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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Pancreatic, splenic and duodenal injuries

and .

Author Information

1 and 2.

1 Principal Surgeon and Head of Unit, Johannesburg Hospital Trauma Unit, South Africa
2 Department of Surgery, University of the Witwatersrand, Section of Surgery, Queens Medical Centre, University Hospital Nottingham, United Kingdom

Introduction

Although the pancreas and duodenum are concealed and relatively protected from injury, the morbidity that arises when they are injured especially when the diagnosis is delayed, accounts for the respect with which these injuries are held. However there is very limited work available from which evidence based standards for the management of these complex injuries could be developed. Of the 87 articles reviewed concerning the diagnosis, treatment and complications associated with pancreatic injury for this article there were five prospective papers of which only one was randomized. These articles along with a few high quality retrospective reviews form the basis of the following guidelines.

Pancreatic injury

Diagnosis of pancreatic injury

The ability to evaluate pancreatic injury accurately remains limited. Computed tomography has been shown to be unreliable in a retrospective review of 17 patients with pancreatic injury where it missed or underestimated the severity of injury in more than 50% (1). A recent retrospective analysis of 73 patients showed that the serum amylase was not diagnostic of pancreatic trauma within three hours of injury (2). Jurkovich (3) analyzed recent work on serum amylase and showed a positive predictive value of 10% and a negative predictive value of 95%. Operative evaluation of the gland remains the only reliable method for determining injury where there is an index of suspicion and the decision to operate has been based on hemoperitoneum.

Classification of pancreatic injury

Injuries of the pancreas are generally classified using the criteria developed by the AAST (American Association for the Surgery of Trauma) (4). See table I.

Table I. Pancreatic organ injury scale. American Association for the Surgery of Trauma (from Moore EE, Cogbill TH, Malangoni MA et al (1990) J Trauma 30: 1427–1429).

Table I

Pancreatic organ injury scale. American Association for the Surgery of Trauma (from Moore EE, Cogbill TH, Malangoni MA et al (1990) J Trauma 30: 1427–1429).

The management of pancreatic trauma

A number of reports including a multi-institution retrospective review have highlighted the importance of injury to the main pancreatic duct in morbidity and mortality (5). The management of pancreatic injuries is therefore based on the following factors:

  • injury without ductal injury,
  • injury with ductal injury which can be either proximal or distal relative to the superior mesenteric vessels.

There is a high associated morbidity with pancreatic injury, the majority is related to the high number of injuries sustained by associated organs and vessels (6).

Drainage has become widely accepted as the management of choice in pancreatic injuries where there is no or low suspicion of ductal injury (7). Patton found no increased morbidity in 30 patients with low suspicion of ductal involvement following drainage. In a prospective randomized trial comparing the type of drainage used, Fabian (8) showed a significant reduction in septic complications when comparing 35 patients with closed suction drainage to 24 with sump drainage. Therefore guidelines should recommend closed suction drainage.

Most surgeons would manage distal injuries where there is a high suspicion of injury to the main pancreatic duct by a distal pancreatectomy (7) although it is associated with a high complication rate - 33% in Patton's (7) series and 45% in Cogbill et al. (9) multi-center retrospective review of 74 patients. It is rarely associated with exocrine or endocrine deficiency. Closure of the transected pancreas can be either by staples (10) or sutures. No further reports have shown an advantage to the stapling technique in reducing the rate of fistula formation and others have found no difference (9).

Management of proximal pancreatic injuries involving the duct depends on the degree of destruction. Isolated injury may be treated by simple closed suction drainage and hence the formation of a controlled fistula (7) whilst massive destruction of the pancreas and duodenum may force pancreatoduodenectomy. Although this procedure is often associated with high mortality, up to 50% in Stone et al.'s (6) 30 year experience, Oreskovich has reported a limited series of ten patients with no deaths (11).

Retrospective reports on the surgical management of injuries allow surgical ‘bias’ or experience to be involved. Consequently without a randomized study it is difficult to validate the results. However Mansour's (12) and Feliciano's (13) retrospective studies, 62 and 129 patients respectively, on combined pancreatoduodenal injuries treated lesser grade/severity injuries with simple repair and drainage. They concluded that although pancreatoduodenectomy may at times be required the addition of pyloric exclusion, gastroenterostomy and feeding jejunostomy to primary repair in moderate injuries may reduce the morbidity associated with this major procedure.

Duodenal injury

Injuries of the duodenum are generally classified using the criteria developed by the AAST (American Association for the Surgery of Trauma) (4)4. See table II.

Table II. Duodenal organ injury scale. American Association for the Surgery of Trauma (from Moore EE, Cogbill TH, Malangoni MA et al (1990) J Trauma 30: 1427–1429).

Table II

Duodenal organ injury scale. American Association for the Surgery of Trauma (from Moore EE, Cogbill TH, Malangoni MA et al (1990) J Trauma 30: 1427–1429).

Cogbill et al. (14) reviewed 164 patients from eight trauma center over a five year period. The injuries were classified by severity and although few of the more severe injuries were seen, the work is a good guide to the treatment of duodenal trauma. The majority of duodenal injuries can be managed by simple repair with pyloric exclusion and gastoenterostomy as an adjunct in more severe injuries. Martin et al. (15) reviewed 128 patients who had this procedure and found a duodenal fistula rate in only 5.5% of those having exclusion. The main cause of morbidity is primarily intra abdominal abscess formation and duodenal fistula and are irrespective of the surgical procedure.

Complications

It is important to differentiate between pancreatic related morbidity and overall morbidity when reviewing the complications associated with pancreatic injury. The high number of injuries to associated organs leads to high complication rates. Early complications include pancreatic fistula formation which is usually self limiting and have a reported incidence of 11% (16). Octreotide has been shown to be of value as a prophylactic agent in reducing the rate of fistula formation in a small prospective non randomized study of seven patients with pancreatic injury (17). Intra-abdominal abscesses are more common with associated colonic injuries and occur with a frequency of 8% (16).

Late complications are rare and include pseudocyst formation and exocrine and endocrine deficiency after resections leaving less than 10–20% of the gland.

Summary

Although difficult to diagnose, the weight of evidence from retrospective reviews shows that the majority of pancreatic and duodenal injuries can be treated by simple techniques and drainage. The less common severe injuries can in the main be managed by the addition of exclusion procedures to simple techniques although occasionally formal high morbidity resections must still be performed. Pancreatic injuries rarely occur in isolation, therefore the surgeon must be prepared to undertake damage control in the first instance and return at a later stage to perform formal reconstruction.

Splenic injury

Injuries of the spleen are generally classified using the criteria developed by the AAST (-American Association for the Surgery of Trauma) (18). See table III.

Table III. Spleen organ injury scale. American Association for the Surgery of Trauma (from Moore EE, Cogbill TH, Jurkovich GJ et al (1990) J Trauma 38 (3): 323–324).

Table III

Spleen organ injury scale. American Association for the Surgery of Trauma (from Moore EE, Cogbill TH, Jurkovich GJ et al (1990) J Trauma 38 (3): 323–324).

Diagnosis

Physical diagnosis is not usually helpful, and the clinician is forced to rely on a number of specific investigations, of which DPL, Ultra-sound and C.T. scanning are the most widely used.

Management

The treatment of splenic injury has been divided into:

  • Operative management
  • Non-operative (“conservative”) management.

Non operative management in selected cases of splenic injury was first popularized in pediatric surgical practice. In a multicentre trial reported by Cogbill et al. (19), the success rate of non-operative management for splenic injury in children was 90%.

In adults, the success rate is more variable, with various studies reporting a success rate of between 30 and 100% (20). Using a decision analysis model, Feliciano (21) compared non-operative management with immediate laparotomy in 72 patients with splenic injury. Their analysis favored their clinical practice guidelines in favor of observation for patients who do not require transfusion, and surgery for those patients whose blood loss has been sufficiently severe as to require transfusion.

Surgical management

In all patients who are unstable, a total splenectomy should be performed, as well as in those patients with concomitant injury.

In patients who are stable, every effort should be made to preserving part or all of the splenic tissue.

Grade I or grade II injuries are generally treated with direct pressure, and limited packing.

Grade III injuries (as well as persistent bleeding from grade II injuries) should be treated by formal splenorrhaphy, involving suture of the splenic parenchyma. This is best done over pledgets.

Complex grade III or IV splenic injuries should be resected anatomically, with the segmental artery to the area of the spleen involved selectively ligated.

Routine drainage is not advised

Overwhelming post splenectomy infection

This well known complication of splenectomy is commonly caused by S. Pneumonia, although there are several other causative agents. In Singers' study (22), a subgroup of 684 patients who underwent splenectomy for trauma had a rate of septic morbidity of 1.45% and an overall mortality of 0.58%. Thus the increased risk for post splenectomy infection suggests the need for prophylaxis and increased awareness of the condition.

Summary

Splenic injury is relatively common in blunt abdominal injury. The majority can be managed non-operatively, but those patients who are unstable, or showing evidence of continuing hemorrhage must be managed more aggressively.

References

1.
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2.
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3.
Jurkovich GJ (1996) Injury to the duodenum and pancreas. In: Feliciano DV, Moore EE, Mattox KL (eds) Trauma 3rd ed. Appleton & Lange, Stamford, pp 573–594 .
4.
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6.
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7.
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8.
Fabian T C, Kudsk K A, Croce M A. et al. Superiority of closed suction drainage for pancreatic trauma. A randomised prospective study. Ann Surg. (1990);211:724–728. [PMC free article: PMC1358123] [PubMed: 2192695]
9.
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10.
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11.
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12.
Mansour M A, Moore J B, Moore E E, Moore F A. Conservative management of combined pancreatoduodenal injuries. Am J Surg. (1989);158:531–535. [PubMed: 2589583]
13.
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14.
Cogbill T H, Moore E E, Feliciano D V. et al. Conservative management of duodenal trauma: a multicenter perspective. J Trauma. (1990);30:1469–1475. [PubMed: 2258957]
15.
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18.
Moore E E, Cogbill T H, Jurkovich G J, Shackford S R, Malangoni M D, Champion H R. Organ injury scaling: Spleen and liver (1994 revision) J Trauma. (1995);38(3): 323–324. [PubMed: 7897707]
19.
Cogbill T H, Moore E E, Jurkovich G J, Morris J A, Mucha P, Shackford S R. Non operational management of blunt splenic trauma: A multicentre experience. J Trauma. (1989);29(10):1312–1317. [PubMed: 2681805]
20.
Esposito TJ, Gamelli RL (1996) Injury to the spleen. In: Feliciano DV, Moore EE, Mattox KL (eds) Trauma 3rd ed. Appleton & Lange, Stamford, pp 525–550 .
21.
Feliciano P D, Mullins R J, Trunkey D D. A decision analysis of traumatic splenic injuries. J Trauma. (1992);33:340–346. [PubMed: 1404500]
22.
Singer DB (1973) Post splenectomy sepsis. In: Rosenburg HS, Bolande RP (eds) Perspectives in paediatric pathology. Vol 1. Chicago Year Book, pp 285–290 .
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6884
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