Surgical management of pancreatic trauma

SURGICAL MANAGEMENT OF PANCREATIC TRAUMA ~

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M. BALASEGARAM, M.D.

0011-3840/79/12001-60-$05.00 © 1979, Year Book Medical Publishers, Inc.

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SELF-ASSESSMENT QUESTIONS True or False? 1. '/'he pancreas is often ruptured because of its normal anatomical position. 2. Blunt trauma accounts for the most common cause of pancreatic injury. 3. Pancreatic trauma is often associated with duodenal injury. 4. The most common presentation of pancreatic injury it; shock, 5. An epigastric mass is usually palpable when the body of the pancreas is ruptured. 6. Injury to the pancreas is always associated with a raised level of serum amylase. 7. Abdominal paracentesis is usually done to evaluate amylase content rather than for detectionof hemoperitoneum. 8. Endoscopic re~,rograde cholangiopancreatography (ERCP) must be per'formed :'outinely preoperatively to detect pancreatic d:,ct r~pture. 9. Pancreatic irau~n~, is always associated with multiple organ

injury. 10. In the prese~.ce of retr0peritoneal hematoma, catheterization of the duodenum is mandatory to exclude pancreatic trauma. 11. Among the operaSons performed for pancreatic rupture, the Whipple operation carries the highest mortality. 12. Distal pancreatectomy is the best treatment for pancreatic rupture medial to the superior mesenteric vessels. 13. Abdominal distention on the 3d postoperative day after laparotomy is due to a missed pancreatic ductal injury. 14. After pancreatectomy, patients should have multiple drainage. 15. Sump drainage is superior to Penrose tube drainage for pancreatic trauma. 16. Pseudocyst formation is the most common postoperative complication of pancreatic trauma. 17. Parenteral nutrition has improved the management of postoperative pancreatic fistula. 18. Pancreatic injury per se has minimal morbidity and mortality. Select the Correct Answer 19. Postoperative complications are common after pancreatic trauma. Which of the following steps is essential to preclude fistula formation: a. Catheterization of the duodenum. b. Dye visualization of the pancreatic duct. 3

L~[). Al~d()lilii~;l] p~r~lct, rllesis is ~l usoJ'ti] (ti~ll411()sti(,', test. W h i c h of" ~ll(, (i)l[()wii~g is thl:, most importal~,t fiildin,g from t h e f~rocc(itll'tU a. Ileritxiilo~lt i'c,t u r n fluid is ~llw~lys t)looct st~line,,l Ii. The ~ll~l)s'l~l.~(, coritent is high, i.e., gl'eiltor ttl~_ln L),,O00 P{A tlni{s, c. l,euk~)cy(osis ii~ the p e r i t o n e a l fluid, :\nswers ~iro li,~tc, d at the end of the article.

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graduated tYom the University of Singapore in 1955 and obtained his London and Edinburgh Fellowships in 1960. A Hunte.rian Professor of Surgery and a Jacksonian Prize winner, Dr. Balasegaram has several other international awards and honorary professorships tu hi.s credit. He is currently Kehormat Professor of Surgery, National University of Malaysia, Senior Consultant Surgeon, Ministry of Health, Malaysia, and Head, Department of Surgery, General Hospital, Kuala Lumpur, Malaysia. He is actively involved in research of hepatobiliary, pancreatic and esophageal surgery, fie is also a member of the International Group for the Study of Liver Diseases. He has contributed more than 130 articles, several monographs and chapters in textbooks on these subjects.

TRAUMA TO THE PANCREAS has perhaps received less attention than is its due. This lack of attention may be attributed to 3 factors. First, since the pancreas is well protected anatomically by the vertebral column behind and the abdominal organs in front, pancreatic injury used to be considered rare. Second, pancreatic t r a u m a usually presents as multiple injury. Finally, diagnosis is difficult because localizing signs and symptoms are minimal and, if present, they tend to be masked by t r a u m a to other organs. However, pancreatic injury is now no longer rare. There are many injuries from high-speed road accidents. The increasing and often compulsory use of seat belts is responsible for compression of the pancreas against the spine, resulting in its rupture and disintegration. Modern high-velocity missiles have added their share of trauma. Yet only about 1,000 cases of pancreatic injury have been recorded i,~, world literature, and t r e a t m e n t has been extremely variable. Some surgeons believe t h a t as much pancreatic tissue as possible should be preserved by various complicated reconstruction procedures, but others have shown t h a t 1 0 - 1 5 % of the pancreatic tissue is adequate to support normal life. Therefore, it is timely to examine the various aspects of pancreatic t r a u m a and its treatment. Ours is the only referral center in Malaysia (population: 12.2 million); we also rank very high in the number of recorded cases of pancreatic injury treated at a single 5

center. 'l'iu. descripti
HISTORICAL BACKGROUND The historical backgrm~nd ~f pancreatic injuries is of' great interes{ and importance to an understanding of their present incidence, diagnosis and treatment. The tirst case of pancreatic trauma was reported in 1827 by Travers, :°e whose patient, a woman, was crushed by the wheel of a stagecoach. The patient was treated expectantly, and at autopsy complete transection of the pancreas was thund in addition to associated multiple abdominal injuries involving the liver, duodenum and jejunum. In 1856, ,faun 's relmrted the first instance of complete rupture of the pancreas as an isolated injury. Froln 1905 to World War l, most pancreatic injuries either were not diagnosed at all or remained undetected at operation, resulting in a 70':i mm'tality. A survey of American military literature revealed that only 85 cases of pancreatic injury were reported from the time of the Civil War to the end of the Korean War; 50% ~4"these injuries occurred in World War II and 22~A in the Korean War. The low incidence of pancreatic injuries during this entire period '~ was attributed to the anatomical position of the pancreas, with the abdominal organs in front and the spine behind often providing sufficient protection from the comparatively lowvelocity missiles then in use. The subject of pancreatic injury was reviewed in detail by Stern ~'-' in l'.J30 and by Phillips and Seybold r" in 1948. The high mortality in earlier cases was largely due to conservative therapy'" that continued until 1905, when Garr6 a' first suceessf\~lly treated a case of isolated complete rupture of the pancreas by primary suture. The torn pancreatic edges were approximated with fine silk: although the patient developed a fistula, it closed spontaneously 6 weeks later. In 1929, Newton ';a initiated more definitive treatment by advocating direct end-to-end anastomosis of the divided pancreatic duct and capsule. A pseudocyst that subsequently developed was treated by "marsupialization." Since that time others have advocated various type~ofsurgical treatment. Walton:'' in 1930 recommended completd removal of the separated body and tail and careful suture of the stump of the neck of the pancreas. Procedures designed to preserve injured pancreatic tissue have been suggested by Bracey" and by Letton and Wilson.a:'.Jones and Shires 4'; sutured both ends of the transected pancreas into the jejunum by a Roux-en-Y anastomosis, stating that this allowed preservation of pancreatic tissue and provided internal drainage of pancreatic secretion. O n the other hand, Doubilet and Mulholland'-"-' recommended intubation of the pancreatic duct and concurrent sphincterotomy as adjuncts to other 6

methods of t r e a t m e n t in order to overcome resistance to the flow of pancreatic juice into the duodenum. They suggested t h a t such a procedure prevented fbrmatlon of fistulas and pseudocysts. Although the total of approximately 1,000 cases of pancreatic injuries so fhr reported in the world l i t e r a t u r e includes these earlier ones, most cases have been reported during the last 2 decades, when there has been a marked increase in the incidence of pancreatic t r a u m a , both blunt and penetrating. High-speed road accidents and civil violence, including the use of high-velocity missiles, have accounted for this increase, as well as the heightened interest in pancreatic injuries. As is usual in a developing field of' surgery there are still widely differing views on methods of m a n a g i n g pancreatic trauma. This account is based on a personal experience in treating 152 cases seen over a 15-year period.

ANATOMY A proper u n d e r s t a n d i n g of the a n a t o m y of the pancreas is of vital importance in the surgical approach to this organ because of its close relationship to other organs and vessels. This is particularly true in pancreatic t r a u m a where other structures have often been injured simultaneously. The pancreas is about 12.5-15-cm ( 5 - 6 t i n . ) long and lies transve~-sely across the upper p a r t of the posterior abdominal wall. Behind the pancreas are the inferior vena cava, aorta, left kidney, both renal veins and right renal artery. Its broad head lies within the concavity of the duodenum and is closely related to the lower p a r t of the common bile duct. Its body is situated behind the stomach and is separated from it by the lesser omental sac. Its tail reaches to the hilum of the spleen, the splenic a r t e r y runs along its upper border and the splenic vein courses behind it. Thus, the relative fixation of the pancreas m a k e s it vulnerable to blunt t r a u m a , which m a y fracture it across the rigid vertebral column. The superior mesenteric vein and a r t e r y lie just behind the neck of the pancreas and are also enclosed behind by a posterior extension of the lower portion of the uncinate process of its head.. The main pancreatic duct of Wirsung u s u a l l y traverses the entire length of the gland slightly above a line halfway between the superior and inferior edges and n o r m a l l y ends by joining the common bile duct. The accessory duct of Santorini branches out from the pancreatic duct in the neck of" the pancreas and empties into the duodenum about 2.5 cm above the duodenal papilla. Our study of 40 normal h u m a n cadaveric pancreases by dissection, perfusion and injection of prevulcanized liquid rubber latex has revealed several anatomical variations of the pancreatic duct and vessel systems. These findings have enabled more r a t i o n a l 7

and, at tilnes, difli, reilt-.method.,~ of a p p r o a c h to wu'ious probI~.,uls t lint m~D' a rise a f t e r resection r)f I)a ncreatic tissue. Itl 2 l ) ' i Of ttl(y CllS(.'S W(.! studit.~d, th(..~ l t c c e s s l g r y duct of S a n t o r i n i ~lrained int() the main p a n c r e a t i c duct, 'lnd in 8',::, it, was the sole duct (trnining the l)'lm'reas. By c(mt.rasI ,;' at)sence of the accessor.v duct was seen in I0¢:;. l a k e C,ross, ~7 we fi)und n u m e r o u s accessory ducts e m i ) t y i n g d ! r e c l l y fi'om the p a n c r e a s into the i n t r a p a n creatic p(~rti~m of the common bile duct; these were present in 50'; (Jr the specimens. In 2c; the p a n c r e a t i c and common bile ducts (q)ened s e p a r a t e l y into the d u o d e n u m . The a r t e r i a l a n d verlotls supply of the p,':lricI'eas showed tbw, if ally, v a r i a t i o n s of iml)(~rtance, Tj except t h a t in 18% of eases the h e p a t i c a r t e r y arose from the s u p e r i o r m e s e n t e r i c a r t e r y . The hepatic a r t e r y might, t he re.tbre, be d a m aged d u ring pa ncrea tic surgery.

PHYSIOLOGY The pancreas is ~ compound tubuloatveolar gland with endocrine and exocrine cells. Tile endocrine ceils produce insulin and glucagon from the [3- and ~.-ce/ls, respectively. The secretion of these two hormones is regulated by blood SLlgaz" levels: a fall causes fflucagon secretion and a rise triggers insulin secretion. The exocrine cells produce the pancreatic juice containing digestive enzymes, which is emptied into the duodenum. Expez'imental studies in animals have shown that survival is possible after complete removal of the duodenum, provided there is no obstruction to the fl'ee flow of bile and pancreatic juice into the upper intestine. Dragstedt '-':',:~:~and other workers have also shown in animals that removal of 80 to 90% of pancreatic tissue causes no defect in carbohydrate or tht metabolism or in digestion and absorption of food as long as the remaining pancreatic tissue is normal and remains connected to the duct so that its secretion has free access to the upper intestine. Removal of 9 0 - 9 5 % of the pancreas produces diabetes, which is characterized by insulin deficiency, marked hyperglycemia, glyeosuria and hyperlipemia although digestion and absorption of food are unimpaired. Our clinical experience confirms that subtotal or near-total (90%) removal of the traumatized pancreas does not require substitution therapy with insulin or digestive enzymes. There is evidence of increased physiologic activity in the remnant of norma• pancreatic tissue, which compensates for the loss and prevents any disturbance. This is in contrast to resection for chronic panereatitis or carcinoma, where the remaining section of the pancreas may be diseased. Total pancreatoduodenectomy does, however, result in the need for replacement therapy. Although Dragstedt "~ reported that the depancreatized dog did not survive for long even with adequate administration of insulin because of the difficulty in controlling 8

the diabetes, we have not encountered this problem clinically. The details of physiologic changes observed and of the substitution t h e r a p y required in our patients are given in the section on complications, under Pancreatic Deficiency.

CAUSES AND PATTERNS OF PANCREATIC INJURY The pancreas is a soft, yielding organ, deeply placed in the abdomen. Although normally well protected, it may be injured if the force of t r a u m a t i c impact is sufficiently great. Although the spinal column provides protection from the back, its unyielding nature may allow the pancreas to be crushed against it from the front or side. High-velocity missiles obviously do not spare the pancreas, but it is surprising t h a t quite mild forces can also cause pancreatic injury. This happens when they are accurately directed toward the organ and the abdominal muscles are not tensed. The close association of the pancreas with the duodenum, spleen, stomach, biliary tract and colon and t h e p r o x i m i t y of major vascular trunks, including its own a b u n d a n t blood supply, m e a n t h a t associated injuries are common and t h a t extensive h e m o r r h a g e can occur. Any compressive force or p e n e t r a t i n g inj u r y to the upper abdomen can produce such lesions, with varying degrees of pancreatic damage. Relatively mild t r a u m a m a y produce contusion of the pancreas with local edema and hemorrhage, r u p t u r e of small vascular branches with ecchymosis and disruption of acini or ductules. The pancreatic capsule usually r e m a i n s intact in such cases. With gross disruption of pancreatic tissue, the large or even the main ducts m a y be injured and the pancreas itself m a y be fractured by compression against the vertebral column. F r a c t u r e s are usually located over or just to the left of the superior mesenteric vessels. The fracture m a y be complete or incomplete, ventral or dorsal, and the pancreas m a y appear intact on its ventral surface when there is an incomplete dorsal fracture. Force delivered from the right, either obliquely or laterally, can compress the head of the pancreas a g a i n s t the side of the vertebral column, injuring the pancreatic head and the m a i n duct. FUNCTIONAL DISTURBANCE

T r a u m a t i c pancreatitis m a y develop as a result of such injuries. If the ducts are not damaged, this m a y be interstitial. Massive e x t r a v a s a t i o n of plasma can occur due to peritoneal irritation by activated enzyme. The plasma loss produces hypovolemia. P a r e n c h y m a l destruction, h e m o r r h a g e and adjacent pancreatic edema are commonly associated conditions. Pancreatic disruption is i n v a r i a b l y associated with local hemorrhage, which m a y be either fl'om i n t r a p a n c r e a t i c vessels or from one or more of the 9

many veins :4urrounding the p'mc.r~zas, commonly from the tributaries ofthu portal venous system. The resultant hematoma may cause th(, surgeon to miss the underlying injury. Partial m" ctm~plett, division of tim ducts, if unrecognized and untreated, leads to persisterlt pancreatic fluid leak, necrosis and ultimately external fistula. The fluid and electrolyte los,~ fi'om a cCm~plete pancreatic fistula can be extreme; rapid weight loss results from the absence of pancreatic ferments in the intestinal tract. ]f an external fistula closes spontaneously, the patient usually has abdominal pain and gastrointestinal symptoms. Fever and chills frequently accompany spontaneous closure when the main d uct of W irsu n~4 has been divided. The consequences of injury to the duct of Santorini depend on i] ~the nature and extent of the injury; (2) the relationship of this duct to the main duct; and (3) whether or not the duct lesion is recognized and dealt with adequately soon after ir0ury. When the duct of Santorini constitutes the main pancreatic duct, unrecognized injury to it can be fatal. The accessory duct does not always communicate with the main duct; nevertheless damage to an accessory duct that drains a small segment of the pancreas and communicates with the main duct, may cause very little physiologic disturbance. A collection of' pancreatic fluid or even an external fistula may develop, but such fistulas are prone to heai spontaneously. In long-standing cases, pseudocysts may form in the course of fibrotic healing of destroyed pancreatic tissue, resulting in chronic pancreatitis of calcul us formation.

CLINICAL PRESENTATION OF PANCREATIC TRAUMA Patients with pancreatic injuries presented to our specialized unit in one of three ways: 1. They were admitted with acute cases due to t r a u m a and were referred directly from the casualty department or fl'orn other hospitals (104 patients). 2. They were referred after primary t r e a t m e n t in other institutions, because of complications following initial treatment. These patients had either been inadequately managed or the diagnosis of pancreatic injury was only suspected at laparotomy (28 patients). 3. They were referred as having late or occult cases with unrecognized pancreatic injuries and unusual presentations, i.e., abdominal masses, chronic pancreatitis, abdominal and perinephric fistulas, intra-abdominal abscesses or pancreatic calculi (20 patients). Injuries to the pancreas incurred during operations on the stomach, duodenum, biliary tract, spleen or left kidney have been excluded from this series, although they constitute some of the most frequent types of t r a u m a to the pancreas. lo

DIAGNOSIS

Penetrating wounds involving the pancreas pose little or no difficulty in diagnosis, especially if the external wound is near the umbilicus. High-velocity missiles causing widespread damage and/or traversing circuitous routes may mask pancreatic injury and make diagnosis more difficult. Blunt pancreatic trauma typically presents a challenge in diagnosis, and associated intra-abdominal, cranial, thoracic, pelvic and skeletal injuries may complicate the clinical picture. Additional diagnostic aids may be required, including biochemical and enzyme studies, abdominal paracentesis, peritoneal lavage, peritoneoscopy and, more recently, use of angiography, hepatic scanning and ultrasound. All these investigations were evaluated and the results were critically assessed to determine the advantages and limitations of each diagnostic aid. The findings are incorporated in the following review of the clinical assessment of both penetrating and blunt pancreatic trauma.

Penetrating Injuries The diagnosis of penetrating injuries to the pancreas did not pose serious problems, especially when the injuries were near the lower chest and upper abdomen and dictated early surgical exploration. Isolated injury to the pancreas, suspected in 10 cases, was confirmed by probing or by injecting a contrast medium into the penetrating wound, followed by radioiogic studies, anteriorly and laterally, which also helped to determine whether a bullet or other foreign body was present. ~ In 8 of these cases, a few hours' observation revealed a changing clinical picture: falling blood pressure, rising pulse rate, pallor, absence of peristalsis with loss of bowel sounds, generalized tenderness, rigidity and leukocytosis. In the other 2 cases involvement of other abdominal organs necessitated an early exploratory laparotomy. Injuries caused by high-velocity missiles and gunshot wounds were often associated with multiple injuries to the upper abdominal viscera, and it was frequently difficult or impossible to detect pancreatic injury clinically because of concomitant major visceral or vascular injuries and hemorrhage. In nearly 80% of our patients with penetrating wounds, diagnosis of injury to the pancreas was established only at laparotomy. The possibility of such injuries should always be borne in mind when there is a penetrating wound of the upper abdomen or near the umbilicus, especially in patients presenting in shock and with severe blood loss. 7, ~2

Blunt or Nonpenetrating Injuries The diagnosis of pancreatic injury due to blunt trauma has presented a greater problem because the clinical picture was deceptiveiy mild and the symptoms and signs were often obscure, variable and/or masked by more obvious multiple injuries. ~9 It was not uncommon for patients sustaining severe pancreatic injuries 11

t() (,liter the h~sl)ital feeling well, with the characteristic signs (lad .,~ymt)tt)ms beirlg dclayccl for several hours. However, the ('vidt, ncc of pancv'c:~tic injury dcvclt,ps early in most cases and is n,w(,:" long delayed, with the clinical picture being similar in severity to that soon in hemorrhagic pancreatic necrosis. A hist(wy of t r~uma to tim upper abdolnen and pain were the most common findings in those patients who were conscious. It was dillicult to) define a tyl)ical pain pattern in our series, since sever~! patients had other intra-abdominal injuries and pain varied in nature and severity. It was localized *.o the upper abdomen in 12 patients with early isolated pancreatic injuries and generalized in later cases and with multiple injuries. Sl~ock was present al the time of admission in 70';.; of the patients with multiple injuries. but was absent in the 12 patients with injury to the pancreas only. The physical signs were variable and often minimal, particularly in the early stages or in isolated pancreatic injuries, becaus(, ~)t'( 1) the protected and retroperitoneal position of the organ, (2J the ab,~;ence of an activating agent for the pancreatic enzyme in isolated injuries and (3) the decrease in pancreatic secretion after significant trauma to the pancreas. Signs of upper abdominal tenderness, muscular spasms of tile anterior abdominal wall and decreased or absent bowel sounds were noted in variable combination, according to the presence or absence of multipl'e injuries. The diagnosis in the 48 patients referred fi'om other centers depended on the nature of the complications or the mode of their presentation.

Specictl In uc'stih~cttions TOTAL WHITE P,I.OOD CELL COUNT( W B C ) . - In 50 patients, total WBC ranged from 7,000 to 18,000 per cu ram. No definite conclusions could be drawn fl'om these results. 72c~ of the 30 patients with blunt t r a u m a to tlle pancreas, abdominal paracentesis in each quadrant proved to be a reliable index. Elevation of amylase concentration in the peritoneal fluid was observed within the first 24 hours after injury in patients primarily affected with pancreatic injury. In 12 patients an initial negative tap was obtained within 8 hours of injury. After 4 more hours, a rise of amylase concentration in the peritoneal fluid was observed. Shortly after injury these patients appeared to have insufficient fluid in the peritoneal cavity to demonstrate a significant amylase level. However, when the main pancreatic duct was ruptured, early positive aspiration was frequently obtained. For abdominal paracentesis we prefer a wide-bore 14-gauge needle instead of an 18-gauge spinal puncture needle. Since 28% of our patients showed false negative abdominal taps, failure to aspirate peritoneal fluid must be considered of no significance and should be ignored if pancreatic injury is still suspected. 12 ABDOMINAL

t'ARACENTEStS. -- In

Donovan et al. '-'t*and K e r r y and Glas ~t have similarly reported a rapid and high elevation of a m y l a s e concentration in the peritoneal fluid tbllowing pancreatic injuries, sometimes rising above serum levels. However, other workers have found t h a t the peritoneal tap was of limited value in diagnosis. Artz a doubted t h a t a diagnosis of pancreatic injury could ever be made by an abdominal tap, because he believed t h e r e often was insufficient fluid in the peritoneal cavity to obtain an adequate a m o u n t of amylase. The greatest potential role of the tap is in aspirating blood from patients with associated multiple injuries, p a r t i c u l a r l y from those who are drowsy or comatose. PERITONEAL LAVAGE.- Of 10 patients with normal serum amylase leve]s in whom it was performed, peritoneal lavage was found to be of value in the diagnosis of pancreatic injuries in 6; the peritoneal washings obtained from those with pancreatic fistulas or t r a u m a t i c pancreatitis showed high a m y l a s e activity although t h e i r serum a m y l a s e levels were then no!'mal. In our experience, peritoneal lavage is a good diagnostic test for intra-abdominal hemorrhage, but it should not replace the established indications for laparotomy. It is of great help in difficult diagnostic situations, e.g., when the pancreas is the sole or main site of injury, in comatose patients with confusing clinical signs and in critically ill patients when laparotomy carries a high risk. SERUM AMYLASE DETERMINATION.--In this series the s e r u m a m y l a s e level was one of the most valuable diagnostic tests; thus, a rise to diagnostic level (above 250 Somogyi units) 83 was ohtained on admission in 60 of 95 patients studied. In the r e m a i n i n g patients, the serum a m y l a s e level was either not determined or not recorded preoperatively because these patients were in critical condition and they were t a k e n directly to the operating theater. In half" of the 60 patients who had raised serum a m y l a s e levels on admission, the rise was followed by a rapid fall, probably corresponding to leakage from the injured pancreas. In 15 patients, the s e r u m a m y l a s e level was n o r m a l when first examined 5 - 1 0 hours after admission, b u t repeated tests at 4-hour intervals showed a steady rise. Although these patients had significant pancreatic injuries, the serum a m y l a s e levels were not related to the severity of the injury. In 3 patients with severe pancreatic injuries the serum a m y l a s e level was normal for as long as 24 hours after admission. Thus repeated estimation of the s e r u m amylase level is m a n d a t o r y when pancreatic injury is suspected, since one normal reading does not rule out the diagnosis. Of the 28 patients with complications referred from other centers, 20 had elevated serum a m y l a s e levels varying from 250 to 3,000 Somogyi units. However, the serum a m y l a s e level was frequently normal in patients with u n u s u a l presentations. Although t h e r e are conflicting reports in the l i t e r a t u r e about 13

the value of serum amylase as a diagnostic test for pancreatic injuz'ies,'" serious note should be taken af tile clinical studies and experimental injuries to the pancreas of dogs by Nick et al., "s which sh~wed in,jury-associated unitbrm elevation of serum amylase levels. Similnrly, Nall~i~er and Mceorkle ';~' found the serum ~mvlase level t~ be elewlled aimve the normal maximum (180 Somo~yi units~ at stone time after the t r a u m a in all patients with tm ncreatic inju ties. Increase in the blood serum amylase level after trauma to the pancreas probably results from leakage of the enzyme out of the it\jured acini and duct.,~ into the interstitial spaces or peritoneal cavity or both, whence it is absorbed into the blood. However, other studies have reported that serum amylase levels were often normal in patients with pancreatic injuries and, conversely, elevated levels were not inwlriably indicative of pancreatic injury; such levels have been recorded in injuries to the duodenum, stomach or small intestine in the absence of significant pancreatic damage. Serum amylase levels may also be elevated in closedloop obstruction, acute cholecystitis and pertbrated duodenal ulcer. White and Benfield""' noted that serum amylase levels were elevated preoperatively in 26'7( of such patients and were routinely normal postoperatively. We adw)cate routine serum amylase estimation in all cases of blunt abdominal injury. A rise of amylase concentration has the advantage of indicating pancreatic trauma before operation is undertaken and alerts the surgeon that the pancreas ''~. ~; should be carefully examined. When objective evidence of intra-abdominal injury is lacking or is uncertain, an increase in the serum amylase level may be the earliest sign ofinjury to the pancreas. U I ( I N A I t Y AMYLASI*: E S T I M A T | O N . -- W e performed evaluations of the urinary amylase levels in only 12 patients in our series. Values of less than 300 Somogyi units per hour or 7,200 units in 24 hours were considered normal. In 8 cases the amylase level was elevated, the values ranging from 500 to 700 Somogyi units per hour. Since the procedure is time-consuming, it is of value only if the patient suspected of having pancreatic injury can be observed over a relatively tonger period. Repeated 2-hour urine collections provide a more reliable index of pancreatic injury than the serum amylase taken at random. .'a Urinary amylase levels were elevated in 20 of the 28 patients referred to us postoperatively, thus providing the best indication of postoperative pancreatitis.

RaDmLOCm STUDISS.-- Plain x-ray and sinogram examination, contrast medium studies, arteriography, splenoportography and inferior venacavography, radioisotope pancreatic scanning have all been tried in the radiologic diagnosis of pancreatic injury. 1. Plain x-ray abdominal studies yielded no distinctive findings of pancreatic injury in our experience. However, the pres14

ence of air in the region of the duodenum, displaced stomach or transverse colon, due either to pancreatic edema or hemorrhage, and localized intestinal ileus, gave indirect evidence suggestive of pancreatic trauma in 28 patients. 2. Sinograms were of diagnostic value in patients presenting with pancreatic fistula. Upper gastrointestinal examination using a water-soluble contrast medium or barium was carried out in 20 patients who had sustained blunt abdominal trauma but in whom there was no in~ dication for laparotomy, although the serum amylase levels were moderately raised (200-250 Somogyi units). These studies were helpful in detecting rupture of the duodenum in 8 patients who, due to elevation of tile serum amylase, were believed to have traumatic pancreatitis. A dilated and distended duodenal loop was found in all patients with pseudocyst. A suspicion ofabdominal abscess was raised by subdiaphragmatic fluid levels and displacement of viscera. 3. The value of aortography and selective arteriography in the diagnosis of acute traumatic lesions in the abdomen, and of the pancreas in particular, has yet to be generally accepted. Aortography and selective pancreatic arteriography studies using percutaneous catheterization of the femoral artery (Seldinger) were carried out in 15 patients with multiple injuries affecting several body areas. These patients were of particular interest because the abdominal signs were minimal. Aortography and selective arteriography proved to be particularly useful in the study of patients with coexisting injuries to the head, chest or pelvis, which made it difficult to interpret abdominal findings. Of the 15 patients so studied, a positive diagnosis of injury to the pancreas was obtained in 5; negative findings in the other 10 excluded such injuries. Distortion of the retroperitoneal structures or displacement of the gastroduodenal artery indicated pancreatic injury with peripancreatic hemorrhage (Fig 1). The information obtained not only established the need for operative intervention, but also helped to assess priorities of treatment. '~'-'However, the greatest value ofthese studies lies in the exclusion of suspected pancreatic injuries in polytraumatized patients and in the diagnosis of pseudocysts 1~ or abscesses, intra-abdominal sepsis and chronic pancreatitis. 4. Splenoportography and inferior venacavograms were helpful in the diagnosis of patients presenting with abdominal masses, fistulas and other pancreatic complications. Displacement or distortion of the splenic vein and inferior vena cava indicated pancreatic pathology. 5. Radioisotope pancreatic scanning was performed in 15 patients with blunt injuries, especiaJly those with multiple injuries involving the head and chest, when the abdominal signs were masked or the patients were semicomatose and unable to give a proper history. Scanning helped to exclude injuries to the pancre15

ii!i,l 2;

img Fig 1 . - A , normal selective pancre~ltic arter,ography showing the pancreahc vessels. In B note their distortion and displacement. The associated chest iniuries and mild concussion necessitated a selective pancreatic arteriography to exclude a suspicion of intra-abdominal injury following blunt trauma. At operation, trauma to the pancreatic head was found and pancreaticoduodenectomy was performed. A minor fistula at the drainage site closed spontaneously alter 3 weeks C, pancreatic arteriography. The vessels are displaced laterally due to a pseudocyst of the head of the pancreas. This patient, a woman, aged 40. presented with a large cystic mass supraumbitically w h i c h had increased progressively since she was hit in the abdomen by the handle bar of a bicycle 6 months earlier. Cystogastrostomy was performed and she is symptom free 10 years later.

as in 8 patients. Positive signs of i n t r a p a n c r e a t i c bleeding appeared as "cold" areas in 3 patients. Scanning was of greatest value in the diagnosis of pseudocysts, ''7 pancreatitis and intrapancreatic abscess. ULTRASOUND EXAMINATION.- The use of ultrasound was found to be helpful in diagnosing pseudocysts presenting as abdominal masses in 6 patients. ~'' COMPUTERIZED AXIAL TOMOGRAPHY. -- W e h a v e found computerized tomography to be most helpful in the diagnosis of pancreatic injuries with complications. These included pseudocysts, chronic pancreatitis, intrapancreatic abscess and intra-abdominal sepsis in 12 patients. 16

Comments Our experience in the diagnosis of pancreatic injuries m a y be summarized as tbllows: 1. The diagnosis of injuries to the pancreas m a y be extremely difficult or it m a y pose no significant problem, depending on the mode of presentation. No particular group of symptoms or abdominal findings can be considered as absolute criteria for the firm diagnosis of pancreatic injuries. The symptoms and signs m a y be deceptively minimal in patients with severe injury. 2. Pancreatic injuries should always be suspected and searched for in any t r a u m a to the upper abdomen. 3. Most pancreatic injuries are associated with multiple injury to the upper abdominal viscera, and frequently it is difficult or almost impossible to diagnose pancreatic t r a u m a clinically when it is obscured or masked by other injuries. 4. Although a rise in enzyme levels in the serum or peritoneal fluid on abdominal paracentesis is not pathognomonic of pancreatic injury, it nevertheless provides a valuable diagnostic indicator. If there is a significant rise in enzyme levels, pancreatic trauma cannot be ruled out. 5. Plain radiologic and contrast studies, scanning and angiogr a p h y are of limited value in acute pancreatic injuries, but they nmy help to exclude pancreatic t r a u m a in polytraumatized patients. However, these methods are extremely useful in the diagnosis of pancreatic injuries with complications. 6. When there is a n y doubt, exploratory laparotomy r e m a i n s the best single m e a n s of early diagnosis. At laparotomy systematic and careful e x a m i n a t i o n of the pancreas is of vital importance to exclude a n y injury, particularly in the presence of retroperitoneal h e m o r r h a g e or multiple abdominal organ t r a u m a .

CLINICAL MATERIAL The 152 patients with pancreatic injuries whom I treated between A u g u s t 1961 and December 1978 at the General Hospitals, Seremban and K u a l a Lumpur, Malaysia, ranged in age from 4 to 76 years, with the vast majority being between 20 and 40. The severity of these injuries varied with the mechanism t h a t produced them. Most were due to road accidents or civil violence; 85 patients had sustained b l u n t t r a u m a , whereas 67 had penetrating injuries. Road accidents were responsible for injuries in 65 of the 85 patients admitted with b l u n t t r a u m a ; of the others, 10 were struck by b l u n t objects and 10 were crushed by falling trees or other h e a v y weights. Analysis of the records of those involved in road accidents showed t h a t 40 were drivers of motor vehicles and 10 were passengers. Only 10 of the drivers wore safety belts. Patients who were crushed by vehicles, and drivers or front-seat 17

TAIII,E I.

T Y I ' E (11." i'AN(:REA'Z'I(: I N J U R Y 1N 152 I)ATI E N T S

rY|'l.: (IF IN.II'IIY

('[m~usttms I,:weru~ runs Stibc:q)sular h P l l l l l l oHl~ls

I'omph,te transection C(mlbim'
IU.|'NT

IU 3: >,

I'ENETIIATIN(;

TOTAl.

:12

(i,l

|{}

;I

]tl

12

13 2S

10

6

16

7 85 (55.9':i)

6 67 (,I,I. I "i }

13 152

"Fuur p a t i e n t s had i n t r u d u c t a l inju ties.

passengers who were involved in head-on collisions, had severe disruption or transection of the pancreas. Of the 67 penetrating injuries, 20 were caused by gunshot or high-velocity missiles and 35 were by stabbing; these 55 patients had multiple and extensive t r a u m a to several organs. The r~.maining 12 were injured by fhlling from trees or by encounters with wild boars or bulls. The types of pancreatic injuries sustained by the 152 patients are listed in Table 1. Among the 85 patients with blunt injuries, there were 10 contusions of the pancreas, 32 lacerations involving its head, body and tail, 10 subcapsular hematomas, 16 complete transections through the neck of the pancreas and 10 injuries to the duodenum and head of pancreas. Seven other patients had complete disintegration of the head of the pancreas. Of the 67 patients who sustained p e n e t r a t i n g injuries, 8 had contusions of the pancreas, 32 had lacerated wounds, 3 had subcapsular h e m a t c m a s , 12 had complete transection ot" the pancreas, and 6 had injury to the pancreatic head and duodenum; the r e m a i n i n g 6 had complete disintegration of the pancreatic head. ASSOCIATED I N J U R I E S

Associated and concomitant injuries were present in 112 (84.8q/~) patients. In p e n e t r a t i n g wounds caused by stabbing, impaling or being gored by animals, the associated injuries were often, situated higher in the abdomen, whereas high-velocity missiles and motor vehicles caused both associated intra-abdominal and concomitant injuries involving the head, chest, pelvis and/or skeleton. The abdominal organs (often more t h a n 1) most frequently involved were the spleen (52), liver (32), kidney (28), small intes18

TABLE 2 . - A S S O C I A T E D INJUR1ES IN 112 PATIENTS WITH PANCREATIC TRAUMA* SITE OF ASSOCIATED I N J U R I E S

Spleen Liver Kidney Small intestine SkeleLon Head Blood vessels Stomach Chest Cohm Mesentery and omentum

NO, OF P A T I E N T S W I T H EACH TYPE

52 32 28 27 24 21 ~8 17 13 13 12

:~Several patients had two or more injuries.

tine (27), blood vessels (18), stomach (17), colon (13) and mesentery and omentum (12), while the most frequent concomitant injuries were to the skeleton (24), head (21) and chest (13) (Table 2). Forty-two patients had isolated pancreatic injuries; of these 20 presented with late complications.

SURGICAL MANAGEMENT PREOPERATIVE MEASURES

Patients with suspected pancreatic injury, especially those in protbund shock, are resuscitated initially with adequate infusion of electrolyte solution intravenously and massive and rapid blood transfusion. It is preferable to start with Ringer's lactate solution. The administration of whole blood and electrolytes is of great importance to combat not only shock but also the traumatic peritonitis that follows intra-abdominal injury and results in considerable loss of electrolytes in solution. Provision must, of course, be made for an adequate airway. A Ryle's tube is passed for continuous suction of gastric contents and a self-retaining catheter is inserted into the urethra. A central venous pressure cannula is inserted though the right basi!ic vein. Blood pressure, pulse rate, blood lo,~".~and blood-gas concentrations are monitored. If bleeding is severe, intravenous transfusion is set up in the external jugular vein. This has proved to be life-saving. Patients referred with complications after initial treatment elsewhere also required nutritional and metabolic correction. This includes replacement of proteins, fats and carbohydrates by infusion of amino acids, 10% intralipid and dextrose, together with high doses of vitamins intravenously. We begin routine t9

administration ()t" broa(l-spectrum antibiotics prcrq)eratively as pr(q~hylaxis against postoperative septicemia, particularly in patierlts with multiple iz~juries. ANEST!IENIA

(;eneral anesth(:sia is used in all patients. The preferred mt:th()d is preoxygenation and adrninistration of a relaxant (1)ttll)octJrarine-chloride or pancuronium), nitrous oxide and oxyl~,~,n. N()other anesthetic adjuvant or amdgesic is required. ()PEIIATIVE AI'I'IiOAI:I! AND TE(21INICAI, CONSII'~ERA'I'IONS

Our surgical approach to tile injured pancreas depends on sev(~t'al factors, especitllly the presence of associated and concomitant injuries. '''~ High-veh~city missile injuries traversing the chest, abdomen and pelvis cause multiple bursting injuries; in such patients either a thor~coabdominal incision or several separate incisions have to be made. In patients with b l u n t t r a u m a to the upper abdolnen we prefer to make an upper pararnedian incision. which can be extended upward, inferiorly or laterally, as a subcostal incision, when required. As soon as the abdomen is opened, the presence of any blood, peritoneal fluid or intestinal contents is noted betbre they are sucked out. After hemorrhage has been a d e q u a t e l y controlled, a quick ,,lssessment is made of the abdominal organs in the peritoneal cavity. Blunt abdominal injuries and retroperitoneal hemorrhage demand systematic and careful examination of the pancreas. Good exposure of the anterior surface and the superior and inferior borders of the body and tail is obtained by opening the lesser pe:'itoneal sac through the gastrocolic l i g a m e n t after per!brining ligation of the vessels just outside the gastroepiploic arteries and retraction of the transverse colon downward and the mobilization of stomach upward and anteriorly. A n y retroperitoneal hemorrhage over the pancreas should always be dealt with by incising the pancreatic capsule or the posterior peritoneum so t h a t the hematoma can be evacuated, allowing the underlying pancreas to be examined. Failure to do this m a y result in overlooking serious pancreatic injuries, especially those associated with subcapsular h e r e o n ' h a t e . Examination of the pancreatic head and duodenum is best accomplished b y mobilizing these structures using Kocher's maneuver, which entails incision of the fascia and peritoneal attachments along the lateral border of the second part of the duodenum and blunt finger dissection posterior to the pancreatic head right up to the anterior surface of the aorta. The entire duodenum with the pancreatic head can now be mobilized and lifted forward and medially. After retraction of the transverse colon and hepatic 20

flexure downward, the mesocolon is separated from the duodenum by blunt dissection. The head of the pancreas is carefhlly inspected and palpated bimanually. Disruption of the pancreatic substance by blunt trauma can be masked by an intact capsule. Damage to the retroperitoneal portion of the duodenum should be identified and injuries to the inferior vena cava and renal vein should be excluded, particularly in the presence ofretropancreatic hematoma. Any bleeding from the portal vein area should also be exposed by dividing the lateral attachments of the right colon and terminal ileum and freeing them medially and upward. If the injury involves the body and tail of the pancreas, mobilization is achieved first by division of the peritoneal attachment lateral to the spleen and colon. The colon, spleen and body and tail of the pancreas are then mobilized forward and medially by creating a plane between the kidney and the pancreas with blunt finger dissection. This procedure permits bimanual palpation of the pa ncreas and inspection of its posterior surface. Suspicion of injury to the pancreatic duct is verified by opening the duodenum, inserting a polythene catheter into the duct and injecting 10 ml of methylene blue solution. If there has been disruption of the pancreatic duct, the dye is extravasated beneath the pancreatic capsule. The same principle can be applied to subcapsular hematoma with intralobar rupture of the liver. This technique is less time-consuming than operative cholangiography and does not require facilities for radiography. The duodenum is closed by double layers of chromic catgut sutures. Salient points in my operative technique for subtotal or neartotal pancreatectomy include mobilization of the injured pancreas and spleen, ligation of the splenic vessels with 2-0 silk and, more important, ligation of the pancreatic duct with 0 black silk. The superior mesenteric vessels need to be carefully separated if resection is required to the right of these vessels. Then I apply the pancreatic crushing clamp at the level of resection. This clamp crushes the pancreatic substance but leaves the capsule intact. The raw edges are sutured anteroposteriorly ~with several interrupted mattress sutures through the pancreatic capsule, using nonabsorbable (polyester) Ethiflex (Ethicon), and are buried in the posterior abdominal wall. This prevents leakage of Pancreatic juices and conseSluent fistula formation. We have not found any evidence that the distal end of the raw surface of the pancreas joins poorly when closed in the superoinferior direction. When pancreaticoduodenectomy is performed for severe injuries to the pancreatic head and duodenum, the technique of pancreatic implantation described by Smith s' is used. The cut margin of the pancreatic duct is anchored to the jejunal mucosa with a catgut stitch and a 5-cm segment of fine rubber tubing, which is inserted for half its length into the pancreatic duct, while the other half is introduced into the jejunal lumen. The 2d anastomosis is 21

t,.O

E x p l o r a t i o n and drainage S u t u r e anti drainage Debridement Ductal r e p a i r P a r t i a l or s u b t o t a l pancreatectomy Pancreatoduodenectomy Ducta! d i v e r s i o n Cystogastrostomy No t r e a t m e n t TOTAL

TREATMENT

TABLE 3.-.TREATMENT

8 13 -

26 7 2 5 6 67 (44.1r,~)

16 -t 4 22 5 4 9 4 85 155.9'7c)

PENETRATIN{;

17

BLUNT

NO, OF INJURIES

48 !"2 6 14 10 152

29 5 4

25

TOTAl.

4 13

1 1 t

2

'2

2

At'FER BLUNT INJURY

'2 4 1 t 6 2(3

3

.3

AI"I'ER PEN~:TRATING |N JURY

3 5 2 ! i0 33 c21.7~:" ~

"2

5

5

TOTAl.

OF P A N C R E A T I C T R A U M A IN 152 P A T I E N T S R E L A T E D TO T Y P E OF INJURY AND MORTALII'Y RATE

end-to-side between the bile duct and the j e j u n u m with a T-tube inserted into the common duct. The gastrojejunal anastomosis is perlbrmed about 3 0 - 40 cm distal to the biliary anastomosis. TREATMENT

The various forms of operative t r e a t m e n t used in the 152 patients in our series are summarized in Table 3. M a n a g e m e n t was determined by the n a t u r e and extent of the pancreatic injury, the presence ofductal injury and a n y associated and concomitant injuries.

Exploratiou aud Dvaiuage Twenty-five patients had contusions of the pancreas without major laceration of the pancreatic tissue and only moderate- tom a r k e d hematoma. Injury to the main ducts had been ruled out by thorough exploration, as outlined previously, and these patients required only Penrose drainage of the lesser sac and pancreatic area. The d r a i n a g e tubes were brought out externally through a separate stab wound. There were 5 deaths in this group, 2 from acute renal failure due to severe blood loss from associated chest and abdominal injuries. Both patients had been referred from another hospital with consequent delay of a few hours before t h e y were seen by us. Another patient, aged 76, died of severe myocardial infarction. The fourth died of p u l m o n a r y embolism and the 5th of an overlooked complete transection of the pancreas. This p a t i e n t is discussed in detail as Case 1. In 2 patients, d r a i n a g e lasted for 3 - 4 weeks but closed spontaneously. An intact pancreatic capsule does not exclude r u p t u r e of the m a i n pancreatic duct. At operation on 3 occasions, h e m o r r h a g e and duct injury have been noted in the head of the pancreas t h r o u g h an intact capsule.

Suture and Drainage Simple lacerations of the pancreas in 16 patients with b l u n t injuries, without evidence of damage to the pancreatic duct, were dealt with by closure of the defect in the pancreatic tissue and capsule with nonabsorbable s u t u r e material and Penrose drainage of the surrounding area. Individual bleeding points were ligated. Pancreatic tissue was sutured to effect hemostasis and to close disrupted tissue, thus preventing further pancreatic necrosis secondary to the spilling of enzymes. T h i r t e e n patients with p e n e t r a t i n g wounds had loss of pancreatic tissue and d a m a g e to the surrounding tract but no ductal involvement; d e b r i d e m e n t of damaged tissue and loose particles made it possible to reapproximate the pancreatic capsule. Drainage of the abdomen was established by using Penrose and sump drainage. There were 5 postoperative deaths in this group, 2 due to secondary h e m o r r h a g e from the portal and splenic veins. (Both patients were initially operated on in another institution, where 23

ductal in,javy to the neck of the pancreas had been overh~oked.) ()he or the other patients died of }mad injury and 2 o['severe chest and hepatic trauma. 1)ucml ,S'uttlr~, Suture of the damaged or disrupted main duct within the pancreas was carried out in 4 patients, all with complete transection ~fthe pmu:reas due to blunt trauma. The ducts were sutured with 5-0 sil k and the edges of the pancreas approximated with nonabsorbable sutures, u,~ing black silk. Two patients developed traumarie tmncreatitis with fistula formation and died of severe hemorrhat,'e. Autopsy revealed complete disruption of the sutured pancreatic duct with escape of pancreatic juices into the adjacent area, resulting in severe t r a u m a t i c pnnereatitis and massive hem()rrhage from the splenic vein and superior mesenteric vessels, We have since abandoned primary ductal s u t u r e (so-called ductplasty) since there are theoretical and practical objections to this procedure. Operating time is prolonged in a patient who may have severe associated multiple injuries and there is a high incidence of pancreatic fistulas and pseudoeyst formation. The anastomosis of the main pancreatic duct is made difticult by its minute size, which predisposes to stricture formation at the s i r e ' o f anastomosis, Fat necrosis in the surrounding tissue makes accurate suture approximation difi'icult. Thus, p r i m a r y ductal suture has not met with the success reported in other series, r':' However, successfuI end-to-end suture of the pancreas with p r i m a r y repair of the pancreatic duct was carried out in 4 cases of complete severance of the pancreas."" None of these patients had a n y complications. Partial or S , b/oral C a u d a l Poncreatectomy Forty-eight patients underwent subtotal or near-total pancreateetomy. All had transection or fracture of the ducts in deep injuries of the pancreatic gland with incomplete or complete rupture of the pancreas. Three died. In the 48 patients 22 pancreatic injuries were due to blunt trauma; the rest were due to penetrating injuries. Ten of the patients were operated on initially in another hospital and t r e a t e d with drainage only; all 10 were referred with complications. Five had intra-abdominal abscess and fistulas, 3 had pseudocysts and 2 had t r a u m a t i c pancreatitis with intra-abdominal sepsis. The last 2 patients died of severe hemorrhagic peritonitis and generalized sepsis, one on the 20th day and the other on the 25th day. Seven other patients who had blunt t r a u m a and who presented with unusual manifestations also had caudal pancreatectomy. Three patients had pseudocysts, 2 had chronic pancreatic fistulas, one had t r a u m a t i e pancreatitis and one had pancreatic calculi. These patients are discussed in detail under Secondary Complications. In the 3d patient who died of the 48 treated by partial or subto24

t~l distal pancreatectomy, death was due to concomitant head and chest injuries. Complications developed in patients with multiple abdominal injuries, previous drainage of pancreatic injuries and in those cases in which there was a long delay before operation. Our experience has shown that distal pancreatectomy controls hemorrhage and saihIy removes both devitalized tissue and the disrupted pancreatic duct. The results obtained justify our aggressive use of caudal pancreatectomy for the injured pancreas with ductal damage or disruption and severe damage to the tissue of part of the head, neck, body and/or tail. Resection at the level of the head and neck was performed in 35 patients; the remaining 13 had resection of the body and tail. Seven of the 35 patients underwent 95% pancreatectomy for fracture or transection of the head of the pancreas. In this procedure, the pancreas was mobilized beyond the superior mesenteric vessels to the site of the injury. A viable rim of pancreatic tissue!' remained along the duodenum; this remnant with a good blood supply is vital to prevent devitalization of the duodenum (Fig 2). Distal resection has the added benefit of avoiding the need to anastomose the pancreas and small bowel, although it has the undesirable element of removing significant amounts of functioning pancreatic tissue. In recent years distal resection of the severely traumatized pancreas has gained greater acceptance in cases where the fracture or transection may be complete or incomplete. In complete transection, the gland has been compressed against the vertebral column, and the fracture is usually located over or just to the left of the superior mesenteric vessels. More Conservative Procedures Other students of the subject recommend a conservative approach for such injuries. As a result several reconstructive procedures have been advocated, with the main purpose of preserving as much normal pancreatic tissue as possible. These conservative procedures have included the following: 1. Letton and Wilson, .~':~and Baker and co-workers ~; advocate jejunal drainage of the distal segment by anastomosis of the distal divided surface of the pancreas with a Roux-en-Y loop of jejunum and closure of the proximal end of the severed pancreas with interrupted sutures after ligation of the proximal duct. They report that this operation has the advantage of preserving normal pancreatic tissue. However, any injury proximal to the closed segment will result in cyst formation and pancreatitis, which have high mortality rates. 2. Doubiiet and Mulholland ~'~,~4 suggested that sphincterotomy and intubation of the pancreatic duct via the ampulla of Vater would promptly restore flow. They demonstrated that intubation extended into the distal severed pancreas enables healing of the 25

i

F~g 2 . - I n t r a o p e r a t i v e views of pancreatic injuries. A, complete tear of the pancreatic duct involving the head of the pancreas at its junction with the neck, The patient sustained a stab injury to the abdomen. A near-total pancreatectomy was performed. Note the use of the clamp (arrow). The patient developed a left subphrenic abscess, which was drained, and recovery was complete, There also was a tear in the transverse colon with some fecal contamination that could have accounted for the intra-abdominal distress. B shows embedment of the remaining portion of the pancreatic head in the posterior abdominal wall of the patient described ~n A. C, large retroperitoneal hernatoma (arrow) covering the lacerated head of the pancreas. This extensive injury to the right of the origin of the superior mesenteric vessels was caused by a steering wheel. Patient had almost complete pancrea':~ctomy; only a rim of pancreatic tissue was left. Secondary hemorrhage t0 days later through the drainage tube stopped spontaneously. No evidence of any functional pancreatic disturbance has been noted during the 7-year follow-up period.

fracture to take place with preservation of important granular tissue. Knowledge of the exact site and extent of injury was easily obtained by pancreatographic examination performed through a tube in the pancreatic duct. 3. Wilson'"' and Jordan 4s also recommend a Roux-en-Y loop of jejunum to the distal segment with end-to-end pancreatojejunostomy and closure of the proximal segment for subtotal or complete transection of the pancreas with ductal transection, provided there is no extensive parenchymal damage. They also reported end-to-end pancreatojejunostomy with a Roux-en-Y loop ofjeju26

num to the proximal segment and caudal pancreatectomy in I patient, after failure of p r i m a r y suture and Penrose drainage. Their m o r t a l i t y rate was 29%, which they a t t r i b u t e d to associated severe, multiple injuries to other organs. Jordan 4s feels t h a t resection should be performed only as a debridement procedure in the tail of the pancreas when there is considerable tissue destruction. 4. ,Jones and Shires 47 found t h a t a Roux-en-Y anastomosis sut u r i n g both ends of the pancreas to a loop of j e j u n u m proved satisfactory for complete transection of the pancreas over the superior mesenteric a r t e r y and to the right of the vessels. A Roux-en-Y anastomosis to both ends of the severed pancreas eliminates the need to find a severed duct or to reanastomose it. This method m a y not lead to pancreatic insufficiency or diabetes as reported by F r e e a r k TM following extensive distal pancreatectomy. There seems to be less risk of injury to the underlying superior mesenteric vessels with this procedure t h a n with resection. 5. Bracey 11 anastomosed the distal pancreas into the stomach and ligated the proximal duct, preserving the pancreatic tissue. But there is the disadvantage of not providing drainage, if there is injury proximal to the point ofligation. 6. In Mul~ and Adaniel's reconstructive procedure, '~':~the distal pancreatic segment is intussuscepted into the free end of the Roux-en-Y loop of j e j u n u m and the proximal pancreatic segment anastomosed to the mesenteric border of the jejunum. The disadvantage of these pancreatic gland-preserving procedures is t h a t additional precious time m a y be spent in attempting to perform multiple anastomoses, and time is an i m p o r t a n t factor in a severely injured p a t i e n t with multiple t r a u m a . There is also the ever present d a n g e r of contamination from the colon or intestinal contents, p a r t i c u l a r l y when these organs are simultaneously injured. The risk of fistula formation, pseudocyst and abscess forfnation is considerably higher. F u r t h e r m o r e , we believe t h a t preservation of the pancreatic gland distal to the transection or fracture is not necessary to prevent exocrine or endocrine pancreatic insufficiency. Weitzman a n d Rothschild "7 believed t h a t distal pancreatectomy was the safest, simplest and most effective form of t r e a t m e n t for pancreatic rupture. They reproved 8 cases of caudal pancreatectomy for isolated pancreatic transections. All the patients recovered with no postoperative fistulas, pseudocysts, abscess formation, h e m o r r h a g e or evidence of pancreatic inefficiency. Pancreaticoduodenecto

my

Pancreaticoduodenectomy was performed in 12 patients with 5 deaths, a m o r t a l i t y rate of 41.6%. E i g h t of the 12 also had associated injuries to the liver, colon, small intestines and stomach. In 5, the injury was due to severe b l u n t trauma; high-velocity missiles accounted for 7 injuries to the head of the pancreas and duodenum. Pancreaticoduodenectomy was performed in 4 patients 27

with d a m a g e to the l',e~lct of the pancreas and extensive devitaliz,iti()n ,)f the duodenum. In 2 of these there were also lacerations of the peripancreatic vessels with transection of the lower end of the common bile duct. Four other patients required pancreaticoduodenectomy for complete r u p t u r e of the 2d part of the duodenum, combined with avulsion or fracture of the head of the pancreas. Two of them had extensive retroperitoneal h e m o r r h a g e due to avulsion of the large peripancreatic arteries and veins, and l also had avulsion of the distal common bile duct. Resection was the only way to control hemorrhage, remove devitalized tissue and restore intestinal and ductal continuity in these cases, which were due to steering wheel i~\iury ~:' (Fig 3). Pancreaticodu~tenectomy was performed in 2 other patients with complete disruption of the head of the pancreas, but no danaage or devascularization of the duodenum. The r e m a i n i n g 2 patients had initially been treated in another center by drainage alone for complete fracture or transection of the pancreatic head; when first seen by us they had pancreatic fistulas, ductal scarring and chronic or persistent pancreatitis. Both u n d e r w e n t pancreaticoducwlenectomy. Both died of generalized peritonitis after breakdown of the pancrcaticojejunal anastomosis due to ischemic necrosis of the residual pancreas, which p r e s u m a b l y resulted from impaired blood supply to the body and tail of the pancreas that had not been clearly recognized at the 2d operation. Three other patients also died of anastomotic s u t u r e disruption with leakage of pancreatic juices, multiple abscess formation, external fistulas and pancreatitis. Because pancreaticoduodenectomy is an extensive operation in a patient already compromised by t r a u m a and carries a considerable m o r t a l i t y and morbidity rate, various other surgical procedures have been advocated. Indications and Alternatives When there are pancreaticoduodenal injuries with r u p t u r e of the ducxtenum, Donovan et al. "° advocate duodenal diverticulization. This procedure consists o f r e p a i r of the duodenal injury, gastric a n t r e c t o m y with antecolic end-to-side gastrojejunostomy, vagotomy, tube duodenostomy and drainage of the common bile duct, followed by adequate d r a i n a g e of the injured region with Penrose drains or sump suction. These workers contend t h a t gastric diversion converts the lateral duodenal fistula into an end fistula, which would invariably close spontaneously. Accordingly, the duodenal s t u m p is closed following antrectomy and duodenostomy is performed along the lateral wall of the duodenum. Although pancreaticoduodenectomy for t r a u m a has been reported by Thal, s'~ Thompson, '~ Walters, 9~ Sawyers, TM Salyer, TM and Brawley za and their colleagues, they hold the view t h a t this procedure is probably never indicated because of the high operative mortality. On the other hand, in 30 patients with injuries to the 28

"

i~:::i'i~'~:,

";1!

"

~..

•

1"7

,

,';'

Fig 3.--Intraoperative views of pancreaticoduodenal injuries. A, complete disintegration of the pancreatic head (arrow) with hematoma of the duodenal loop due to high velocity missile injury. This patient had pancreaticoduodenectomy and, after breakdown of the anastomosis, multiple complications develo p e d - secondary hemorrhage, fistula, peritonitis, abscess formation- and the patient died of generalized sepsis 3 weeks later. 13, pancreaticoduodenal injuries demonstrating complete disruption of the duodenum and pancreatic head caused by steering wheel injury. After pancreaticoduodenectomy, the patient had minor leakage from the anastomotic site, resulting in localized peritonitis with drainage of bile and pus through the tube. Intravenous alimentation and broad-spectrum antibiotics were administered and the patient recovered after 3 weeks.

duodenum and head of the pancreas, Thompson and Hinshaw.'" reported a mortality of 30% when pancreaticoduedenectomy was not performed. Such wounds accounted for 9 of the 15 deaths in their series of 87 patients with pancreatic trauma. These deaths were usually associated with injuries to vessels, duodenum or viscera. Berne et al. 1°3 reported in 1969 on 16 patients with combined pancreaticoduodenal injuries treated by duodenal diverticulization, a less extensive procedure which converts the duodenum 29

with its attached hiliary and pancreatic ductal system into a diverticulum cormected distally to the proximal loop of a gastrojejunostmny. Thirteen of these patients survived and a low incidence of complicatim~s related to the duodenum and pancreas was re. corded. They c(msidered their results to be superior to those from pancreat.icoduodenectomy. Bach and Frey:' find indication for pancreaticoduodenectomy when there is extensive damage or avulsion of the head of the pancreas associated with compromise of the blood supply to the du(denum, and tbr combined injuries involving the head of the pancreas, duodenum or common bile duct. They believe that pancreaticoduodenectomy for these injuries encompasses the anatomical limits of injury. As testimony to this they had only 1 death and 6 complications in the 5 patients who underwent pancreatico.dtmdenectomy after injury to the pancreatic head and duodenum. The patient who died had initially been treated by drainage alone and presented with chronic relapsing pancreatitis. Foley, Gaines and Fry:"' suggest that pancreaticoduodenectomy should be considered where there is damage to the head of the pancreas and extensively devitalized pancreatic tissue, particularly if this is accompanied by disruption of the pancreatic duct in the head of the gland; whm~ bleeding in the head of the pancreas cannot be controlled safely and certainly by simple suture; and in combined injuries to the head of the pancreas and duodenum with destruction of both. Our experience would indicate that patients with major fractures or avulsion of the pancreatic head not involving the duodenum are better treated by pancreatectomy, leaving a rim of pancreatic head close to the duodenal loop and taking care to avoid injury to the superior mesenteric vessels. However, like Bach and Fry, we also strongly advocate pancreaticoduodenectomy for pancreatic(~uodenal injuries whenever possible, This operation is often easier when performed for trauma as it is not unusual for the macerated head to be torn from its portal vein. Compared with carcinoma patients, those requiring pancreaticoduodenectomy for trauma are frequently young and in excellent health apart from'the effects of the acute insult, which can be rapidly corrected with blood and electrolytes. Although several anastomoses are required, the procedure accomplishes the removal of all injured and devitalized tissues which are the most common cause of morbidity and mortality. Ductal Diversion More recently, because pancreaticoduodenectomy is a formidable procedure and has a high mortality rate in polytraumatized critically ill patients with extensive injuries to the head of the pancreas and duodenum, we have performed a less major procedure described as the diversion operation. ~ Its rationale is temporary diversion of the pancreatic juices from the injured panere30

as to the stomach or jejunum, t h e r e b y creating an internal fistula t h a t prevents the development of an external fistula. In laboratory expe~iments we opened the pancreatic duct lengthwise, inserted a small plastic tube into the duct and sutured the duct and the capsule; we found they healed completely. At later removal of the catheter, we could h a r d l y tell t h a t the pancreas had been opened. When the head and neck of the pancreas are completely disrupted, it is not possible to s u t u r e the duct itself because the pancreas resembles crumbly cheese. Diversion Procedure In the type of injury to the head of the pancreas and duodenum where the p a t i e n t m a y not be able to tolerate pancreaticoduodenectomy, I first pertbrm a distal pancreatectomy at the level of the body of the pancreas close to the pancreatic injury. The pancreatic duct is then identified in the raw cut surface of the pancreatic r e m n a n t which includes the injured head. Next, 1 limb o f t h e T-tube is threaded proximally into the pancreatic duct to reach and lie in the injured head; the other limb is placed in a Roux-enY loop of the jejunum, which is now anastomosed to the cut end of the pancreas r e m n a n t in the m a n n e r described by Rodney Smith for pancreaticojejunostomy. In the presence of a r u p t u r e of the duodenum, appropriate debridement is performed and the edges are sutured with black silk. The long arm of the T-tube is then b r o u g h t out e x t e r n a l l y through the abdominal wall, via the posterior and anterior walls of the stomach, which is sutured to the injured head of the pancreas t h r o u g h the capsule. Thus an internal fistula is created into the stomach. Ruptures of the duodenum in 4 patients were sutured with black silk after adequate debridement, and the pancreatic area was drained with both sump and Penrose drains. In the last 2 of the 6 patients who u n d e r w e n t the diversion procedure, we abandoned pancreaticojejunostomy and placed 1 a r m of the T-tube in t h e injured pancreatic duct and the other in the lumen of the stomach. The posterior wall of the stomach was anastomosed to the anterior surface of the pancreatic head. The long a r m of t h e T-tube was brought out e x t e r n a l l y t h r o u g h the abdominal wall via the anterior wall of t h e stomach. This allows passage of radiopaque dye into the T-tube and enables us to ibllow the progress of operative procedure. Both these patients survived (Figs 4 and 5). It is still too early to comment on t h e long-term aspect of the diversion procedure, but our initial results are encouraging. Of the 6 patients, 2 died, 1 from multiple organ t r a u m a , notably severe chest injuries, and the other from generalized septicemia. Both had injuries to the colon with fecal contamination. At autopsy t h e r e was disruption of t h e anastomosis between the pancreas and the jejunum. Elliott ~6postulated t h a t good functional results m a y be obtained 31

Fig 4. --Duclal dWers~on by par~crealico~lastrostomy A 5mall tube has been brought out exlernally throu(.lla the anterior abdomirlal w311 via tile anterior and posterior walls of the stomach Dye iniected through the tube shows the pancreatic ducl and the lower end el the c o m m o n bile (Juct. This pahent had trauma Io the pancreatm head but pancreaticoduodenectomy was not feasible because of muPtiple organ trauma. Secondary hemorrhage from the stomach developed after 10 days and was stopped after treatment with cimetidine (300 mg every 8 hours) and blood transfusions.

for injuries of the head of the pancreas with disruption of the pancreatic duct by inserting a stent into the duct and suturing the duct and capsule. The stent acts as a splint. We believe this approach-which is supported by clinical and experimental evidence-to be sound. N o n operct tit,e M a n c~genten t

Ten patients died be[bre any operative procedure could be attempted. Eight were victims of large-scale civil violence in which they sustained several associated and concomitant injuries. Six of these 8 were wounded by high-velocity missiles, sustaining injuries to the head of the pancreas, stomach, spleen, liver, kidney, bladder, chest and major blood vessels. They were admitted in profound shock and exsanguination and died before any resuscitative measures could be instituted. These deaths were attributed to hemorrhage and multiple trauma. Two other patients admitted the same day with blunt injuries died in the operating room; autopsy revealed complete disruption with avulsion of the head of the pancreas, rupture of duodenum, severe laceration of the liver and large retroperitoneal hemorrhage due to injury to the peripancreatic vessels. Both had been struck in the abdomen by iron pipes. There was considerable delay before they were admitted to our hospital because they were initially treated elsewhere. The remaining 2 patients in this group had blunt trauma injuries and they, too, died on the operating table. One had avulsion of the pancreatic head with laceration to the portal vein, rupture of the duodenum and a lacerated liver; autopsy revealed a large 32

Fig 5 . - A u t h o r ' s procedure for combined duodenopancreatic injury. A shows extensive trauma to the head of the pancreas and to the duodenum. B, first procedure, a distal pancreatectomy, is performed at the level of the body of the pancreas near its neck or away from the injured pancreatic area. The lacerated duodenum is shown sutured after any necrotic tissue has been cut away. C shows that one arm of a T-tube has n o w been inserted through the duct of the remnant pancreas, while the other arm ties in the jejunum. The longer arm of the T-tube is then brought out externally through the abdominal wall, via the posterior and anterior walls of the stomach. In D the posterior layer of the stomach is now sutured to the injured head of the pancreas through the capsule, thus creating an internal fistula into the stomach.

subdural hematoma. The other patient had extensive i n j u r i e s t o 12 abdominal organs in addition to chest and head injuries. Both were injured in head-on collisions with motor vehicles.

Debridement Debridement of necrotic pancreatic tissue in the head and neck of the pancreas was performed in 5 patients who had intra-abdominal sepsis with subphrenic or pancreatic abscesses. 33

After excluding ductal involvement by opening the duodenum, <:alhetcrizing the Imn<:rt;atic duct and injecting methylene blue, we dehrided t ht.' necr~tic tissue, evacuated the abscesses and then used adequate Penrose and sump drainage. All 5 had a stormy convalescent period, with minor fistula formation at the drainage siD.:, bt|t they recovered and have remained well. All had minor blunt trauma and presented as unusual manifestations due to occult complaints. They will be discussed in detail later. ( 'yst,a, a s t r o s t , m y

Cystogastrostomy was performed in 14 patients with pseudocysts. Eight presented with abdominal masses consequent to late complications of pancreatic trauma. The remaining 6 were referred fr~m~ other centers alter conservative operations for pancreatic injuries. Since the cysts were located in the head or around the neck of the pancreas and were adherent to the duodenum and surrounding structures, resection was not feasible and internal dn.inage was the preferred treatment. We prefer cystogastrostomy because it is easier to perform, there are fewer complications and the results are excellent. Other authors, however, advocate cystojejunostomy with Roux-en-Y anastomosis. In this group of 14 cystogastrostomies there was 1 death due to peritonitis after leakage of the anastomotic area with abscess formation and septicemia. There were no complications or recurrences in the other patients. During the early postsurgical period these patients are best managed in the intensive care unit where frequent consultations with various specialists should be routine, as should the monitoring of physiological parameters. The central venous pressure is taken every half hour to check the patient's hydration; if necessary, blood transfusions are given. If urinary output falls below 50 ml/hr mannitol 20% solution followed by Ringer's lactate solution should be given until a satisfactory rate of urine excretion is obtained. Routine blood gas analysis and biochemical and enzyme studies should be carried out including frequent measurement of blood sugar levels. We have tried many types of analgesic, such as pethidine, pentazocine and Talwin, but prefer Entonox (a mixture of ,50% oxygen and 50% nitrous oxide). Broadspectrum antibiotics are given routinely. Since the abdominal drainage tubes may discharge blood or pancreatic fluid, the skin around them should be covered with a protective paste to prevent excoriation. We have found Orabase paste (Squibb) to be extremely effective. The type and number of drainage tubes used depends on the nature and extent of the pancreatic injuries and on associated in tra-abdominal injuries, particularly when there is fecal contamination due to colonic or small bowel injury, We prefer to use Penrose drains for contusions or minor lacerations of the pancreas without ductal injury. In the presence of major pancreatic lacerations or after reset34

tions, a Penrose drain is used, with additional soft rubber sump drains connected to suction pumps.'-' The drainage tubes are placed adjacent to the pancreatic area and brought out externally through the bed of the 12th rib. Anteriot sump drainage is accomplished by placing 2 French catheters between Penrose drains, applying suction to 1 and utilizing the 2d as an air vent. We administer a broad-spectrum antibiotic intraperitoneally through the drainage tubes daily. In the presence of prolonged discharge, the appropriate antibiotic is given when the organism(s) and sensitivity have been identified. In other cases, the intraperitoneal antibiotic instillation is discontinued after 4 or 5 days. The drainage tubes are removed only when the discharge has ended. It is, however, routine for us to start withdrawing the tubes slowly on the 5th day after operation; on several occasions we have found copious drainage at the 1st partial withdrawal of the tubes. It is important that the drainage tubes do not accidentally slip out prematurely. Normally, they are removed after 7 to 10 days since significant pancreatic drainage often ceases after the 1st ibw postoperative days. COMPLICATIONS AFTER PANCREATIC TRAUMA

The postoperative complications of pancreatic trauma I encountered in this series are best discussed under two main headings, primary and secondary. Primary complications arose during initial management of 132 patients with acute pancreatic trauma. These included the 28 patients who had initial treatment elsewhere. Several of them presented with complications of fistulas, abscesses and pancreatitis. (They are not included in the author's complications and have already been discussed under Treatment.) Secondary complications include those of 20 patients with complications consequent to a history of blunt trauma. They are often of a minor nature and have unusual features.

Primary Complications Thirty-five patients (33.5%) developed 49 complications of" varying degree, as shown in Table 4. The frequency and nature of the complications were related to the site and extent of the primary injury, the type of operative intervention, the presence of preoperative shock and accompanying visceral injury. Among these 35 patients the complications were pancreatic fistula (15), wound infection (8), pancreatitis (7), hemorrhage (4), intra-abdominal abscesses (6), pseudopancreatic cyst (3), septicemia (2) and pancreatic insufficiency (4). Pancreatic fistula was the most common postoperative complication in this group. Ten patients developed 35 FISTULA

FORMATION.

--

TAIII,I.: , I I'()ST()I'i':IIATIV E ¢'~)MI'IJ('ATI('iNS liI':SIII,'I'INc:; FROM M A N A i I I ' : M E N T Ill" 132 P A T I E N T S W I T I I A(:I t't'!'; I N . I I I I I I E S ( ' ( ) M I ' I I ( ' A T I ( NS

W~nlnd tnf;,clmn \Your~d (hqlis¢'enc(, with infccti¢)n Sel)~is Subphrenic I'erih)niti,~ l'ancreatic ,~,('pt lct,qt~ i'l

}*~IDCt'PIIIit" fi.~tula [ [t~HIcWFII~Ig(, (,'pper gastr.intestinal |)rainage Pancrcatic deficiency t~st, udocyst P a n c r e a t itis TOTAl.

N(). ()F ('ASES ~

,| 4

,1 I l ?.

15 2 2 ,1 3 7 ,19

' T h i r t y - l i v e patients developed ,19 complications,

only temporary pancreatic fistulas, which drained for 2 - 4 weeks and closed spontaneously. These are considered minor fistulas since it is normal for pancreatic injuries to drain pancreatic juice for 10- 14 days. Three patients had major fistulas which drained for over a month but did not require any definitive operation. Only 2 patients had persistent fistulas which drained for weeks or months and required operation. The pancreatic fistulas developed in 6 patients after simple drainage and in 4 patients after suture with drainage. Only Penrose drains were used. Major fistulas developed in 3 patients after pancreaticoduodenectomy but closed spontaneously after 6 weeks. Ten of the 15 patients with pancreatic fistulas had an elevated serum amylase level from several days to 2 months. A persistent pancreatic fistula after operation in 2 patients injured by blunt t r a u m a required reoperation. Debridement of necrotic tissue in the head and neck of the pancreas in the 1st patient was followed by successful closure of the fistula. This patient had originally undergone exploration and drainage for what was thought to be a simple contusion of the pancreas. The 2d patient's persistent fistula continued to drain for more than 4 months after caudal pancreatectomy. The patient was reoperated on 36 hours after admission to the hospital, and traumatic pancreatitis with a localized abscess was found. The abscess was drained; the necrotic edges of the pancreatic tissue were excised and resutured; the fistula closed 2 weeks later. In both these patients, management of the fistula presented several problems. Drainage varied between 800 and 2,000 ml of pancreatic juices in 24 hours, with loss of fluid and electrolyte imbalance. The pa36

tient.s were maintained on intravenous hyperalimentation through a subclavian vein. Excoriation and digestion of the skin around the fistulas also required t r e a t m e n t to protect t h e skin from furthel' damage by this painful and morbid complication. Orabase paste* has proved to be very effective in preventing the skin complications? '~, '~:~Stomahesive waferst prevented further excoriation. TRAUMATIC PANCREATITIS.Seven patients had traumatic pancreatitis, but continuing pancreatitis after operation was difficult to establish. Abdominal pain, paralytic ileus and upper abdominal tenderness were present in all 7. A:mylase concentration was elevated in the serum and in the discharge from drainage tubes. Treatment of traumatic pancreatitis in these patients was the same as for nontraumatic pancreatitis and it responded quite well to conservative measures, consisting of care of the fistula drainage, constant gastric aspiration with Levine's or Ryle's tube, withholding of all oral feeding, adequate administration of a broad spectrum antibiotic and replacement of calcium salts ibr the sequestrated calcium at the site of injury. Traumatic pancreatitis [bllowed operation for contusion of the pancreas in 2 patients and distal pancreatectomy for complete transection of the body of the pancreas in 3; the remaining 2 patients in this group had suture and drainage :~ (Fig 6).

HEMORRHAGE. - - Four patients had secondary hemorrhage from the drainage tubes. In 2, hemorrhage ibllowed prolonged pancreatic discharge; both responded to debridement of the necrotic tissue and evacuation of the abscess cavity. Originally, these patients had been treated with suture and drainage for extensive lacerated wounds in the head of the pancreas. Two others had upper gastrointestinal bleeding due to stress ulcers following pancreaticoduodenectomy; both responded to adequate blood transfusion and drug t h e r a p y - C i m e t i d i n e 300 mg every 8 hours fbr 5 days. SEPSIS.--In this series sepsis was related to the multiplicity of injuries, the type of wounding agent and the diverse sources of contamination, shock and necrosis of pancreatic tissue. It took the form of septicemia in 2 patients, wound infection in 8 and intra-abdominal abscesses and peritonitis in 6 others. Wound abscess occurred in 4 of the 8 patients who had transincisional drainage of the abscess cavity. Localized abscess forma*Orabase is a protective paste which adheres to weeping skin surfaces and mucous m e m b r a n e s and contains gelatin, pectin and sodium carboxymethylcellulose in Plastibase ointment base. ~Stomahesive is prepared as a compressed wafer from nonsensitizing ingredients including gelatin, pectin, sodium carboxymethylcellulose and polyisobutylene. It is coated ori the upper surface with a polythene film and on the adhesive side with a parchment release paper. 37

F{g 6.--Traumatic pancreatitis. A, arrow in plain x-ray of the abdomen indicates ileus of the duodenum and downward displacement of the transverse colon due to acute traumat,c pancreatibs after penetrating injury in which patient sustained ductal iniury in ~he neck of the pancreas. Near-total pancreatec.-' tomy was followed by a stormy convalescence with secondary hemorrhage, fistub~ formation at 1he drainage site and a telt subphrenic abscess. The abscess was drained and the pancreatic fistula closed after excision of the necrotic edges of the pancreas. B, endoscopic pancreatography showing irregularity of the pancreatic duct and dilatation of the acini due to traumatic pancreatitis. Patient had sustained blunt trauma to the pancreatic body and head 4 months prewously and presented with recurrent abdominal pain. After a near-total panc~eatectomy he was relieved of pain but has mild diabetes, which is controlled by replacement therapy.

tion developed around the anastomotic site in 1 patient after pancreaticoduodenectomy. There were 2 cases of left subphrenic abscess after distal pancreatectomy and splenectomy for extensive injury to the body of the pancreas and spleen despite appropriate surgical treatment and what appeared to be adequate drainage. All these patients were treated by surgical drainage of the abscess. Generalized peritonitis that developed in 1 patient responded to adequate antibiotic therapy and drainage of the abdominal cavity. PANCREATIC DEFICIENCY.-- Four patients developed pancreatic deficiency after undergoing pancreaticoduodenectomy. The exocrine functions were investigated by biochemical and enzyme studies, particularly insulin assays, triolein uptake using isotopes, and estimation of intestinal enzyme levels. In the face of pancreatic insufficiency lifetime supplementary medical therapy is necessary to avoid a malabsorption syndrome and diabetes. Pancreatic deficiency was corrected by supplementary therapy in 2 patients; 1 defaulted fromtreatment and 1 has been lost to fol33

Fig 7. - Postpancreatectomy pancreatic insufficiency. Barium meal studies show flocculations and constrictions of the small intestine because of pancreatic deficiency after pancreaticoduodenectomy for corr, bined injuries to the duodenum and head of the pancreas. Patient has malabsorption and diabetes and is being treated by replacement therapy.

low-up. None of the patients treated by partial pancreatectomy developed pancreatic insufficiency even when 90% of the pancreas was removed (Fig 7). PSEUDOCYST.-- This complication was present in 3 patients (7.4%) with blunt trauma, in 2 patients with suture of lacerated wounds and in 1 with contusion of the pancreas. All these complications occurred very early in our series. In recent years there have been no pseudocysts, reflecting our aggressive approach to blunt trauma, including t r e a t m e n t of the pancreatic wound with adequate drainage. Surgical therapy was carried out to relieve the symptoms and to avoid rupture, which is associated with a high mortality rate. All these patients had internal drainage by cystogastrostomy. The serum amylase level was elevated in all 3 patients, but none of them had any complications and there were no deaths.

Secondary Complications~Unusual Presentations (Tables 5 and 6) PSEUDOCYST.-- Eleven patients presented with gradually increasing abdominal masses; 2 had jaundice with ascites, while 3 had signs of incomplete small bowel obstruction, and 1 had marked pallor due to internal bleeding. All gave a history of blunt injury to the abdomen 3 to 6 months earlier. Diagnosis of pancreatic pseudocyst was made by barium contrast studies, ultrasound image, pancreatic isotope scanning using 75selenomethionine, coeliac axis arteriography and splenoportography including computerized axial tomography. Of the total 39

TAIU.F; 5. - - I , A T E ( ) R UNUSUAL PRESENTATION OF (.OMt LICAIIONS IN 20 PATIENTS 'rYl'E OF CIIMI'I.II'ATION

NO. OF P A T I E N T S

l)s(~udocyst.~

1l

Pancreatiiis Irl tra-a t~.lt)m in a IIi h:acess Persistent pancreatic fistula f'ancreatic calculi

1 5 2 !

of 1 1 p s e u d o p a n c r e a t i c cysts, 8 w e r e located in the head of the p a n c r e a s a n d t h e rest in the body a n d tail. The j a u n d i c e in 2 patients was due to obstruction of the bile duct. A d h e s i o n s w e r e respmlsible for small bowel o b s t r u c t i o n in 3 p a t i e n t s , while t h e pallor in a n o t h e r w a s due to bleeding into t h e cyst. C y s t s in the body a n d tail of t h e p a n c r e a s were t r e a t e d by subtotal p a n c r e a t e c t o m y . W h e n t h e cyst w a s located in t h e h e a d of the p a n c r e a s , resection w a s not feasible. The presence of a t h i c k n o n r u p t u r e d , m a t u r e pseudocystic wall facilitated i n t e r n a l d r a i n age into the stomach. All 11 p a t i e n t s survived. One of t h e 8 who u n d e r w e n t c y s t o g a s t r o s t o m y developed a fistula, w h i c h healed s p o n t a n e o u s l y . The l o n g - t e r m follow-up h a s been excellent in all these p a t i e n t s (Figs 8 a n d 9). iNTRA-ABDOMINAL ABSCESS.--Five p a t i e n t s had i n t r a - a b d o m i nal abscesses c o n s e q u e n t upon b l u n t i n j u r y to t h e u p p e r a b d o m e n 3 w e e k s to 2 m o n t h s prior to s e e k i n g medical advice. Two patients had been involved in a m o t o r vehicle accident, 2 fell from a tree and I w a s kicked in t h e a b d o m e n . T h r e e of t h e p a t i e n t s w e r e t r e a t e d by n a t i v e p h y s i c i a n s lbr a b d o m i n a l pain, b u t the o t h e r 2 did not seek a n y i m m e d i a t e medical t r e a t m e n t . T h r e e of the 5 p a t i e n t s p r e s e n t e d w i t h a s w i n g i n g p y r e x i a , polym o r p h o n u c l e a r leukocytosis a n d a t e n d e r m a s s a r o u n d the epigt~strium: the o t h e r 2 h a d p y r e x i a a n d a n e n l a r g e d , t e n d e r liver. D i a g n o s i s of s u b p h r e n i c abscess w a s m a d e in t h e s e 2 p a t i e n t s by TABLE 6.-MANAGEMENT OF UNUSUAl, PRESENTATIONS IN 20 PATIENTS WHO SUSTAINED BLUNT TRAUMA TYPE OF U N U S U A l , PRESENTATION

NO. OF PATIENTS

DEFINITIVe: TREATMENT

Pseudopancreatic cyst Traumatic pancreatitis Pancreatic calculi Intra-abdominal abscess

11

Cystogastrostomy (8) Distal pancreatectomy (3) Subtotal pancreatectomy Near-total pancreatectomy Evacuation of abscess With debridement of necrotic tissue Caudal pancreatectomy

Persistent fistula 40

1 1 5 2

RESULTS

Good Survival Symptom-free Survival Excellent

Fig 8.-Pancreatic pseudocyst. A, lateral view of patient shows supraumbilical swelling that developed after minor blunt abdominal trauma 6 weeks earlier. Investigation revealed a pseudocyst of the head of the pancreas. Cystogastrostomy was performed with no postoperative complications and patient remains symptom free. B, barium meal studies of the same patient showing a large pseudocyst of the pancreas.

a combination of clinical examination and chest and abdominal radiographic examination, including lung-liver scanning. In 4 patients, barium studies and pancreatic scanning led to a suspicion of an abscess around the pancreas. Diagnosis of pancreatic abscesses was confirmed at laparotomy, the abscesses were evacuated, debridement of the necrotic pancreatic tissue performed and the abdomen drained with sump and Penrose drains. All 5 patients had a stormy convalescent period with prolonged fistula formation in 2; these closed spontaneously. PANCREATIC CALCULI.--One patient presented with chronic, relapsing epigastric pain radiating to the back, and a history of trauma that had occurred 6 months earlier was obtained. Plain xray examination showed multiple pancreatic calculi in the main ducts. A near-total pancreatectomy was performed and the patient has remained symptom free. PERSISTENT PANCREATIC FISTULA.-- One

patient presented with a persistent abdominal fistula, while in the other the fistula was in the perinephric region. The duration of the fistulas varied from 2 to I0 months. Diagnosis of pancreatic fistula was made by elevated serum amylase level, fistulography through the external opening, barium meal studies and pancreatic scanning. In both patients the fistulographic examination revealed direct commu41

A 4~

i

¢ e o

Fig 9 . - P a n c r e a t i c pseudocyst resection. A, scan showing no uptake of isotope in the body and tail of the pancreas (arrow). The patient, a woman aged 62 years, slipped and fell on a heavy object, sustaining nonpenetrating injury around the umbilicus. She did not seek medical advice but had noticed a gradually increasing abdominal mass over the past few months. Since the pseudocyst (8) was located in the body and tail of the pancreas, resection of the cyst was performea. Recovery was uneventful and patient has remained symptom free. The pseudocyst was due to disruption of the pancreatic duct in the body of the pancreas.

nication to the neck of the pancreas when an abscess cavity was present. Pancreatic scanning in 1 patient showed a space-occupying lesion due to disruption of the pancreatic duct. In an investigation of chronic pancreatic fistula the 1st priority is to establish the site of the fistula and try to assess w h e t h e r distal obstruction is present t h a t will prevent it from healing and, therefore, m a k e s surgery mandatory. The most valuable investigations are fistulography t h r o u g h the external opening, conventional barium studies and ultrasound. Such studies, supplemented when necessary by angiography, give a good indication as to whether the fistula will heal and w h e t h e r abscess cavities are present. Identifying abscesses can be very difficult, yet it is crucial to the progress of the patient. A swinging pyrexia and poly42

morphonuclear leukocytosis, though suggestive of abscess formation, are not reliable indications; conversely, the absence of these signs does not exclude the presence of pus. Abscesses in typical areas, such as the subphrenic space and the pelvis, can be diagnosed by the use of clinical and chest radiographic examinations and the other techniques described above. The use of lung-liver scanning may be required at other sites. Although common sense dictates t h a t there may be a few exceptions, the following guidelines provide a rational and effective approach to therapy. If there is distal obstruction, it is obvious that only relief of the obstruction will allow the fistula to close. '~ Where a small fistula leads into a large abscess cavity t h a t is draining through a small outlet, only adequate drainage of the abscess will enable the fistula to close. These surgical techniques are generally well tolerated, but they should only be carried out when the patient is well nourished .~4and free of other sepsis and after thorough investigation. The fundamental rule governing management of fistula is to remove all diseased '-'~,TM tissue. Accordingly, both these patients had distal pancreatectomy.

MORTALITY In this series of 152 patients with pancreatic injuries 33 died, for a mortality of 21.7%. Of significant importance was the fact that 15 of the 33 patients who died were initially treated in another hospital or center and were referred either late or with complications (Table 7). Six other patients had severe multiple organ t r a u m a and possibly would have died anyway. Among the factors related to mortality, the type of wounding agent was of considerable significance. Penetrating wounds accounted for 20 of the deaths (60.6%) and blunt t r a u m a for 13 (39.4%). Mortality was greatest in penetrating injuries from high-velocity missiles and gunshot wounds that caused extensive pancreatic t r a u m a and multiple injuries to several other organs, whereas high-speed road accidents accounted for more t h a n 80% of the fatalities from blunt pancreatic injuries. Associated and concomitant injuries presenting with shock were the primary cause of 16 deaths; 10 of these patients were admitted in a moribund state with multiple injuries to several organs. All 10 died within a few hours without any effective resuscitation or operative intervention being possible. The diagnosis of pancreatic injury was established at postmortem examination. Parts of the body affected by concomitant injuries included the head, chest, pelvis and skeletal system and there was a direct relationship between mortality and the number of associated visceral and vascular injuries. Trauma to the liver, spleen, colon, small intestines, kidney and peripancreatic vessels, frequently difficult to manage, were the main types of associated visceral injuries present in 72% of the patients who died. In more than 43

4a ga

2 6 6

Pseudopancreatic cyst

Multiple organ trauma

TOTAL

2

Laceration of pancreatic duct Transection of pancreatic duet Combined pancreaticoduodenectomy

28

10

2

NO. O F PATIENTS

Contusion

T Y P E O F INITIAL PANCREATIC INJURY

No treatment

Internal drainage

Exploration and drainage Suture and drainage Sub- or near-total pancreatectomy Pancreaticod uodenectomy

DEFINITIVE TREATMENT

RATE

Both died of renal failure due to prolonged shock Both died of secondary hemorrhage Two patients died or fistula and sepsis Both died ar fistulas. abscess, hemorrhage One patient died of peritonitis All died of shock and hemorrhage 15 deaths

MORTALIT'f

TABLE 7.-DETAILS OF INITIAL INJURY. DEFINITIVE TREATMENT AND RESUI,TS OF 28 REFERRED PATIENTS WITH PANCREATIC TRAUMA

h a l f o f t h e s e 16 p a t i e n t s 3 or more o r g a n s were injured, a n d d e a t h w a s due m a i n l y to m a s s i v e uncontr'ollable h e m o r r h a g e r e s u l t i n g in shock, sepsis and m u l t i p l e o r g a n failure. The p a n c r e a t i c i n j u r y w a s not a c o n t r i b u t o r y c a u s e of d e a t h in all t h e s e p a t i e n t s . T h e type, site and e x t e n t of p a n c r e a t i c injury, i n c l u d i n g the m e t h o d of t r e a t m e n t c a r r i e d out, were also i m p o r t a n t factors in m o r t a l i t y . E x t e n s i v e injuries to t h e h e a d of the p a n c r e a s or combined p a n c r e a t i c o d u o d e n a l injuries in which t h e d u o d e n u m w a s r u p t u r e d or its blood s u p p l y w a s c o m p r o m i s e d r e s u l t e d in 7 deaths. Five of t h e s e p a t i e n t s u n d e r ' w e n t p a n c r e a t i c o d u o d e n e c t o m y a n d d e a t h w a s due to m u l t i p l e complications resulting fi'orn b r e a k d o w n of a n a s t o m o t i c sites w i t h c o n s e q u e n t h e m o r r h a g e , fistula f o r m a t i o n , i n t r a - a b d o m i n a l abscesses a n d g e n e r a l ized sepsis. Fecal c o n t a m i n a t i o n from t h e colon or s m a l l i n t e s t i n e w a s a c o n t r i b u t o r y factor in t h e d e a t h of 3 of t h e s e 5 p a t i e n t s . R e p a i r of t h e t r a n s e c t e d m a i n p a n c r e a t i c duct r e s u l t e d in t h e d e a t h of 2 p a t i e n t s who should h a v e h a d a distal p a n c r e a t e c t o m y . D e l a y in d i a g n o s i s of t h e p a n c r e a t i c injury, i n a d e q u a t e explor a t i o n of t h e p a n c r e a s at l a p a r o t o m y w i t h f a i l u r e to recognize t h e e x t e n t of p a n c r e a t i c injury, r e s u l t i n g in a n i n a p p r o p r i a t e s u r g i c a l p r o c e d u r e at t h e initial o p e r a t i o n , led to t h e d e v e l o p m e n t of fistulas, t r a u m a t i c p a n c r e a t i t i s , sepsis a n d h e m o r r h a g e w i t h d e a t h in 6 p a t i e n t s (18.2% of t h e fatalities). All 6 w e r e r e f e r r e d from o t h e r h o s p i t a l s or i n s t i t u t i o n s a n d h a d 1 or m o r e operations. D e a t h of t h e 2 r e m a i n i n g p a t i e n t s w a s c a u s e d by c a r d i o r e s p i r a t o r y complications.

ILLUSTRATIVE CASES CASE HISTORY NO. 1. --A. B., a 17-year old man, previously in good health, was involved in a motor vehicle accident on July 22, 1978 and admitted to the casualty department complaining of vague abdominal pain. His general condition was satisfactory, blood pressure was 110/80 mm Hg, and he had abrasions over the right forehead and right lower chest. X-ray examination of the chest and abdomen revealed right-sided fractures of the 6th rib and the transverse process of the 1st lumbar vertebra. He was referred to the surgical department the next day with a provisional diagnosis of intra-abdominal injury. On examination, his general condition was still satisfactory, but he had slight guarding and rebound tenderness over the right hypochondrium. There was no evidence of free fluid in the peritoneal cavity and 4-quadrant abdominal aspiration yielded no fluid. No evidence was noted of any pallor, fall in blood pressure or rise in pulse rate. Repeat x-ray examination of the abdomen and chest did not reveal any gas under the diaphragm. The serum amylase level was within normal limits at repeated examinations. In the absence of any definite diagnosis, an exploratory laparotomy was performed on the same day. Multiple superficial lacerations were found over the anterior surface of the liver with a large retroperitoneal hematoma involving the right paracolic gutter. There was also contusion of the 2d and 3d parts of the duodenum. The abdomen was closed with 45

nd~,qtmt~, ['t.nrc~se draina~m after peritmmal toikd,. Pos~<~peratively, he w~Lqput ~m gm~t:tmi¢'in and ulhm" sul.)l)orlive theral)y. ()n the 2d t)~sll~poralive day his I~lood gases slmwed evidence of h~wer~,d ~xygen tensi~m nn(l respirat<,ry alknlosis. A plain ×-ray examination of the chest showed bilateral ImeUm<.,nitis. l)uring this period the pat imp! Imss~'d 1.5 t~, 2 liters of urine daily and the specific gravity was within m w m a l limit::. ()n the 5th lmstopernlive day yellowish e×udate drained from the ahdmnina} wmlnd ~lnd t Iu~ patient was found to have wound dehiscence. "l'hv abd(mmn was r,.,(q)ene(I. Ah(,ut 200 ml of Iluid was present in the perit~mt,al cavity, with fht necr¢~sis in the h.,sscr sac and greater o m e n t u m , hut the re.troperitoneal h e m a t m n a had cleared. On e.xamination ol" the pancreas after openinl4 the lesser sac, it was concluded that the patient hn(l only c(mtusion of the head of the pancreas, with some evidence of traumatic pnncreatilia. However, the duodenum and the head of the pancreas were not mobilized t~ virmalize the posterior surface and no injet'l i~m of dye or a methylene blt,e test was done to exclude ductal injury. The abdomen was closed with nonabsorbablc, suture.~ after draining the peritmmal cavity. Postoperatively, fluid from the drainage tube and blr,~rd samples were sent daily fiw estimation of serum amylase levels. The amylase ira the peritoneal fluid ranged from 2,000 to 4,400 Somogyi t, nits and that in the serum from :~00 to 500 Sonmg.yi units. Serum calcium and urinary diastase were within normal limits. On the .gth postoperative day the patient began to have generalized fits. lasting from one-half to one-and-a-half mint, tes. Biochemicul test~ showed bh)rul urea 28() mg/l()0 ml, serum creatinine 5.0 m g l l 0 0 ml anti random blood sugar 36B mg/lO0 nil. Other lfiochemical variables were within normal limits. The patient was seen by the neurologist who felt that the ills could be attributed to metabolic or traumatic causes. On the lOth day "coffee-ground" aspirate was obtained from the draina~e sites and abdon~inal distention gradually developed. This was confirmed by n plain x-ray exatnination of the abdomen, but erect and supine views revealed no si~mificant additional finding except for haziness around the 1st lumbar vertebra. On the 15th day a fecal fistula developed from the main wound and there was generalized bleeding from the stomach, drainage site and the abdominal incision. After resuscitation, a laparotomy was pertbrmed on the 20th day, when the abdomen was fi)und to contain a liter of bile-stained peritoneal tluid and extensive retroperitoneal tissue necrosis. The pancreas was found to be transected posteriorly between neck and body with complete disruption of the main pancreatic duct. A fistulous track was discharging bile-stained fluid from the duct; the stomach and d u o d e n u m were edemalous; and a right subphrenic abscess was present. No obvious perforation was noted in the hollow viscera. Subtotal pancreatectomy was performed with d e b r i d e m e n t of the necrotic tissue and a T-tube inserted into the common bile duct. The abdomen was a d e q u a t e l y drained. Postoperatively, the patient began h a v i n g large a m o u n t s ( 1 . 5 - 2 L) of "coffee-ground" aspirate and bled from the drainage sites. Blood urea rose to 119 rag/100 ml, platelet count was 160,000 and urine output, gradually d i m i n i s h e d to 500 m1124 hours. He died on the 22d day. Blood coagulation studies showed d i s s e m i n a t e d i n t r a v a s e u l a r d o t t i n g and autopsy revealed large a m o u n t s of blood in the peritoneal cavity. A large abscess was located around the pancreas, the pancreatic stump was necrotic and 46

the sutures were broken clown. The splenic vein had been eroded. The stomach and small intestines contained altered blood and the liver had multiple necrotic abscesses. This case illustrates the progressive course of events following failure to carefully examine and exclude major pancreatic injury during the 2 [apar(~tomies. The presence of a large retroperitoneal hematoma and cm~tusion of the duodenum during the initial laparotomy and the findings of flit necrosis and peritoneal exudate d u r i n g the 2d laparotomy makes :nobiJizntion and meticulous visualization of the duodemJm and pancreas, particularly the posterior surface, mandatory. P r i m a r y pancreatic resection in this patient would have averted the major complications, such ~s fistulas, abscess formation, pancreatitis, septicemia with disseminated i n t r a v a s c u l a r clotting, and, ultimately, his death. CASE HISTORY NO. 2. ~ A Chinese man, 22 years of age, was admitted to our d e p a r t m e n t 3 hours after being involved in a road accident. On admission, he complained of generalized abdominal pain, maximal in the epigastric and umbilical regions, nausea and faintness. Initially his blood pressure was 120/70 mm Hg and his pulse rate 96 beats/minute with good pulse volume, ']['here were abrasions on the chest and over the anterior abdominal wall in the region of the epigastrium. Generalized abdominal tenderness and muscular rigidity were m a x i m a l in the region of the umbilicus and epigastrium. There was rebound tenderness with mirdmal abdominal distention. Urinalysis was reported normal. The hemotocrit was 37% and hemoglobin concentration was 90 gm/L. Chest x-ray examinations were reported as normal. A 14-gauge needle paracentesis of the abdomen in the iliac fossae revealed fresh blood in the peritoneal cavity. The patient had a t e m p e r a t u r e of 38 C. A tentative diagnosis was made of ruptured liver or spleen combined with enteric rupture, and an emergency ]aparotomy was performed after resuscitation. At operation, 1 L of blood was found lying free in the peritoneal cavity and there were 2 linear tears in the uncinate process of the pancreas, each 1 cm in length. The uncinate process was partially avulsed. In addition there were 2 lacerations, each 2 cm in length, in the mesenteric vessels with active bleeding. The superior mesenteric vein had a laceration which was bleeding profusely. There was a perforation l-cm long in the ileum about 20 cm from the ileocecal junction, with soiling of the peritoneal cavity. This tear and t h a t in the superior mesenteric vein were repaired with continuous 4-0 silk sutures. The avulsed uncinate process was excised and interrupted 4-0 sutures used to suture the adjoining portions of the head of the pancreas and to control bleeding. The tears in the mesentery were repaired with 4-0 black silk. A T-tube was inserted into the common bile duct. Peritoneal toilet was performed using warm saline solution, and the pancreatic area was drained by m e a n s ofa Penrose drain before the abdomen was closed. On the 1st postoperative day the patient went into hypovolemic shock. The pulse rate rose to 130 beats/minute with poor volume, and the blood pressure was 70/40 mm Hg. U r i n e output was reduced to 0.2 ml per minute. The hematocrit was 30% and the hemoglobin concentration 80 gm/L. The abdomen was distended. About 300 ml of blood-stained fluid drained through the d r a i n a g e tube. The acid-base and electrolyte balanee was normal. Infusions of 2 pints of fresh blood and 2 pints of plasma were instituted without delay, and dexamethasone (4rag) was given in47

tr'.venou.~:l.v. The patient also received 8() zn~ of gent.amicin intramuscuhu'ly ~wice d'dly and ,Sq)t)mg of ampicillin every 6 hours. ()n the 2d postopt, rnliwe day llis lllo~>d pressurt, wlls 120170 lnnl t|g lind the urine output 1.7 inlinlinuto t h; was febrih: wi t h a tenH)erature of38.2 C,. ()n t he "/'ti i postoperlit i~,'e day ~liStl'iC aspiration prod uced fresh blood. lli.~ bh,nt pressure wns 120t70 inin Iti{ l.uid pulse rate 100 per minute with good vOltlnle avid tension. Since lie had aclite stress ulcers of the stou'ulch tie was treated wi t h trar~e×iunic acid (1 ffin every 6 hours) and cinmtMine (JOl) nll.e every 8 hotlrs for 12 dosesl. The gastric aspiration w a s frt;e of blood in 2,1 iiotlrs, and no further blood transfusions were given. The henlalocrit lilid tlemoglobiil eoncent.ration were both reported Illlrllllli. ()n the 13th l)l)stoperal.ive day again he had heinatenlesis. The blood lu-e~stiro fell to 90160 Innl l lg ill'ld the pulse rate was I l(} heats/minute, wi th l)oor volume and tension, tlis hemoglobin concentration was 90 gin!l, and hematocri! 3(V~. All coagulation factors were screened and reported to be normal. Tranexainic acid and c i m e t i d i n e were again administered intravenously, as on the 7th day. Two pints of blood were also iran.~fused and the blood pressure rose t.o 120/70ram Hg. Melena, however, continued until the 15th postoperative day. A central venous line was established arid the pressure was found to be normal. Total parenterm nutrition was begun on the 14th postoperative day. Intravenous fat emulsion, essential amino acid solutions and 50Of. dextrose solutions were administered intravenously. Vitamins were also given systemically and hydration and electrolytes were meticulously monitored. Electro: }yte concentrations were reported normal. By the 16th postoperative day the patient's t e m p e r a t u r e chart showed i n t e r m i t t e n t variations between 37 C and 39.2 C, with chills and rigor. Three blood samples were cultured and sensitivities to antibiotics were determined. E.~chericDia coil and Pseudomonas were isolated, and both organisms were sensitive to gentamicin and Cephradine. Ampicillin therapy was stopped and g e n t a m i c i n was continued. In addition, 500 mg of Cephradine was given intravenously 4 times a day. Abdominal x-ray examination was reported to show infection in the left upper quadrant. The total leukocyte count was 20,000 mm :~, with polymorphs predominating (78~t}. Urine output was about I ml per m i n u t e and urinalysis results were normal. The discharge from the abdominal drainage tube consisted of fleshly blood-stained fluid', coagulation factors were shown to be normal. The T-tube drained 300 ml ofbile a day. On the 17th postoperative day, bilious discharge was seen coming from the abdominal d r a i n a g e tube; about, '/2 L of fluidwas collected in 24 hours. Serum amylase estimation at. this stage was reported n o r m a l 100 Somogyi units/L. Gastric aspiration fell from 200 ml to 180 ml/day. A diagnosis of enterocutaneous fistula was made and contrast studies of the upper gastrointestinal tract were performed. The discharge of bilious fluid through the drainage tube showed progressive decrease and by the 23d day was down to 105 nil/day. B a r i u m meal studies were reported to show significant w i d e n i n g of the duodenal loop, s u g g e s t i v e of an abscess in the pancreatic head (Fig I0). There w a s n o d e m o n s t r a b l e fistula nor any evidence of obstruction. Subsequently, a T-tube choiangiographic e x a m i n a t i o n was performed. Contrast m e d i u m was reported to leak from the site of the choledochotomy into an a r e a : a n t e r i o r to and around the body of t h e stomach (Fig 11). a8

]

Fig 1 0 . - P a n c r e a t i c abscess. A, barium meal studies showing widening of the duodenal loop in a patient with closed abdominal trauma. An abscess around the pancreatic head was suspected. The manner of presentation and treatment-including complicationsare discussed in Case 2. B, another view of the same patient indicating irregularity and narrowing of the second part of the duodenum due to external pressure. Operation confirmed multiple abscess cavities around the pancreatic head, stomach and duodenum. The abscesses were drained and all necrotic tissue excised. A persistent pancreatic fistula developed and was treated with Stomahesive wafer. In C barium meal demonstrates a fluid level in the lesser sac in a patient who presented with a tender supraumbilical swelling. Laparotomy confirmed an abscess in the lesser sac. There was lacerated injury to the body of pancreatic tissue not involving the pancreatic duct. The abscess was drained and the necrotic tissue debrided. Ten days later secondary hemorrhage that developed from the pancreatic drainage tube was treated by blood transfusion. A major pancreatic fistula persisted for 4 weeks but closed spontaneously. Patient has remained symptom free.

A p e r i g a s t r i c abscess w a s d i a g n o s e d d u e to collection of bile from a choled o c h o p e r i g a s t r i c fistula. L i v e r function t e s t s w e r e r e p o r t e d n o r m a l a n d t h e p a t i e n t w a s not c l i n i c a l l y icteric. T h e t e m p e r a t u r e was still indicative of an i n t r a - a b d o m i n a l abscessl w h i c h w a s found b e t w e e n t h e a n t e rior wall of t h e s t o m a c h a n d t h e a n t e r i o r a b d o m i n a l wall. On the 21st d a y a d i a g n o s t i c tap for t h e abscess w a s m a d e u n d e r local a n e s t h e s i a a n d a b o u t 2 ml of t h i c k y e l l o w i s h g r e e n pus obtained. On 49

Fig 11.-Pancreatic abscess. Left, T-tube of Case 2 demonstrates escape of dye into the abscess cavities around the stomach and duodenum. Right, subsequent view illustrates stretching of the lower end of the bile duct with passage of dye into the pancreatic duct. Arrow indicates multiple abscess cavities. culture and sensitivity testing, this yielded Pseudomonas organisms, which were sensitive only to tobramycin and Cephradine; 80 mg of tobramycin was administered intravenously twice a day. On the 32d postoperative day a laparotomy was performed under general anaesthesia. A perigastric abscess was found in the region of the body of the stomach and 400 ml of thick greenish yellow pus was evacuated; this abscess had been walled off' b y firm adhesions involving the omentum and small gut. The head of the pancreas was debrided and all necrotic material was removed. After adequate toilet, the abdomen was closed. The p a t i e n t became afebrile in a few days, started t a k i n g a normal diet by the 35th postoperative day and was discharged on the 61st postoperative day. In the course of follow-up in the outpatient department, a liver p a r e n c h y m a l scan and a flush aortogram were done and the results of both were reported normal. This p a t i e n t demonstrates the successtui m a n a g e m e n t of injury to the uncinate process of the head of the pancreas and the adjacent vessels and viscera. In retrospect, proper initial debridement of the head of the pancreas could probably have averted the series of complications resulting from t r a u m a t i c pancreatitis. Early detection and aggressive managem e a t of the various complications of pancreatic t r a u m a results in recovery oi'the patient.

DISCUSSION In recent y e a r s there has been a sharp increase in the incidence of pancreatic t r a u m a because of high-speed automobile accidents and the use of high-velocity missiles. Two decades ago, pancreatic t r a u m a accounted for only 1 or 2% of abdominal injuries. 50

DIAGNOSIS

Less than half the patients with blunt pancreatic trauma were diagnosed preoperatively in our series, and similar findings have been reported by others. .~.~.7,:,~..~..,Diagnosis of pancreatic injuries requires a high level of suspicion. 4~ A clinical diagnosis is not often possible because no single feature or syndrome is characteristic of pancreatic trauma. The clinical picture also is variable, ranging from early presentation of a severity comparable to that found in hemorrhagic pancreatitis to mild symptoms and delayed recognition of the underlying pancreatic lesion. The various diagnostic aids available have already been discussed in detail. Although none of these procedures can always be relied on, abdominal paracentesis, peritoneal lavage and determination of serum amylase levels contribute greatly to a provisional diagnosis of pancreatic trauma in case of upper abdominal injury, facilitating a more positive approach to its therapy. We do not regard a raised serum amylase level alone as an invariable indication for exploratory laparotomy. A laparotomy is always indicated, however, if signs of peritonitis are present, such as spasm, tenderness and absent bowel sounds. The many patients who have elevated serum amylase levels but negative abdominal findings need close observation and repeated serum amylase determinations. Jones and Shires 47 fbund the serum amylase level to be elevated in 91% of blunt pancreatic traumas, but in only 29% of penetrating injuries, and the degree of elevation did not relate to the severity of the injuries. Plain x-rays, radiologic contrast studies, angiography, peritoneoscopy, ultrasound, computerized axial tomography and other recently introduced diagnostic aids are of limited value, but may help in diagnosing pancreatic injuries that present with complications, They are also particularly useful for excluding pancreatic trauma in patients with multiple injuries. Diagnostic difficulties are often compounded by the presence of associated and concomitant injuries. Because the liver, duodenum, spleen and/or colon are often injured with the pancreas, it may even be hard for the surgeon to make an accurate diagnosis at laparotomy. Moreover, the back of the pancreas is not readily visualized, and the proximity of major vascular trunks and the abundant blood supply to the pancreas itself account for extensive hemorrhage, further complicating and masking the pancreatic injury. SURGICAL TREATMENT

The treatment for pancreatic injury is surgical intervention. Although it is generally expected that contusions and lacerations that do not involve the pancreatic du~t only require drainage or suture and drainage, controversy rages as to the management of 51

severe pancreatic trauma.:"'. ,i It is, however, generally recognized that a conserv~ttive approach to such injuries is often fbllowed by seri ous pa ncreati c corn plications. ;:'. rT. st. s,; In c;ts¢;s o f tile pancreatic duct injury we advocate immediate distal oi" c~:~udal pancreatectomy. As much as 95% of the distal imncreatic tissue has been removed without any serious metabolic or playsioiogic changes. ". ';;. ss Distal pancreatectomy also reduces the incidence of pancreatic complications.""-' This aggressive approach is nat preferred by all other workers. Fear of producing pancreatic insufficiency has led Letton and Wilson, '~:~Baker and co-workers '* and Jones and Shires"; to elaborate techniques for preserving as much normal pancreatic tissue as possible and rei ntrod uci ng exocri ne secretion into the gastroi ntesti nal tract. We are net alone in our view that the time required to fashion several anastomoses in a severely traumatized patient with duct injury anti the possibility of contamination are important objections to those procedures.';:'. ~'~ Like Foley et el.,:"' we prefer pancreaticoduodenectomy for extensive injuries of the head of the pancreas and duodenum, although Freeark and his colleagues, TM and Doubilet and Mulholland ::~ advocate a less radical operative procedure, based on stenting the injured pancreatic ducts. In general, however, the most appropriate type of operative management for pancreatic injury depends on the condition of the patient and the nature, extent and anatomical location of the pancreatic damage. ~. t,~ If the patient's condition is precarious, the smallest amount of operating procedure consistent with recovery is indicated. Thus, while we advocate aggre~;sive surgery when this is called for, ductal splinting and ductal diversion operations have important roles in specific conditions. ';s Doubilet and Mulholland,'-"-' for instance, have reported successful stenting of a transected pancreatic duct in a patient with laceration of the pancreas. Opinions differ widely on the management of severe injuries to the head of the pancreas and combined pancreatoduodenal injuries. Theoretically, these injuries should be treated by aggressive resection, pancreaticoduodenectomy or Whipple's procedure being the preferred operation, with distal pancreaticojejunostomy.:~. :,;, ,~t This formidable operation reduces the morbidity but the mortality attributed to the procedure is significant due to the m a g n i t u d e o f the injury and to the presence of multiple associated intra-abdominal organ and vascular injuries) ~7 Operative mortality for pancreaticoduodenectomy in our experience was 41.2% and the complications were considerable. Jordan 4s believes that there is very little indication for pancreaticoduodenectomy. Similarly Thai, s~ Thompson," Waiters :~ and Sawyers TM and others consider t h a t pancreaticoduodenectomy is probably never indicated because of the high mortality. An alternative procedure termed duodenal diverticulization by Berne and his colleagues:' preserves the valuable juncture at the 52

ampulla of Vater. Pancreaticoduodenectomy should be the last choice, reserved for massive injuries involving disruption of both the biliary tract and the main pancreatic duct. Extensive damage to the duodenal wall does not necessitate resection of the entire duodenum if the burden on the closure is reduced by isolating the duodenum. Similarly, the ductal diversion procedure I perform has a definite place in patients with extensive injuries to the head of the pancreas and duodenum in whom pancreaticoduodenectomy is not t~asible either because there are coexisting multiple injuries or because the patient's condition does not permit extensive surgery. This procedure is simple, less time-consuming and has low operative mortality and morbidity. Of the 6 patients who underwent ductal diversion, 2 died, 1 from multiple organ trauma, notably severe chest injuries. At autopsy, the ductal diversion.was found to be intact. The 2d patient died of generalized septicemia and duct disruption between the pancreas and jejunum. Therefore, these deaths were not attributable to failure of this technique, and I advocate that ductal diversion b e used more frequently. Regardless of the operative procedure selected, adequate drainage of the abdomen is essential to a: decrease in postoperative fistulas, pseudocysts and abscesses. The. advantages of the Combined use ofsump and Penrose drains cannot be overestimated." MORTALITY AND MORBIDITY

The mortality and morbidity associated witih pancreatic injuries are far from satisfactory. Currently, the o~erall .mortality in our series.is 21.7%and the morbidity, 33%. This is in keeping with other reported series.', .~0,8~ The mortality ~in our series is relatedto the number of associated injuries, thepresence of shock due to hemorrhage, inju~'ies to the head of the pancreas and duodenum, the presence of\penetrating trauma and unsatisfactory earlier management. Werschky and Jordan 'J9 in their series of 140 patients with pancreatic trauma reported that the m o r t a l i t y for penetrating wounds was more than twice that for blunt injury, but associated injuries accounted for 35% of the deaths, compared with 45% in our series. Freeark and his associates 3~ recorded a 14% mortality in patients with traumatic disruption of the head of the pancreas; Donovan and Hagen ~' reported 33% imortality for pancreaticodu: odenectomy patients, compared with 41.6% in our series. Fogelman and Robinson 29 found that the mortality with pancreatic injuries rose steadily with the number of associated injuries. Thus, the mortality w a s 33% when 2 additional organs were involved and 75% when there were 4 associated injuries. Jones and Shires, 46, 4T in contrast, reported that the mortality was directly related to the number of major vessels injured rather 53

than to the n u m b e r ot" organs. In their series, the mortality was closely associated with the type of wounding agent, such as a sh¢~tgun blast or blunt t r a u m a to the abdomen, and was not closely correlated with the region of the pancreas injured. They also reported a mortality of 20% for-penetrating injuries and 16~: for blunt trauma. The mortality for injuries to the head of the pancreas was 22% and only 12% for injuries to the tail. Although the mortality for pancreatic injury per se has been reported as less than 5%,";. ':'our rate for isolated injuries was nearly 15%. Most of these patients were referred from other centers and had established complications. Among the 152 patients in our series there were 33 deaths. Fifteen occurred in the group of 28 patients who were referred after initial t r e a t m e n t at other centers. These 15 deaths were directly related to the delay in t r e a t m e n t , resulting in increased complications, prolonged shock, inadequate resuscit,'~tion and sepsis as well as to the type of wounding agent and a n y associated vascular, visceral and other injuries. In 6 of the 15 cases (40%) there were multiple injuries from high-velocity missiles. Seven (46.6%) died after persistent pancreatic fistula, septicemia and secondary hemorrh~ge; 2 died as a result of prolonged shock and inadequate resuscitatior~. We believe m a n y of these patients would have survived had they been admitted directly to our d e p a r t m e n t without prior t r e a t m e n t elsewhere. The r e m a i n i n g 18 deaths occurred in the 104 patients admitted directly to our unit following acute t r a u m a , for a mortality of 17.3(;~. Associated intra-abdominal and concomitant injuries were responsible for 10 (55.5%) of the deaths and were directly related to the n u m b e r of organs involved. Other factors contributing to the mortality in our series were the type, site and extent of pancreatic injury and the method of treatment. Extensive injuries to the head of the pancreas or a combination of pancreaticoduodenal injuries resulted in 3 deaths (I6,6~;:). All these patients had pancreaticoduodenectomy. Two (11.8%) of the 4 patients who had p r i m a r y ductal repair for complete transection of the pancreatic duct died of peritonitis after breakdown of the anastomosis. Failure to recognize ductal inj u r y in 1 p a t i e n t and postoperative cardiorespiratory complications in 2 others resulted in the d e a t h of the r e m a i n i n g 3. In contrast, there were no deaths among the 20 who sustained blunt injury and presented with u n u s u a l manifestations after pancreatic t r a u m a , namely, pseudopancreatic cyst, t r a u m a t i c pancreatitis, persistent fistula or intra-abdominal abscess.

COMPLICATIONS In most series, a high incidence of major complications is reported to follow pancreatic surgery; their frequency and n a t u r e is related to t h e site, type and extent of p r i m a r y injury. "t2,72, ~, .o0 54

Other factors influencing the morbidity rate are the presence of multiple abdominal injuries, delay in diagnosis and the type of treatment performed. Major complications after pancreatic surgery include fistulas, abscesses, secondary hemorrhage, pseudocysts"' and pancreatitis. "~:'.''~,~" Sturim ~7 reported 74 complications in 40 patients, of whom 32% developed pancreatic fistulas, 2~,% pseudocysts and 11% intra-abdominal abscesses. Howell, Burrus and Jordan 4' reported pancreatic fistulas in one third of their patients. Half of them had blunt trauma. In our series the postoperative complications depended on whether the patients were treated initially at our hospital or were referred with complications from other centers. Thirty-five patients (33.6%) of the 104 treated for acute trauma developed 49 complications, which were related to the site and extent of primary trauma, type of operative procedure, presence of preoperative shock and associated injuries, particularly of the abdominal organs. The most common complication (16 patientsor 32.7%) was infection-either intra-abdomiual or wound infection. Fifteen (30.6%) had pancreatic fistulas in spite of adequate drainage, meticulous debridement of the traumatized tissue and hemostasis. Seven (1.4.3%) developed traumatic pancreatitis, whereas pancreatic deficiency occurred in 4 (8.2%) after pancreaticoduodenectomy. Four patients (8.2%) had hemorrhage either from the upper gastrointestinal tract or from drainage tubes; 3 (6.0%) developed pseudocysts. Twenty-eight patients who were initially treated elsewhere were referred to us with complications that included sepsis, fistulas, pseudocysts, secondary hemorrhage, irreversible shock due to multiple organ trauma and inadequate resuscitation. Of the remaining 20 patients who sustained blunt abdominal injuries and who presented with unusual manifestations, 11 (55.0%) had pseudocysts, 5 (25.0%) had intra-abdominal abscesses, 2 (t0.0%) had persistent fistulas and 1 each (5.0%) had traumatic pancreatitis, and pancreatic calculi. Twenty patients who were treated for pseudocysts, traumatic pancreatitis, persistent fistulas and intra-abdominal abscesses had only minor complications, such as wound infections and pneumonitis. With experience and careful pre- and postoperative management the complication rate is now showing a downward trend. In conclusion: prompt diagnosis, aggressive correction of hypovolemia, and early and definitive operative treatment are important factors in the management of pancreatic trauma.

ACKNOWLEDGMENT I wish to express my grateful thanks to the doctors and nursing staff of the Surgical and Anaesthetic Departments for their devoted care of these patients, and to the various consultants who referred the complicated problems to us. 55

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SELF-ASSESSMENT ANSWERS 1. 2. 3. 4. 5. 6. 7.

F T T F T F T

8. 9. 10. 11. 12. 13. 14.

F F T T T F T

15. 16. 17. 18. 19. 20.

F T T F a b

59