clinically b? the presence of air along the psoas muscle on x-ray of the abdomen or by the instillation of IipiodoI via a Levin tube with x-ray demonstration of leakage from the duodenum. If there is doubt concerning the diagnosis (that is, suspicion of other injuries), an extremely worth while procedure is the use of paracentesis to obtain peritoneal fluid.‘,” This may be clone in the right lower quadrant with the patient in the right lateral position (or even attempted in all four quadrants as suggested bv Prigot*). The fluid in typical pancreatic injuries is thin :tnd blood-tinged, and arnylase determinations (on as little as 0.2 cc.) are anywhere reported from 5,000 to 50,000 Somogvi units. The presence of bile or intestina! contents in the fIuid can easily be ascer-
453
Kinnaird the typica green-bIack peritonea1 discoIoration.3 In the presence of contusion with edema or hematoma, simple drainage of the invoIved areas is indicated. Commonly, drains are pIaced behind the mobilized duodenum to the head, through the gastrocoIic ligament, to the body and tail, and via the Iesser omenta1 bursae to the body. The use of a sump type of drain wiI1 obviate difflcuIty with erosion of the skin. When extensive or compIete Iacerations are present, carefu1 attention to the injured ducts is required. If the proxima1 duct is transected, repair may be necessary. Distal duct injuries can be controIled by Iigation. Devitalized portions of the gland shouId be excised. The cut ends, in cases of compIete transection, should be cIosed with mattress sutures. Adequate drainage once again in all cases shouId be exercised. If there are serious associated intra-abdomina1 injuries (such as to the liver, spIeen or hoIIow viscera) with warning symptoms and signs, certainly exploration and management according to estabIished practices is carried out. Pancreatic injuries discovered at such times are handIed as noted heretofore. Mortality. No Iarge series have been reported, but it was possibIe to review case reports of forty-seven instances of bIunt trauma to the pancreas aIone over the past ten
to produce spasm of the sphincter of Oddi. (b) Continuous epiduraI anaIgesia.6 In the past, spIanchnic or Iumbar paravertebra1 bIocks were used to interrupt the visceral afferent fibers from the pancreas. Although these were often effective, epidura1 block has recentIy proved to be more efficient with the added ease of intermittent injections. A smaI1 catheter is passed to the IeveI of the eighth thoracic vertebra and procaine is injected once to twice per twenty-four hours. 3. Prevention of abscesses, or contro1 of secondary infection, with the broad-spectrum antibiotics. 4. Repeated intravenous injections of serum aIbumin have been shown to have a decidedIy beneficial effect on non-traumatic pancreatitis,g and probabIy traumatic pancreatitis as weI1. This has been attributed to its known antitryptic effect, although present work suggests that this is due simpIy to repIacement of depIeted body proteins. 3. Finally, rigid controt of the body electrolytes and fluid requirements must be exercised, as we11 as replacement of any defects in this system. Under this heading wouId come prophylaxis or treatment of hypocaIcemia. Operative Principles. Extreme conservatism15*16 as regards surgery in a11 types of pancreatitis has been practiced in the past, and this is true today in a number of cIinics. This reIuctance to operate stems from the high mortaIity reported previousIy. On the other hand, there are cIinics where immediate surgery with drainage is the recommended procedure for a11 cases of traumatic pancreatitis.*fz5 However, the majority of writers seem to favor non-operative management of the miId cases and reserve operative intervention for those cases which fai1 to improve or worsen after the institution of the foregoing pIan of therapy.3,5vlj In this connection, I wouId Iike to quote from Dr. Joseph HamiIton’s discussion of a paper on this subject at the meeting of The American Association for the Surgery of Trauma in 1931.~ He stated, “It wouId seem that the great amount of highIy active juice, as we11 as bits of digested pancreas that drain from some of these patients are better outside than inside the abdomen.” In undertaking expIoration of this type of injury it is mandatory that the duodenum be mobiIized and inspected in its retroperitoneal areas for perforation, even in the absence of
years.2,7.8,1~,1~.18,19,22.23,25,26,29,30
There
were
three
deaths among these cases, a mortaIity rate of 6 per cent. There is no question but that the mortaIity in traumatic pancreatitis with associated injuries is higher and reflects the seriousness of injuries to the spleen, Iiver, hoIIow viscera and so forth.3 Sequelae and Treatment. FistuIas are common sequeIae, usuaIly occurring in the operative cases. These tend to cIose spontaneousIy,26 provided there is no obstruction (damage) to the proxima1 duct system. Management of fistuIas revoIves around protection of adjacent skin and contro1 of electroIytes. Persistent fistuIas may require surgery7 with excision of a portion of the pancreas or impIantation of the f?stuIa. Pseudocysts may deveIop in either operative or non-operative cases. RareIy the cysts subside spontaneousIy, aIthough the large majority require surgica1 drainage. It is preferabIe to withhold- treatment until the cysts enIarge and produce symptoms. Treatment of choice 554
Injuries
Pancreatic
In cases of complete transection Comment. such as this one the clinical picture estabIishes the need for immediate laparotomy. Although this t> pe of in jur,v has carried :I high mortalit! ri~:~r~:~geri~crit in the past, \I-ith present-day
is some type of internal drainage such as cystogastrostomy or cystojejunostomy. hlarsupialization may- be used in poor risk cases, but persistent fist&s may rr:suIt. OccasionaIly cysts may be excised if location is favorable.
5004
/ DAYS
---------3
I’~I”I~~I”1~,1’~(~~1~‘,.~,
3
6
9
12
15
18
21
24
27
30
60
Amylase values in case of severe trauma (bIunt‘\ to pancreas.
FIG.
2. (hse
they- should surviva I. Fro. I. Case 1. Blunt abdominal division of the pancreas.
have
an equally
good chance
for
a sixty-three year old white CASEi II. w. kk, man, was admitted on January 8, 1953, with a history of having been in an automobile accident. The patient apparentIy was inebriated at the time of the accident. Severe pain and upper abdominal tenderness and rigidity were present. Fracture of the fifth and sixth ribs on the right was noted, with pneumothorax as well as suggestive subluxation of the second lumbar on the third Iumbar vertebra. The white blood count was 13,800. Serum amylase was 320 Somogyi units. Paracentesis yielded bloody lluid with amylase of 5,139 Somogyi units. At cxploration there was dark, thin bloody fluid with diffuse fat necrosis. The pancreas was edematous with hematoma. The galIbIadder was found to be tense and non-compressible. Operation was cholecystostomy with drainage of the pancreas. Psychosis developed on the sixth postoperative day. A fistula drained for eight weeks but was finally controlled by catheter suction. On follow-up cxamination six months later, the patient was asymptomatic.
injury with complete
Impermanent or permanent diabetes can be controlled fly usual dietary regulation with insulin therapy. Digestive disturbances, such as steatorrhea due to pancreatic insufficiency, are a probIem; however, replacement therapy with pancreatin (8 gm. three times a day) is of value.iv13 Chronic recurrent pancreatitis may follow, and this is perplexing and difficult as evidenced by the mubiplicity of operative procedures proposed for its solution. Time wiII not permit discussion of procedures designed for this distressing complication. CASE
IV.
REPORTS
CASE I. P. c., a twenty-eight year old white man, was admitted on January 6, 1954, with a history of crushing injury (railroad cars). The patient exhibited profound shock and his abdomen was rigid. On admission the white blood count was 22,900. At operation 3,500 cc. of bIood were present in the peritoneal cavity. There was complete laceration of the dista1 pancreas and splenic vessels. (Fig. I.) Distal pancreatrctomy was performed with splenectomy and drainage. Moderate drainage from the pancreas occurred with no excoriation. On the fifth postoperative day therapy m-as begun with anticoaguIants as a prophylactic measure in view of a rising pIatelet count. Death resulted from massive hemorrhage on the eighth postoperative day before emergency measures could be instituted. Postmortem examination showed no definite site of hemorrhage.
This patient was explored as he Comment. was not improving under treatment, and the peritonea1 tap suggested significant intraperitoneal hemorrhage. The development of psychosis fins been reported by others.ZR &SE III. K. hf., a fifty-eight year oId white man, was admitted on November IO, 1952, with a history of crushing injury (truck and loading platform). A large 5 by 7 cm. movable tender mass was present in the left hypochondrium. Vital signs were stable. The white blood count was 19,000. Amylase was 176 Somogyi units. At exploration there was massive hematoma of the pancreas as we11 as the base of mesentery, mesocolon and duo555
Kinnaird denum. Suggestive fat necrosis was noted. Simple drainage was instituted. No fistulas developed postoperatively, but the mass remained, apparentIy as a pseudocyst. The patient was discharged, only to return two weeks later with an acute con-
months after discharge he was asymptomatic. ShortIy thereafter he was sent to prison for chicken steaIing. Reports from the patient’s mother indicate he is asymptomatic but she states, “Doctor, he just don’t act right anymore.”
I______;,--_____,
OAYS 3
6
9
12 I5 I6
21
60
FIG. 4. Case v. Persistent eIevation of serum amylase in patient with blunt pancreatic injury. Comment. We had an unusua1 opportunity to see the injured pancreas on two occasions in this case, and it was impressive to note the progression of the edematous pancreas to that of hemorrhage with necrosis. This patient was extremeIv sick and he Dresented many probIems in management of the severe injury to the pancreas. The psychosis folIowing Iong-continued atropine cIeared rapidIy following its cessation.
FIG. 3. Case IV. Edema and hemorrhage of pancreas at time of exploration foIIowing blunt trauma. dition of the abdomen and disappearance of the mass. Serum amyIase at this admission was 921 Somogyi units. At operation the large pseudocyst of the pancreas had ruptured into free peritonea space. The cyst was drained. AmyIase on the cystic contents was 40,000 Somogyi units. The fistuIa cIosed in severa months. Ten months Iater, at the time of ventral hernia repair, there was only residual nodularity of the head of the pancreas. The patient is now asymptomatic.
1
CASE v.
D. J., a thirty-three year oId white on July 12, 1952, with a history of being thrown from a truck thirty hours prior to admission. ApparentIy he was inebriated at the time of the accident. There was diffuse abdominal pain, aIong with tenderness and spasm. Fracture of the ninth and eleventh ribs on the Ieft side, and also compression of the eleventh thoracic vertebra were noted. Vita1 signs were stable. Amylase was 344 Somogyi units. (Fig. 4.) The white blood count was 14,000. Non-operative management was instituted, with improvement. On the eighth day the patient became psychotic; this condition was attributed to massive atropine therapy. Nineteen days Iater recurrence of symptoms developed, which was quickly controIled by banthinem therapy. He returned one month after discharge with symptoms of pancreatitis, again controlled by banthine. FoIIow-up two years Iater revealed a history of occasional epigastric pains, nausea and vomiting. Work-up at that time was negative.
man, was admitted
Comment. This spontaneous rupture of the pseudocyst is quite unusua1, aIthough Koucky and co-workers reported six cases.28 The tendency toward spontaneous cIosure of the fistuIa is Zustrated by this patient. CASE IV. K. B., a twenty-eight year oId Negro man, was admitted on May 18, 1951. His abdomen had been stomped on by assailants forty-eight hours previousIy. The white bIood count was 8,700, with 36 stab forms. Amylase was 410 Somogyi units. (Fig. 2.) Vita1 signs were stabIe. AbdominaI findings were diffuse. At exploration there was dark brown, thin fluid, with fat necrosis of the omentum. (Fig. 3.) The pancreas was markedIy edematous and rubbery. The pancreas was drained. Four weeks postoperativety the patient was reoperated upon, with release of obstructing, encircling scars of the distal portion of the stomach. The pancreas at this time showed marked hemorrhage and necrosis. A fistuIa was a diffIcuIt problem but it cIosed in three months. The patient deveIoped toxic psychosis due to atropine poisoning. Four
Comment.
response Iished the
The cIinica1 picture and the to non-operative management estabdiagnosis
in this
case.
and
bve were
abIe to continue without surgery; at times, however, we were on the verge of operating upon this Datient. This oatient demonstrated again a toxic psychosis from atropine. Banthine I
556
Pancreatic
Injuries IO. SWISH, R. S. Traumatic rupture of the pancreas. Northzuest ,Vled., 47: 892, 1948. I I. THISTI.EHU..UTE, .I. R. The effect of banthine, vagotomy, and subtotal gastrcctomy upon pancreatic secretion. Surg., &rec. @ Ohsl., 93 : hr6,
was substituted and it was effective in controlling symptoms for several months. We suspect this patient will continue to have difficulty, as he will abuse his pancreas with bouts of heavy- drinking.
,c)jr.
PO~IBER, H. L. and NECHELES, II. Pancreatic injuries, an experimental study. Surf., Gynec. c1Ohst., 93: 621, 1951. 13. DKA(;STED.I., L. R. Some physiologic problems in surgery of the pancreas. Ann. Surp., I 18: 576. 12.
SUMMARY I. Blunt trauma to the pancreas occurs more often than is generally recognized. 2. This injury is frequentIy associated with other intra- and extra-abdominal injuries. 3. A pIan of non-operative treatment of aI1 cases has been outhned. 4. Operative intervention, according to principles listed, is reserved for the more serious cases and for those cases in which there are grave associated intra-abdominal injuries. 5. The mortality rate in pancreatic injuries alone, incIuding both operative and non-operatives cases, is around 6 per cent, according to the recent literature. 6. Five cases, personally observed, have been reported.
19.43. 14. NA~;I,ZIGER,H. C. and MCCORKLE, I-I. J. The recognition and management of acute trauma to the pancreas, with particular reference to use of the serum amylase test. Ann, Surg., I 18: 594, 1943. 15. SHALLOW, T. B. and WAGKER, F. B., JR. Traumatic pancreatitis. Ann. Surg., I 27: 66, 1947. 16. BERK, .I. E. Management of acute pancreatitis. J, A. M. A., 152:-r, 1953. 17. HITKEN. N. F. and STEVENSON. V. L. Traumatic rupture of the choIedochus associated with an acute hemorrhagic pancreatitis and biIe peritonitis. Ann. Surg., 128: I 178, 1948. 18. BERKE, C. J. and WALTERS, R. L. Traumatic pancreatitis. California Med., 79: 279, 1953. 19. BECKER, W. F. Traumatic pancreatitis. Am. Surgeon, 20: 525, 1954. 20. HOWARD, J. hl. SurgicaI physioIogy of pancreatitis. S. Clin. North America, 29: 1789, 1949. 21. KEITH. L. M.. JK.. ZOLLINGER. R. M. and M&LEERY, ‘R. S. PeritoneaI kuid amyIase determinations as an aid in diagnosis of acute pancreatitis. Arch. Surg., 61: 930, 1950. 22. ZOLLINGER, R. M. and BOLES, T. The probIem of pancreatitis. Rock,y Mountain M. J., so: $54, 1953. 23. COFFEY, R. J. UnusuaI features of acute pancreatic disease. Ann. Surg., 135: 715, 1952. 24. MACKENZIE. W. C. Pancreatitis: fundamenta1 and clinica aspects. Bull. Am. Coil. Surgeons. 40: 23,
REFERENCES I. BAKNBROOK, D. H. Impermanent
z. 3.
4.
5.
6.
diabetes: a complication of traumatic pancreatitis. Canad. M. A. J., 40: 143, 1952. KINI, J. M. Traumatic pancreatitis. Am. Surgeon, 18: 596, 1052. ESTES, W. L., Jr<., BOW&IAN,T. L. and MEILICKE, F. F. Non-penetrating abdominal trauma with special reference to the duodenum and pancreas. Am. J. Surg.. 83: 434, 1952. I IAMILTON. J. E. American Association for the Surgery ‘of Trauma Meeting, 1951. Am. J. Surg., 83: 450, 1952. MATHEWSON, C. and IIALTER, B. L. Traumatic pancreatitis with and without associated injuries. Am. J. Surg., 83: 409, 1952. ORIT, R. B. and WARREN, K. W. EpiduraI anaIgesia in acute pancreatitis. Luhey Clin. Bull., 6: 204,
1955. 25. JOSEPH, IM. The pancreas
and the steering whee1. B’est. J. Surg., 60: 129, 1952. 26. ALDIS, A. S. Injuries to the pancreas and their surgicaI treatment. Brit. J. Surg., 33: 323, 1946. 27. STRODE, J. E. and GILBERT, F. I. Retro-peritoneal rupture of the duodenum foIlowing non-penetrating injuries to the duodenum. Arch. Surg.,
I gso. 7. \VARKEN, K.
W. Management of pancreatic injuries. S. C&n. North America, 31: 789, 1951. 8. WRIGHT, L. T., PRIGOT, A. and HILL, L. M. Traumatic subcutaneous injuries to the pancreas. Am. J. Sup-., 80: 170, 1950. 9. KENWEI.L, H. N. and WELLS, P. B. Acute hemorrhagic pancreatitis; report of eleven consecutive cases treated with human serum albumin. Surg., Grxec. C* Ohst., 96: 169, 1953.
70: 343. 1955. 28. KOI CKY, J. D., BE~:K, W. C. and Tono, hl. D. The perforation of pancreatic pseudocysts: ;I report of six cases. Surg., Gynec. t-7 Ohst., 75: I I 3, 194 I. 29. BURKETT, W. Traumatic rupture of the pancreas. Brit. ,v. J., 4928: 1455, 1955. 3”. GWINN, J. L.. ELLIS, F. H. and HAYLES, A. B. Injury of the pancreas in a child. Pmt. Smfl Meet., Mayo Clin., 30: Ior, Igjj.
557
Injuries Due to Non-penetrating Abdominal Trauma W. KINNAIRD,
DAVID
M.D., Louisville,
From the Department of Surgery, University of Louisville
condition. Other bIows, as from a policeman’s biIIy, bicycle handIebars and basebalI bats, are causative. Accident victims that are thrown from, run over, or crushed by automobiIes are particularly prone to injury of the pancreas. It is significant that even trivial bIows may be foIIowed months Iater by symptoms referabIe to the pancreas3 The widespread use of alcohol, with its attendant stimulation of the pancreas,12 may predispose the victim’s injured pancreas to inflammation. Pathology. Injuries to the pancreas can be convenientIy divided into three types as fol10~s: (I) simpIe contusion with edema, (2) hematoma or hemorrhage, and (3) varying degrees of Iacerations to compIete transection of the pancreas.3 The typica inffammatory response to injury occurs, and in addition, acinar Ieakage of pancreatic ferments with activation may result. The exact mechanism of activation is not cIear (various theories relate it to necrotic tissue, bite, ischemia or bacteria). The enzyme Iipase speeds the breakdown of fat to glycerin and fatty acids. CaIcium then combines with the fatty acids to produce typical findings of fat necrosis, which is a process of saponification. Activated trypsin may break down ceIluIar and in so doing open up damaged protein, bIood vessels, Ieading to further delayed hemorrhage. Amylase is apparentIy absorbed from the damaged organ, and a resultant rise in serum amyIase occurs. If the damage is sufbcient, an outpouring of these secretions and an attempt by the body to Iocalize this process wiI1 resuIt. This gives rise to the characteristic pseudocyst which may graduaIIy enIarge if there is continued Ieakage of secretions particuIarIy when there is obstruction or damage to the proxima1 duct system. Likewise, enzymatic breakdown of hematoma may resuIt in pseudocyst formation. If the inffammation subsides spontaneousIy, fibrosis (or caIcif?cation) of the pancreas may resuIt which may be
School of Medicine and the Louisville Veterans Administration Hospital, Louisville, Kentucky. ANCREATIC
injuries due to trauma are of etiologic types: operative, penetrating 7 SurgicaI trauma is by and non-penetrating. far the most common of these? Penetrating wounds of the pancreas, not commonly encountered in civiIian hospitals, are best considered under the genera1 problem of abdominal penetrations. BIunt injuries of this organ occur more frequentIy5J5 than generaIIy recognized (TabIe I), and for this reason deserve further emphasis. Mechanism. The pancreas, whiIe Iying in the dorsal region of the abdomen, has the disadvantage of fixation over the first Iumbar vertebra. This anatomic situation lends itseIf readiIy to the cIassic contrecoup type of injury folIowing bIows to the upper abdomen. In the day of super horsepower automobiles the steering whee1 injury is often responsibIe for this
P three
TABLE I FREQUENCY OF BLUNT TRAUMA TO PANCREAS
-
-
Acute HospitaI
j Years
Pan-
Blunt rrauma
FFE
,creas 1ilone
atitis
I
I San Francisco Hospital. . .‘1942-1950 St. Luke’s HospitaI, Bethlehem, Pa.. 1935-195 I Los AngeIes County HospitaI.. 1939-195 I Charity HospitaI of Louisiana. 1944-1954 Ohio State HospitaI 1948-1954 HarIem Hospital.. 1936-1946 Georgetown University HospitaI . 1946-195 I LouisviIIe Veterans Administration HospitaI.. . 1946-1954 American
Journal
of Surgery,
,_
I‘71
9
5
4
3
1,328
18
14
109
6
75
5 4
I35
4
155
-I
Volume gr. April,
4 rgr;b
Kentucky
I 552
Injuries
Pancreatic severe enough disturbances.
to produce
diabetes
tained. This procedure has been employed in a number of instances at the LouisviIle Veterans Administration Hospital, and so far as we kno\\, there has been no morbidity or mortality. Lahorator\-. Elevation of the serum am~lase is a definite aid in diagnosis. This test is quickI?- and easil)- run, and most laboratories report results in Somogyi units, the normal being from 60 to 200 (varies with hospitals). Characteristically, the amylase level ma\ fall to normal within forty-eight hours. It is 1~~ no means infallible, as high amvlase may result from upper intestinal perforation or following use of morphine SO, with production of spasm of the sphincter of Oddi. A rising amvlase is, of course, more diagnostic than an isolated elevated reading. The white blood count most often is elevated to 10,000 to 12^,000. The red f,lood count and hemoglobin are within normal limits in the early phase unless there has been massive hemorrhage, but falI in the red cell mass as well as plasma volume can be anticipated. As fat necrosis is not often extensive in comparison to non-traumatic pancreatitis, the level of serum calcium is usually normal. Scout x-ray films of the abdomen often reveal some degree of localized ileus, the so-called “sentinel loop.” ~Ffanagement. The following are general principles of management applied to injuries to the pancreas alone. These should not be construed as a conservative regimen; rather they are the basis of active treatment in both operative and non-operative cases. I. Reduction of pancreatic secretion, ;iccomplished b?;: ia) Absolute starvation to diminish gastric secretory activity and hence humoral (secretin) stimulation of the pancreas. (b) Nasogastric indwelling tube with removal of stomach contents, which has dual purpose of decreasing pancreatic secretions and relieving distressing ileus. (c) Parasympatholytic drugs which fjlock the neurogenic (vagal) control of pancreatic function. Atropine is effective although pro-banthine@ is the drug of choice. Pro-banthine is given in doses of 50 mg. intravenousl,v, four times a day, until tablets can be substituted. These drugs, in addition. reduce gastric hydrochloric acid formation. 2. Reduction of pain I~\- the use of: (a) DemeroI,@ IOO mg. every three to four hours. Morphine sulfate is contraindicated as it tends
or digestive
Clinicul Picture. When the pancreas alone is injured, the symptoms and physical findings vary depending on the severity. There is often a delay of twenty-four to seventy-two hours in onset of the complaints.2,7 Pam is always present and ma)- be mild to excruciating. It is usually upper abdominal (left, right or epigastric), not necessarily fjand-like, and frequentIS is diffuse. Radiation to back and shoulders occurs at times. Nausea and vomiting may be pronounced. Shock, contrar?; to most books, is rare’ except with complete transection where major vessels are severed. Physical Iindings are tenderness lvith guarding or rigidity, and rebound of the upper abdomen, although occasionally these signs may be more diffuse. A low grade temperature elevation is most often present. In approximatelv 50 per cent of cases, there are important associated intraand extraabdominal injuries which may mask the pancreatic injury. Head injuries, rib, long bone and spinal fractures are common, and too much stress cannot be placed upon diligent observations for the deveIopment of abdominal symptoms in these unfortunate accident victims. Lacerations of the liver, spleen and kidne?; are the most frequently” associated intra-abdominal injuries. The signs and symptoms following injuries to these solid viscera or to the hollow\\- viscera may overshadow pancreatic trauma. A not too common, but grave, associated injury is retroperitoneal laceration of the duodenum.3,x Occasionally, this suspected injur!, may be diagnosed clinically b? the presence of air along the psoas muscle on x-ray of the abdomen or by the instillation of IipiodoI via a Levin tube with x-ray demonstration of leakage from the duodenum. If there is doubt concerning the diagnosis (that is, suspicion of other injuries), an extremely worth while procedure is the use of paracentesis to obtain peritoneal fluid.‘,” This may be clone in the right lower quadrant with the patient in the right lateral position (or even attempted in all four quadrants as suggested bv Prigot*). The fluid in typical pancreatic injuries is thin :tnd blood-tinged, and arnylase determinations (on as little as 0.2 cc.) are anywhere reported from 5,000 to 50,000 Somogvi units. The presence of bile or intestina! contents in the fIuid can easily be ascer-
453
Kinnaird the typica green-bIack peritonea1 discoIoration.3 In the presence of contusion with edema or hematoma, simple drainage of the invoIved areas is indicated. Commonly, drains are pIaced behind the mobilized duodenum to the head, through the gastrocoIic ligament, to the body and tail, and via the Iesser omenta1 bursae to the body. The use of a sump type of drain wiI1 obviate difflcuIty with erosion of the skin. When extensive or compIete Iacerations are present, carefu1 attention to the injured ducts is required. If the proxima1 duct is transected, repair may be necessary. Distal duct injuries can be controIled by Iigation. Devitalized portions of the gland shouId be excised. The cut ends, in cases of compIete transection, should be cIosed with mattress sutures. Adequate drainage once again in all cases shouId be exercised. If there are serious associated intra-abdomina1 injuries (such as to the liver, spIeen or hoIIow viscera) with warning symptoms and signs, certainly exploration and management according to estabIished practices is carried out. Pancreatic injuries discovered at such times are handIed as noted heretofore. Mortality. No Iarge series have been reported, but it was possibIe to review case reports of forty-seven instances of bIunt trauma to the pancreas aIone over the past ten
to produce spasm of the sphincter of Oddi. (b) Continuous epiduraI anaIgesia.6 In the past, spIanchnic or Iumbar paravertebra1 bIocks were used to interrupt the visceral afferent fibers from the pancreas. Although these were often effective, epidura1 block has recentIy proved to be more efficient with the added ease of intermittent injections. A smaI1 catheter is passed to the IeveI of the eighth thoracic vertebra and procaine is injected once to twice per twenty-four hours. 3. Prevention of abscesses, or contro1 of secondary infection, with the broad-spectrum antibiotics. 4. Repeated intravenous injections of serum aIbumin have been shown to have a decidedIy beneficial effect on non-traumatic pancreatitis,g and probabIy traumatic pancreatitis as weI1. This has been attributed to its known antitryptic effect, although present work suggests that this is due simpIy to repIacement of depIeted body proteins. 3. Finally, rigid controt of the body electrolytes and fluid requirements must be exercised, as we11 as replacement of any defects in this system. Under this heading wouId come prophylaxis or treatment of hypocaIcemia. Operative Principles. Extreme conservatism15*16 as regards surgery in a11 types of pancreatitis has been practiced in the past, and this is true today in a number of cIinics. This reIuctance to operate stems from the high mortaIity reported previousIy. On the other hand, there are cIinics where immediate surgery with drainage is the recommended procedure for a11 cases of traumatic pancreatitis.*fz5 However, the majority of writers seem to favor non-operative management of the miId cases and reserve operative intervention for those cases which fai1 to improve or worsen after the institution of the foregoing pIan of therapy.3,5vlj In this connection, I wouId Iike to quote from Dr. Joseph HamiIton’s discussion of a paper on this subject at the meeting of The American Association for the Surgery of Trauma in 1931.~ He stated, “It wouId seem that the great amount of highIy active juice, as we11 as bits of digested pancreas that drain from some of these patients are better outside than inside the abdomen.” In undertaking expIoration of this type of injury it is mandatory that the duodenum be mobiIized and inspected in its retroperitoneal areas for perforation, even in the absence of
years.2,7.8,1~,1~.18,19,22.23,25,26,29,30
There
were
three
deaths among these cases, a mortaIity rate of 6 per cent. There is no question but that the mortaIity in traumatic pancreatitis with associated injuries is higher and reflects the seriousness of injuries to the spleen, Iiver, hoIIow viscera and so forth.3 Sequelae and Treatment. FistuIas are common sequeIae, usuaIly occurring in the operative cases. These tend to cIose spontaneousIy,26 provided there is no obstruction (damage) to the proxima1 duct system. Management of fistuIas revoIves around protection of adjacent skin and contro1 of electroIytes. Persistent fistuIas may require surgery7 with excision of a portion of the pancreas or impIantation of the f?stuIa. Pseudocysts may deveIop in either operative or non-operative cases. RareIy the cysts subside spontaneousIy, aIthough the large majority require surgica1 drainage. It is preferabIe to withhold- treatment until the cysts enIarge and produce symptoms. Treatment of choice 554
Injuries
Pancreatic
In cases of complete transection Comment. such as this one the clinical picture estabIishes the need for immediate laparotomy. Although this t> pe of in jur,v has carried :I high mortalit! ri~:~r~:~geri~crit in the past, \I-ith present-day
is some type of internal drainage such as cystogastrostomy or cystojejunostomy. hlarsupialization may- be used in poor risk cases, but persistent fist&s may rr:suIt. OccasionaIly cysts may be excised if location is favorable.
5004
/ DAYS
---------3
I’~I”I~~I”1~,1’~(~~1~‘,.~,
3
6
9
12
15
18
21
24
27
30
60
Amylase values in case of severe trauma (bIunt‘\ to pancreas.
FIG.
2. (hse
they- should surviva I. Fro. I. Case 1. Blunt abdominal division of the pancreas.
have
an equally
good chance
for
a sixty-three year old white CASEi II. w. kk, man, was admitted on January 8, 1953, with a history of having been in an automobile accident. The patient apparentIy was inebriated at the time of the accident. Severe pain and upper abdominal tenderness and rigidity were present. Fracture of the fifth and sixth ribs on the right was noted, with pneumothorax as well as suggestive subluxation of the second lumbar on the third Iumbar vertebra. The white blood count was 13,800. Serum amylase was 320 Somogyi units. Paracentesis yielded bloody lluid with amylase of 5,139 Somogyi units. At cxploration there was dark, thin bloody fluid with diffuse fat necrosis. The pancreas was edematous with hematoma. The galIbIadder was found to be tense and non-compressible. Operation was cholecystostomy with drainage of the pancreas. Psychosis developed on the sixth postoperative day. A fistula drained for eight weeks but was finally controlled by catheter suction. On follow-up cxamination six months later, the patient was asymptomatic.
injury with complete
Impermanent or permanent diabetes can be controlled fly usual dietary regulation with insulin therapy. Digestive disturbances, such as steatorrhea due to pancreatic insufficiency, are a probIem; however, replacement therapy with pancreatin (8 gm. three times a day) is of value.iv13 Chronic recurrent pancreatitis may follow, and this is perplexing and difficult as evidenced by the mubiplicity of operative procedures proposed for its solution. Time wiII not permit discussion of procedures designed for this distressing complication. CASE
IV.
REPORTS
CASE I. P. c., a twenty-eight year old white man, was admitted on January 6, 1954, with a history of crushing injury (railroad cars). The patient exhibited profound shock and his abdomen was rigid. On admission the white blood count was 22,900. At operation 3,500 cc. of bIood were present in the peritoneal cavity. There was complete laceration of the dista1 pancreas and splenic vessels. (Fig. I.) Distal pancreatrctomy was performed with splenectomy and drainage. Moderate drainage from the pancreas occurred with no excoriation. On the fifth postoperative day therapy m-as begun with anticoaguIants as a prophylactic measure in view of a rising pIatelet count. Death resulted from massive hemorrhage on the eighth postoperative day before emergency measures could be instituted. Postmortem examination showed no definite site of hemorrhage.
This patient was explored as he Comment. was not improving under treatment, and the peritonea1 tap suggested significant intraperitoneal hemorrhage. The development of psychosis fins been reported by others.ZR &SE III. K. hf., a fifty-eight year oId white man, was admitted on November IO, 1952, with a history of crushing injury (truck and loading platform). A large 5 by 7 cm. movable tender mass was present in the left hypochondrium. Vital signs were stable. The white blood count was 19,000. Amylase was 176 Somogyi units. At exploration there was massive hematoma of the pancreas as we11 as the base of mesentery, mesocolon and duo555
Kinnaird denum. Suggestive fat necrosis was noted. Simple drainage was instituted. No fistulas developed postoperatively, but the mass remained, apparentIy as a pseudocyst. The patient was discharged, only to return two weeks later with an acute con-
months after discharge he was asymptomatic. ShortIy thereafter he was sent to prison for chicken steaIing. Reports from the patient’s mother indicate he is asymptomatic but she states, “Doctor, he just don’t act right anymore.”
I______;,--_____,
OAYS 3
6
9
12 I5 I6
21
60
FIG. 4. Case v. Persistent eIevation of serum amylase in patient with blunt pancreatic injury. Comment. We had an unusua1 opportunity to see the injured pancreas on two occasions in this case, and it was impressive to note the progression of the edematous pancreas to that of hemorrhage with necrosis. This patient was extremeIv sick and he Dresented many probIems in management of the severe injury to the pancreas. The psychosis folIowing Iong-continued atropine cIeared rapidIy following its cessation.
FIG. 3. Case IV. Edema and hemorrhage of pancreas at time of exploration foIIowing blunt trauma. dition of the abdomen and disappearance of the mass. Serum amyIase at this admission was 921 Somogyi units. At operation the large pseudocyst of the pancreas had ruptured into free peritonea space. The cyst was drained. AmyIase on the cystic contents was 40,000 Somogyi units. The fistuIa cIosed in severa months. Ten months Iater, at the time of ventral hernia repair, there was only residual nodularity of the head of the pancreas. The patient is now asymptomatic.
1
CASE v.
D. J., a thirty-three year oId white on July 12, 1952, with a history of being thrown from a truck thirty hours prior to admission. ApparentIy he was inebriated at the time of the accident. There was diffuse abdominal pain, aIong with tenderness and spasm. Fracture of the ninth and eleventh ribs on the Ieft side, and also compression of the eleventh thoracic vertebra were noted. Vita1 signs were stable. Amylase was 344 Somogyi units. (Fig. 4.) The white blood count was 14,000. Non-operative management was instituted, with improvement. On the eighth day the patient became psychotic; this condition was attributed to massive atropine therapy. Nineteen days Iater recurrence of symptoms developed, which was quickly controIled by banthinem therapy. He returned one month after discharge with symptoms of pancreatitis, again controlled by banthine. FoIIow-up two years Iater revealed a history of occasional epigastric pains, nausea and vomiting. Work-up at that time was negative.
man, was admitted
Comment. This spontaneous rupture of the pseudocyst is quite unusua1, aIthough Koucky and co-workers reported six cases.28 The tendency toward spontaneous cIosure of the fistuIa is Zustrated by this patient. CASE IV. K. B., a twenty-eight year oId Negro man, was admitted on May 18, 1951. His abdomen had been stomped on by assailants forty-eight hours previousIy. The white bIood count was 8,700, with 36 stab forms. Amylase was 410 Somogyi units. (Fig. 2.) Vita1 signs were stabIe. AbdominaI findings were diffuse. At exploration there was dark brown, thin fluid, with fat necrosis of the omentum. (Fig. 3.) The pancreas was markedIy edematous and rubbery. The pancreas was drained. Four weeks postoperativety the patient was reoperated upon, with release of obstructing, encircling scars of the distal portion of the stomach. The pancreas at this time showed marked hemorrhage and necrosis. A fistuIa was a diffIcuIt problem but it cIosed in three months. The patient deveIoped toxic psychosis due to atropine poisoning. Four
Comment.
response Iished the
The cIinica1 picture and the to non-operative management estabdiagnosis
in this
case.
and
bve were
abIe to continue without surgery; at times, however, we were on the verge of operating upon this Datient. This oatient demonstrated again a toxic psychosis from atropine. Banthine I
556
Pancreatic
Injuries IO. SWISH, R. S. Traumatic rupture of the pancreas. Northzuest ,Vled., 47: 892, 1948. I I. THISTI.EHU..UTE, .I. R. The effect of banthine, vagotomy, and subtotal gastrcctomy upon pancreatic secretion. Surg., &rec. @ Ohsl., 93 : hr6,
was substituted and it was effective in controlling symptoms for several months. We suspect this patient will continue to have difficulty, as he will abuse his pancreas with bouts of heavy- drinking.
,c)jr.
PO~IBER, H. L. and NECHELES, II. Pancreatic injuries, an experimental study. Surf., Gynec. c1Ohst., 93: 621, 1951. 13. DKA(;STED.I., L. R. Some physiologic problems in surgery of the pancreas. Ann. Surp., I 18: 576. 12.
SUMMARY I. Blunt trauma to the pancreas occurs more often than is generally recognized. 2. This injury is frequentIy associated with other intra- and extra-abdominal injuries. 3. A pIan of non-operative treatment of aI1 cases has been outhned. 4. Operative intervention, according to principles listed, is reserved for the more serious cases and for those cases in which there are grave associated intra-abdominal injuries. 5. The mortality rate in pancreatic injuries alone, incIuding both operative and non-operatives cases, is around 6 per cent, according to the recent literature. 6. Five cases, personally observed, have been reported.
19.43. 14. NA~;I,ZIGER,H. C. and MCCORKLE, I-I. J. The recognition and management of acute trauma to the pancreas, with particular reference to use of the serum amylase test. Ann, Surg., I 18: 594, 1943. 15. SHALLOW, T. B. and WAGKER, F. B., JR. Traumatic pancreatitis. Ann. Surg., I 27: 66, 1947. 16. BERK, .I. E. Management of acute pancreatitis. J, A. M. A., 152:-r, 1953. 17. HITKEN. N. F. and STEVENSON. V. L. Traumatic rupture of the choIedochus associated with an acute hemorrhagic pancreatitis and biIe peritonitis. Ann. Surg., 128: I 178, 1948. 18. BERKE, C. J. and WALTERS, R. L. Traumatic pancreatitis. California Med., 79: 279, 1953. 19. BECKER, W. F. Traumatic pancreatitis. Am. Surgeon, 20: 525, 1954. 20. HOWARD, J. hl. SurgicaI physioIogy of pancreatitis. S. Clin. North America, 29: 1789, 1949. 21. KEITH. L. M.. JK.. ZOLLINGER. R. M. and M&LEERY, ‘R. S. PeritoneaI kuid amyIase determinations as an aid in diagnosis of acute pancreatitis. Arch. Surg., 61: 930, 1950. 22. ZOLLINGER, R. M. and BOLES, T. The probIem of pancreatitis. Rock,y Mountain M. J., so: $54, 1953. 23. COFFEY, R. J. UnusuaI features of acute pancreatic disease. Ann. Surg., 135: 715, 1952. 24. MACKENZIE. W. C. Pancreatitis: fundamenta1 and clinica aspects. Bull. Am. Coil. Surgeons. 40: 23,
REFERENCES I. BAKNBROOK, D. H. Impermanent
z. 3.
4.
5.
6.
diabetes: a complication of traumatic pancreatitis. Canad. M. A. J., 40: 143, 1952. KINI, J. M. Traumatic pancreatitis. Am. Surgeon, 18: 596, 1052. ESTES, W. L., Jr<., BOW&IAN,T. L. and MEILICKE, F. F. Non-penetrating abdominal trauma with special reference to the duodenum and pancreas. Am. J. Surg.. 83: 434, 1952. I IAMILTON. J. E. American Association for the Surgery ‘of Trauma Meeting, 1951. Am. J. Surg., 83: 450, 1952. MATHEWSON, C. and IIALTER, B. L. Traumatic pancreatitis with and without associated injuries. Am. J. Surg., 83: 409, 1952. ORIT, R. B. and WARREN, K. W. EpiduraI anaIgesia in acute pancreatitis. Luhey Clin. Bull., 6: 204,
1955. 25. JOSEPH, IM. The pancreas
and the steering whee1. B’est. J. Surg., 60: 129, 1952. 26. ALDIS, A. S. Injuries to the pancreas and their surgicaI treatment. Brit. J. Surg., 33: 323, 1946. 27. STRODE, J. E. and GILBERT, F. I. Retro-peritoneal rupture of the duodenum foIlowing non-penetrating injuries to the duodenum. Arch. Surg.,
I gso. 7. \VARKEN, K.
W. Management of pancreatic injuries. S. C&n. North America, 31: 789, 1951. 8. WRIGHT, L. T., PRIGOT, A. and HILL, L. M. Traumatic subcutaneous injuries to the pancreas. Am. J. Sup-., 80: 170, 1950. 9. KENWEI.L, H. N. and WELLS, P. B. Acute hemorrhagic pancreatitis; report of eleven consecutive cases treated with human serum albumin. Surg., Grxec. C* Ohst., 96: 169, 1953.
70: 343. 1955. 28. KOI CKY, J. D., BE~:K, W. C. and Tono, hl. D. The perforation of pancreatic pseudocysts: ;I report of six cases. Surg., Gynec. t-7 Ohst., 75: I I 3, 194 I. 29. BURKETT, W. Traumatic rupture of the pancreas. Brit. ,v. J., 4928: 1455, 1955. 3”. GWINN, J. L.. ELLIS, F. H. and HAYLES, A. B. Injury of the pancreas in a child. Pmt. Smfl Meet., Mayo Clin., 30: Ior, Igjj.
557