Surgical Management of Pancreatic Trauma M.Balasegaram,
MB, FRCS, FRCS (Engl), FRACS, FACS, Kuala Lumpur,
In the past decade there has been a marked increase in the incidence of pancreatic injuries treated by me at the General Hospitals, Seremban and Kuala Lumpur, Malaysia. This is mainly due to increased automobile accidents and civil disturbances. Pancreatic injuries are associated with a very high mortality. The fact that surgeons differ widely on the surgical management of the pancreas prompted me to study an attempt to improve and standardize its treatment. Material and Methods Ninety-one patients (71 males, 20 females) with pancreatic injuries treated between August 1961 and December 1973 were reviewed. Patients’ ages ranged from four to seventy-six years, the vast majority of them being between twenty and forty years. Analysis of these ninety-one patients showed that the pattern of these injuries varied with the severity and mechanism of the injuring force. Auto-. mobile accidents and civil violence accounted for most of these injuries. Forty-four patients sustained blunt trauma and the rest had penetrating injuries, due either to stab wounds or high velocity missile injuries, which caused multiple and extensive trauma to several organs. Of the forty-four patients with blunt trauma, thirty-two were involved in automobile accidents; the remaining twelve were involved in falls or were struck by blunt objects. The types of injuries encountered in the ninety-one patients are listed in Table I. Associated and concomitant injuries were present in eighty-one patients, including the following injured structures: head (15 patients), chest (7), skeleton (12), mesentery and omentum (6), spleen (39), small intestine (17), colon (lo), kidney (15), and liver (26). Several patients had two or more injuries. Associated intra-abdominal injuries most frequently involved the spleen, liver, or stomach, whereas high velocity missile
From the Department of Surgery. General Hospital, Kuala Lumpur, Malaysia. Reprint requests should be addressed to Professor M. Balasegaram, Departmentof Surgery, General Hospital, Kuala Lumpur. Malaysia.
536
Malaysia
injuries and motor vehicle accidents caused severe concomitant head, chest, or pelvic injuries. Table II lists the various forms of surgical treatment in the ninety-one patients.
Result? and Complications Mortality. Nineteen of the ninety-one patients in this series died, a mortality of 20.8 per cent. Ten patients were admitted in a moribund state with multiple injuries, of whom six had complete disintegration of the pancreas. All died before any effective resuscitative or surgical treatment could be instituted. Two of the four patients who had ductal repairs and five of the eight patients with pancreatoduodenectomy died of anastomotic suture disruption with leakage of pancreatic juices, multiple abscess formation, external fistulas, and pancreatitis. One patient with ductal drainage died of severe chest injuries, and another patient who had subtotal pancreatectomy died of head injuries. Complications. Complications in this series are divided into two groups: (a) those complications, both pre- and postoperative, that occurred in diagnosed injuries and (b) those complications that occurred in undiagnosed injuries. The latter group of patients presented several days or weeks after sustaining the injuries. Of the twelve patients, three had penetrating injuries and nine had blunt trauma. Of the patients with preoperative pancreatic complications, 21 were in shock, 10 had traumatic pancreatitis, and 2 had abscess formation. Shock was mainly due to the presence of other associated injuries, namely hepatic or vascular injuries or complete disintegration of the pancreas. Traumatic pancreatitis and abscess formation followed delay in diagnosis and treatment. Most of the postoperative complications such as pancreatitis (2 patients), fistulas (31, pseudocysts (2), and intra-abdominal result
of primary
abscess formation suture
(3) were the
of the damaged
duct
or
The American Journal ol Surgery
Pancreatic
pancreatoduodenectomy. Two patients had left subphrenic abscesses after subtotal pancreatectomy. Three patients had pancreatic deficiency. Of patients with unusual presentation, four with abdominal lumps were diagnosed preoperatively as having pseudopancreatic cysts. All gave a history of blunt injury to the abdomen varying from three to six months. Of the total six pseudopancreatic cysts, three were located in the head of the pancreas and three in the body and tail. When the cyst was located in the head, resection was not feasible and cystogastrostomy was performed with excellent results. Cysts in the body and tail required subtotal pancreatectomy. Fistula formation was the result of damage to the pancreatic duct in the neck; after distal resection the fistulas healed. Five patients had intra-abdominal abscess presenting as localized abscess formation around the pancreas or as subdiaphragmatic abscess and required surgical drainage. Two patients presented with perinephric fistulas, and one patient had pancreatic calculi.
TABLE
vdunu
181, M8y 1076
Pattern
of Pancreatic
in 91 Patients
Number of Patients with Blunt Trauma
Total
5 25 2
3 17 8
8 42 10
Complete transection at body or neck
3
10
13
Duodenum and head of pancreas
6
6
12
Complete disintegration
6
. .
Contusions Lacerations Subcapsular hematomas*
Total
47
* 3 patients
TABLE
II
had intraductal
Treatment
Treatment Drainage only Suture Ductal repair Partial pancreatectomy Pancreatoduodenectomy No treatment Ductal drainage Total --___-
.
Injuries
Number of Patients with Penetrating Injury
Type of Injury
Comments
Early diagnosis of pancreatic injuries is of paramount importance, in view of the manifold complications and possible mortality [l-3]. Penetrating wounds of the pancreas pose no problem in diagnosis, especially when the external injury is located in the region around the umbilicus. In most cases, however, involvement of other abdominal organs warrants exploratory laparotomy. In contrast, blunt pancreatic trauma presents a great diagnostic problem [2,4]. The presence of concomitant and associated intraabdominal, head, chest, pelvic, and skeletal injuries (with high velocity missiles traversing circuitous routes) further aggravates the difficulties in diagnosis. This led me to use the following diagnostic aids, namely, abdominal paracentesis, peritoneoscopy, and more recently hepatic scanning, angiography [5], and biochemical and enzyme analyses. The conclusions drawn from this study are: (a) pancreatic scanning, angiography, and peritoneoscopy are of limited value; (b) a significant increase in enzyme levels in the serum or pancreatic fluid on abdominal paracentesis is a reliable diagnostic index; and (c) when the surgeron is in doubt, exploratory laparotomy remains the single means of diagnosis [6-81. Review of the present series showed that in addition to early diagnosis, rapid and massive resuscitation to combat shock is vital. It must be stressed that the injured pancreas is often only one of the organs simultaneously traumatized [9].
I
Trauma
6
44
91
rupture.
for Pancreatic Trauma No. of Patients 17 15 4 35 8 10 2 91
Mortality
. . ... 2 1 5 10 1 19 (20.8%)
In treating the present 91 patients, I have found that: (a) Of greatest importance in the injured pancreas is the damaged duct, because mortality and morbidity were directly related to leakage of pancreatic juices. The use of a T tube placed in the pancreatic duct to temporarily divert pancreatic juices may be a life-saving device especially in the critically injured, polytraumatized patient. The T tube brought out via the stomach or jejunum through the anterior abdominal wall will result in an internal, not external, fistula [lo]. (b) Contusions and lacerations not involving the pancreatic ducts are best left alone with adequate drainage of the lesser sac and pancreatic region with Penrose or sump drains. (c) Since primary suture of the pancreatic ducts resulted in multiple complications and was associated with high mortality, this form of treatment must be abandoned; any lacerated injuries involving the ducts should have immediate resection. (d) Because pancreatoduodenal injuries were also associated with high mortality [11,12], despite my aggressive surgical resection, temporary diversion of
537
Balasegaram abdomen, and pelvis, causing multiple and bursting injuries. In such patients either a thoracoabdominal or several incisions have to be made. Blunt abdominal injuries and retroperitoneal hemorrhages demand opening of the lesser sac since ductal injuries or transection of the pancreas can be hidden by a he[14,15]. matoma or intact peritoneum
Figure Pancreatic 1. scan showing no uptake by the pancreas of radioactive kzotopesdue to pancreatic pseu&cyst.
the pancreatic
juices with a T tube in the pancreatic duct and pancreatojejunostomy may be life-saving [2]. When the head of the pancreas is injured close to the duodenum, repair is almost impossible. Distal pancreatojejunostomy with an indwelling T tube is then a logical operation. Such measures avoid the mortality from traumatic pancreatitis, which may progress rapidly within 12 to 24 hours after injury. The surgical approach to the injured pancreas in this series depended on several factors, namely the presence of other associated and concomitant injuries [131. High velocity missile injuries traverse the chest,
The salient points in operative technic for subtotal or near total pancreatectomy include the dissection of the injured pancreas, ligation of the splenic vessels and more importantly the pancreatic duct, and application of my own pancreatic crushing clamps. The raw edges are sutured with several interrupted mattress sutures, using unabsorbable (polyester) ethiflex (Ethicon@), and buried in the posterior abdominal wall. Pseudocysts may present as abdominal masses. (Figure 1.) When they are located in the head of the pancreas, resection is not feasible and internal drainage is the treatment of choice. I prefer cystogastrostomy, although other authors have advocated cystojejunostomy with Roux-en-Y anastomosis [10,16]. An illustrative case of pancreatic pseudocyst follows. A forty-five year old male Chinese presented with a gradually increasing mass in the upper aspect of the abdomen. He gave a history of having been assaulted in the region of the epigastrium four months before his present admission. On that occasion complaining of severe abdominal pain above and around the umbilicus, he was admitted to another hospital. He was discharged ten days
Figure 2. Left, barium meal stud& of patient after cystogastrostomy; note the fluid level. Middle, some of the barium has now entered the cyst. Right, the barium has now evacuated from the cyst after 20 minutes.
538
The American Journal of Surgery
Pancreatic Trauma
later when the pain was less intense and was told that the abdominal pain was due to muscular contusion since all investigations proved negative. Two weeks after his discharge from hospital, he noticed a lump above the umbilicus, which gradually increased in size until we saw him. On examination, the general condition of the patient was fair. Palpation of his abdomen revealed a large cystic mass extending from the xiphisternum to 3 inches below the umbilicus. Laterally, the mass appeared to be continuous with the liver. Serum amylase level was 40 Somogyi units/100 ml. Except for upward displacement of the liver, hepatic scan showed no abnormalities. Barium meal studies showed enlargement of the duodenal loop and lateral films that indicated forward displacement of the stomach. Splenoportography showed uniform and upward displacement of the splenic vein, whereas selective pancreatography revealed lateral displacement of the pancreatic vessels. Pancreatic scan showed no uptake of the radioisotope in the head of the pancreas. Preoperative diagnosis was pancreatic pseudocyst. At laparotomy, a 12 by 8 inch pancreatic pseudocyst was seen arising from the head of the pancreas. Cytogastrostomy was performed. Postoperative barium studies performed a week later showed excellent results. (Figure 2.) The patient has since remained free of symptoms. When these cysts are present in the body and tail, subtotal or near total pancreatectomy can be performed with ease. Pancreatic fistulas (Figures 3A and B) and intraabdominal abscesses (Figure 4) are frequently the result of diagnostic errors, delay in therapy, and complications of operative procedures [ 171. Most of these complications occurred in the initial years of the present series. With improvements in diagnosis and experience in the management of the injured pancreas, the complication rate has since been min-
Figure 3A. A patient a with fistula due to blunt injury of the pancreas sustained four months previously and undiagnosed at that time.
imized. Three patients with pancreatoduodenectomy had pancreatic insufficiency. The exocrinal and endocrinal functional manifestations may be investigated by biochemical and enzyme studies, particularly insulin assays, triolin uptake using isotopes, and estimation of intestinal enzymes. Since the pancreatic tissue does not regenerate, supplementary medical therapy must be instituted for life. Failure to do so would result in malabsorption syndrome and diabetes. Pancreatic deficiency was successfully corrected by supplementary therapy in two patients whereas one patient defaulted treatment. (Figure 5.) In conclusion, pancreatic
the success
injuries
more aggressive
depends
surgery.
always be considered patients with multiple important
of the treatment on early diagnosis
Pancreatic
Vduma 131, May 1976
should
and excluded, especially in injuries. This is all the more
in this age of increased
dents and civil violence.
injuries
of and
automobile
acci-
Figure 38. Scan of the patient Figure i? 3A with disruption of the pancreatic duct and abscess formation.
539
Balasegaram
Summary Ninety-one patients treated for pancreatic injuries are reviewed. Difficulty of diagnosis, including the surgical management of these injuries and their complications, are discussed in detail. The presence of associated multiple injuries, delay in diagnosis, and -lack of sound surgical principles of treatment are directly proportional to the rate of complication and mortality. Acknowledgment: I wish to thank the DirectorGeneral of Medical Services, Federation of Malaysia, for permission to publish this paper and to Mrs Jessie Cardoza for typing this manuscript.
Addendum Since this report was prepared, twenty-two additional patients have been treated for pancreatic injuries. References
Figure 4. Len abscess subphrenic a in patient after subtotal pancreatectomy. Note the fluid level outside the stomach.
Figure 5. Pancreatic insufficiency after pancreatoduodenectomy. Note the flocculation and distension the of small intestines due to malabsorption syndrome. This patient defaulted treatment after surgery.
540
1. Bach RD. Frey CF: Diagnosis and treatment of pancreatic trauma. AmJSurg 121: 20, 1971. 2. Balasegaram M: The traumatised patient in large-scale civil disturbances with special reference to the pancreas and liver. Abraham Colles Memorial Lecture delivered at the Royal College of Surgeons, Ireland. March 1974. 3. Donovan AJ, Turrill F, Berne CJ: Injuries of the the pancreas from blunt trauma. Surg C/in North Am 52: 649, 1972. Pancreatic trauma. Arch Surg 102: 424, 4. Jones RC, Shires GT: 1971. 5. Freeark RJ, Shoemaker WC, Baker RJ: Aortography in blunt abdominal trauma. Arch Surg 96: 705, 1968. 6. Strohl EL: Traumatic injuries to the pancreas. Surg Gynecol Cbstet 124: 115, 1967. 7. Sturim HS: The surgical management of pancreatic injuries. Surg Gynecol Obstet 122: 133, 1966. 8. Werschky LR, Jordon GL Jr: Sugical management of traumatic injuries to the pancreas. Am J Surg 116: 768, 1968. the Pancreas. 9. Howard JM, Jordan GL Jr: Surgical Diseases of Philadelphia, JB Lippincott, 1960. 10. Simpson A. Srivastava VK: Pseudocyst of the pancreas. Br J Surg 60: 45. 1973. 11. Berne CJ. Donovan AJ, Hagen WE: Combined duodenal pancreatic trauma. The role of end-to-side gastrojejunostomy. Arch Surg96: 712, 1968. 12. Freeark RJ, Corley RD. Norcross WJ, Baker RJ: Unusual aspects of pancreatoduodenal trauma. J Trauma 6: 482, 1966. Pancreatic review 13. Barnett WO, Hardy JD, Yelverton RL: trauma: of twenty-three cases. Ann Surg 163: 892, 1966. 14. Doubilet H. Mulholland JH: Some observations on the treatment of trauma to the pancreas. Am J Surg 105: 741, 1963. 15. Kerry RL. Glas WW: Traumatic injuries of the pancreas and duodenum. Arch Surg 85: 813.1962. 16. Ebbesen KE. Schonebeck J: Post pancreatic pseudocysts in children. Acta Chir Stand 132: 280, 1966. 17. Welch CE, Edmunds LH: Gastrointestinalfistulas. Surg C/in North Am42: 1311, 1962.
The American Journal of Surgery
MB, FRCS, FRCS (Engl), FRACS, FACS, Kuala Lumpur,
In the past decade there has been a marked increase in the incidence of pancreatic injuries treated by me at the General Hospitals, Seremban and Kuala Lumpur, Malaysia. This is mainly due to increased automobile accidents and civil disturbances. Pancreatic injuries are associated with a very high mortality. The fact that surgeons differ widely on the surgical management of the pancreas prompted me to study an attempt to improve and standardize its treatment. Material and Methods Ninety-one patients (71 males, 20 females) with pancreatic injuries treated between August 1961 and December 1973 were reviewed. Patients’ ages ranged from four to seventy-six years, the vast majority of them being between twenty and forty years. Analysis of these ninety-one patients showed that the pattern of these injuries varied with the severity and mechanism of the injuring force. Auto-. mobile accidents and civil violence accounted for most of these injuries. Forty-four patients sustained blunt trauma and the rest had penetrating injuries, due either to stab wounds or high velocity missile injuries, which caused multiple and extensive trauma to several organs. Of the forty-four patients with blunt trauma, thirty-two were involved in automobile accidents; the remaining twelve were involved in falls or were struck by blunt objects. The types of injuries encountered in the ninety-one patients are listed in Table I. Associated and concomitant injuries were present in eighty-one patients, including the following injured structures: head (15 patients), chest (7), skeleton (12), mesentery and omentum (6), spleen (39), small intestine (17), colon (lo), kidney (15), and liver (26). Several patients had two or more injuries. Associated intra-abdominal injuries most frequently involved the spleen, liver, or stomach, whereas high velocity missile
From the Department of Surgery. General Hospital, Kuala Lumpur, Malaysia. Reprint requests should be addressed to Professor M. Balasegaram, Departmentof Surgery, General Hospital, Kuala Lumpur. Malaysia.
536
Malaysia
injuries and motor vehicle accidents caused severe concomitant head, chest, or pelvic injuries. Table II lists the various forms of surgical treatment in the ninety-one patients.
Result? and Complications Mortality. Nineteen of the ninety-one patients in this series died, a mortality of 20.8 per cent. Ten patients were admitted in a moribund state with multiple injuries, of whom six had complete disintegration of the pancreas. All died before any effective resuscitative or surgical treatment could be instituted. Two of the four patients who had ductal repairs and five of the eight patients with pancreatoduodenectomy died of anastomotic suture disruption with leakage of pancreatic juices, multiple abscess formation, external fistulas, and pancreatitis. One patient with ductal drainage died of severe chest injuries, and another patient who had subtotal pancreatectomy died of head injuries. Complications. Complications in this series are divided into two groups: (a) those complications, both pre- and postoperative, that occurred in diagnosed injuries and (b) those complications that occurred in undiagnosed injuries. The latter group of patients presented several days or weeks after sustaining the injuries. Of the twelve patients, three had penetrating injuries and nine had blunt trauma. Of the patients with preoperative pancreatic complications, 21 were in shock, 10 had traumatic pancreatitis, and 2 had abscess formation. Shock was mainly due to the presence of other associated injuries, namely hepatic or vascular injuries or complete disintegration of the pancreas. Traumatic pancreatitis and abscess formation followed delay in diagnosis and treatment. Most of the postoperative complications such as pancreatitis (2 patients), fistulas (31, pseudocysts (2), and intra-abdominal result
of primary
abscess formation suture
(3) were the
of the damaged
duct
or
The American Journal ol Surgery
Pancreatic
pancreatoduodenectomy. Two patients had left subphrenic abscesses after subtotal pancreatectomy. Three patients had pancreatic deficiency. Of patients with unusual presentation, four with abdominal lumps were diagnosed preoperatively as having pseudopancreatic cysts. All gave a history of blunt injury to the abdomen varying from three to six months. Of the total six pseudopancreatic cysts, three were located in the head of the pancreas and three in the body and tail. When the cyst was located in the head, resection was not feasible and cystogastrostomy was performed with excellent results. Cysts in the body and tail required subtotal pancreatectomy. Fistula formation was the result of damage to the pancreatic duct in the neck; after distal resection the fistulas healed. Five patients had intra-abdominal abscess presenting as localized abscess formation around the pancreas or as subdiaphragmatic abscess and required surgical drainage. Two patients presented with perinephric fistulas, and one patient had pancreatic calculi.
TABLE
vdunu
181, M8y 1076
Pattern
of Pancreatic
in 91 Patients
Number of Patients with Blunt Trauma
Total
5 25 2
3 17 8
8 42 10
Complete transection at body or neck
3
10
13
Duodenum and head of pancreas
6
6
12
Complete disintegration
6
. .
Contusions Lacerations Subcapsular hematomas*
Total
47
* 3 patients
TABLE
II
had intraductal
Treatment
Treatment Drainage only Suture Ductal repair Partial pancreatectomy Pancreatoduodenectomy No treatment Ductal drainage Total --___-
.
Injuries
Number of Patients with Penetrating Injury
Type of Injury
Comments
Early diagnosis of pancreatic injuries is of paramount importance, in view of the manifold complications and possible mortality [l-3]. Penetrating wounds of the pancreas pose no problem in diagnosis, especially when the external injury is located in the region around the umbilicus. In most cases, however, involvement of other abdominal organs warrants exploratory laparotomy. In contrast, blunt pancreatic trauma presents a great diagnostic problem [2,4]. The presence of concomitant and associated intraabdominal, head, chest, pelvic, and skeletal injuries (with high velocity missiles traversing circuitous routes) further aggravates the difficulties in diagnosis. This led me to use the following diagnostic aids, namely, abdominal paracentesis, peritoneoscopy, and more recently hepatic scanning, angiography [5], and biochemical and enzyme analyses. The conclusions drawn from this study are: (a) pancreatic scanning, angiography, and peritoneoscopy are of limited value; (b) a significant increase in enzyme levels in the serum or pancreatic fluid on abdominal paracentesis is a reliable diagnostic index; and (c) when the surgeron is in doubt, exploratory laparotomy remains the single means of diagnosis [6-81. Review of the present series showed that in addition to early diagnosis, rapid and massive resuscitation to combat shock is vital. It must be stressed that the injured pancreas is often only one of the organs simultaneously traumatized [9].
I
Trauma
6
44
91
rupture.
for Pancreatic Trauma No. of Patients 17 15 4 35 8 10 2 91
Mortality
. . ... 2 1 5 10 1 19 (20.8%)
In treating the present 91 patients, I have found that: (a) Of greatest importance in the injured pancreas is the damaged duct, because mortality and morbidity were directly related to leakage of pancreatic juices. The use of a T tube placed in the pancreatic duct to temporarily divert pancreatic juices may be a life-saving device especially in the critically injured, polytraumatized patient. The T tube brought out via the stomach or jejunum through the anterior abdominal wall will result in an internal, not external, fistula [lo]. (b) Contusions and lacerations not involving the pancreatic ducts are best left alone with adequate drainage of the lesser sac and pancreatic region with Penrose or sump drains. (c) Since primary suture of the pancreatic ducts resulted in multiple complications and was associated with high mortality, this form of treatment must be abandoned; any lacerated injuries involving the ducts should have immediate resection. (d) Because pancreatoduodenal injuries were also associated with high mortality [11,12], despite my aggressive surgical resection, temporary diversion of
537
Balasegaram abdomen, and pelvis, causing multiple and bursting injuries. In such patients either a thoracoabdominal or several incisions have to be made. Blunt abdominal injuries and retroperitoneal hemorrhages demand opening of the lesser sac since ductal injuries or transection of the pancreas can be hidden by a he[14,15]. matoma or intact peritoneum
Figure Pancreatic 1. scan showing no uptake by the pancreas of radioactive kzotopesdue to pancreatic pseu&cyst.
the pancreatic
juices with a T tube in the pancreatic duct and pancreatojejunostomy may be life-saving [2]. When the head of the pancreas is injured close to the duodenum, repair is almost impossible. Distal pancreatojejunostomy with an indwelling T tube is then a logical operation. Such measures avoid the mortality from traumatic pancreatitis, which may progress rapidly within 12 to 24 hours after injury. The surgical approach to the injured pancreas in this series depended on several factors, namely the presence of other associated and concomitant injuries [131. High velocity missile injuries traverse the chest,
The salient points in operative technic for subtotal or near total pancreatectomy include the dissection of the injured pancreas, ligation of the splenic vessels and more importantly the pancreatic duct, and application of my own pancreatic crushing clamps. The raw edges are sutured with several interrupted mattress sutures, using unabsorbable (polyester) ethiflex (Ethicon@), and buried in the posterior abdominal wall. Pseudocysts may present as abdominal masses. (Figure 1.) When they are located in the head of the pancreas, resection is not feasible and internal drainage is the treatment of choice. I prefer cystogastrostomy, although other authors have advocated cystojejunostomy with Roux-en-Y anastomosis [10,16]. An illustrative case of pancreatic pseudocyst follows. A forty-five year old male Chinese presented with a gradually increasing mass in the upper aspect of the abdomen. He gave a history of having been assaulted in the region of the epigastrium four months before his present admission. On that occasion complaining of severe abdominal pain above and around the umbilicus, he was admitted to another hospital. He was discharged ten days
Figure 2. Left, barium meal stud& of patient after cystogastrostomy; note the fluid level. Middle, some of the barium has now entered the cyst. Right, the barium has now evacuated from the cyst after 20 minutes.
538
The American Journal of Surgery
Pancreatic Trauma
later when the pain was less intense and was told that the abdominal pain was due to muscular contusion since all investigations proved negative. Two weeks after his discharge from hospital, he noticed a lump above the umbilicus, which gradually increased in size until we saw him. On examination, the general condition of the patient was fair. Palpation of his abdomen revealed a large cystic mass extending from the xiphisternum to 3 inches below the umbilicus. Laterally, the mass appeared to be continuous with the liver. Serum amylase level was 40 Somogyi units/100 ml. Except for upward displacement of the liver, hepatic scan showed no abnormalities. Barium meal studies showed enlargement of the duodenal loop and lateral films that indicated forward displacement of the stomach. Splenoportography showed uniform and upward displacement of the splenic vein, whereas selective pancreatography revealed lateral displacement of the pancreatic vessels. Pancreatic scan showed no uptake of the radioisotope in the head of the pancreas. Preoperative diagnosis was pancreatic pseudocyst. At laparotomy, a 12 by 8 inch pancreatic pseudocyst was seen arising from the head of the pancreas. Cytogastrostomy was performed. Postoperative barium studies performed a week later showed excellent results. (Figure 2.) The patient has since remained free of symptoms. When these cysts are present in the body and tail, subtotal or near total pancreatectomy can be performed with ease. Pancreatic fistulas (Figures 3A and B) and intraabdominal abscesses (Figure 4) are frequently the result of diagnostic errors, delay in therapy, and complications of operative procedures [ 171. Most of these complications occurred in the initial years of the present series. With improvements in diagnosis and experience in the management of the injured pancreas, the complication rate has since been min-
Figure 3A. A patient a with fistula due to blunt injury of the pancreas sustained four months previously and undiagnosed at that time.
imized. Three patients with pancreatoduodenectomy had pancreatic insufficiency. The exocrinal and endocrinal functional manifestations may be investigated by biochemical and enzyme studies, particularly insulin assays, triolin uptake using isotopes, and estimation of intestinal enzymes. Since the pancreatic tissue does not regenerate, supplementary medical therapy must be instituted for life. Failure to do so would result in malabsorption syndrome and diabetes. Pancreatic deficiency was successfully corrected by supplementary therapy in two patients whereas one patient defaulted treatment. (Figure 5.) In conclusion, pancreatic
the success
injuries
more aggressive
depends
surgery.
always be considered patients with multiple important
of the treatment on early diagnosis
Pancreatic
Vduma 131, May 1976
should
and excluded, especially in injuries. This is all the more
in this age of increased
dents and civil violence.
injuries
of and
automobile
acci-
Figure 38. Scan of the patient Figure i? 3A with disruption of the pancreatic duct and abscess formation.
539
Balasegaram
Summary Ninety-one patients treated for pancreatic injuries are reviewed. Difficulty of diagnosis, including the surgical management of these injuries and their complications, are discussed in detail. The presence of associated multiple injuries, delay in diagnosis, and -lack of sound surgical principles of treatment are directly proportional to the rate of complication and mortality. Acknowledgment: I wish to thank the DirectorGeneral of Medical Services, Federation of Malaysia, for permission to publish this paper and to Mrs Jessie Cardoza for typing this manuscript.
Addendum Since this report was prepared, twenty-two additional patients have been treated for pancreatic injuries. References
Figure 4. Len abscess subphrenic a in patient after subtotal pancreatectomy. Note the fluid level outside the stomach.
Figure 5. Pancreatic insufficiency after pancreatoduodenectomy. Note the flocculation and distension the of small intestines due to malabsorption syndrome. This patient defaulted treatment after surgery.
540
1. Bach RD. Frey CF: Diagnosis and treatment of pancreatic trauma. AmJSurg 121: 20, 1971. 2. Balasegaram M: The traumatised patient in large-scale civil disturbances with special reference to the pancreas and liver. Abraham Colles Memorial Lecture delivered at the Royal College of Surgeons, Ireland. March 1974. 3. Donovan AJ, Turrill F, Berne CJ: Injuries of the the pancreas from blunt trauma. Surg C/in North Am 52: 649, 1972. Pancreatic trauma. Arch Surg 102: 424, 4. Jones RC, Shires GT: 1971. 5. Freeark RJ, Shoemaker WC, Baker RJ: Aortography in blunt abdominal trauma. Arch Surg 96: 705, 1968. 6. Strohl EL: Traumatic injuries to the pancreas. Surg Gynecol Cbstet 124: 115, 1967. 7. Sturim HS: The surgical management of pancreatic injuries. Surg Gynecol Obstet 122: 133, 1966. 8. Werschky LR, Jordon GL Jr: Sugical management of traumatic injuries to the pancreas. Am J Surg 116: 768, 1968. the Pancreas. 9. Howard JM, Jordan GL Jr: Surgical Diseases of Philadelphia, JB Lippincott, 1960. 10. Simpson A. Srivastava VK: Pseudocyst of the pancreas. Br J Surg 60: 45. 1973. 11. Berne CJ. Donovan AJ, Hagen WE: Combined duodenal pancreatic trauma. The role of end-to-side gastrojejunostomy. Arch Surg96: 712, 1968. 12. Freeark RJ, Corley RD. Norcross WJ, Baker RJ: Unusual aspects of pancreatoduodenal trauma. J Trauma 6: 482, 1966. Pancreatic review 13. Barnett WO, Hardy JD, Yelverton RL: trauma: of twenty-three cases. Ann Surg 163: 892, 1966. 14. Doubilet H. Mulholland JH: Some observations on the treatment of trauma to the pancreas. Am J Surg 105: 741, 1963. 15. Kerry RL. Glas WW: Traumatic injuries of the pancreas and duodenum. Arch Surg 85: 813.1962. 16. Ebbesen KE. Schonebeck J: Post pancreatic pseudocysts in children. Acta Chir Stand 132: 280, 1966. 17. Welch CE, Edmunds LH: Gastrointestinalfistulas. Surg C/in North Am42: 1311, 1962.
The American Journal of Surgery
