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Pancreatic trauma

Pancreatic trauma. Iain Cameron. How does it happen?. Blunt trauma to abdomen Deceleration injuries (seatbelts) Significant force needed Likely to have other injuries. Diagnosis of injury. Clinical history Serum amylase often elevated No correlation amylase : severity injury

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Pancreatic trauma

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  1. Pancreatic trauma Iain Cameron

  2. How does it happen? • Blunt trauma to abdomen • Deceleration injuries (seatbelts) • Significant force needed • Likely to have other injuries

  3. Diagnosis of injury • Clinical history • Serum amylase often elevated • No correlation amylase : severity injury • CT scan - free fluid around pancreas - in lesser sac - oedema / changes in periP fat • Often underestimates the problem

  4. Injury classification • Grade 1 – capsular injury with contusion • Grade 2 – major duct injury body/tail • Grade 3 – major duct injury head +/- CBD • Commonest site of injury = neck • Asssociated injury = duodenal

  5. Sites of injury

  6. Initial treatment • Integrity of main duct is key to management • Delayed diagnosis associated with poor outcome • CT reasonable – identifying pancreatic injury • Poor : assessing duct integrity • ERCP / MRCP needed

  7. ERCP/MRCP • Early imaging in stable patient • PD injury key to treatment plan • No disruption = trial of conservative Rx • Major duct injury = surgery likely • ? Duodenal injury

  8. Laparotomy • Open lesser sac, full kockerisation of D2 • Complete gland examination • Most cases drainage only needed • 60% G1, 20% grades 2 and 3 • Distal duct injury – distal pancreatectomy

  9. HOP injury • Controversial • Drainage only – risk pancreatic fistula • Alternative : drain into roux loop • Duodenal injury : 1° repair Drain into roux loop Treatment is tailored to individual injury

  10. Complications • Pancreatic abscesses – drain (USS guided) • Fistula – greater with drainage vs. resection • Octreotide, NBM, TPN • Pseudocysts – as acute pancreatitis • Options : - Percutaneous drainage - Drainage into GI tract - Pancreatic stents ineffective

  11. Summary • Suspect from MOI • CT - presence not extent injury • Evaluation of duct integrity essential • Exploration / drainage main surgical Rx. • Selected injuries treated with resection

  12. Case discussion • MF, 30 year old male 2am • A+E, Alcohol ++, Fallen off bicycle • Conscious but rambling • Facial bruising, no fractures • O/E abdominal tenderness • AXR/CXR normal

  13. Next morning • Abdomen still tender, no guarding • Slight tachycardia • Bloods o/a amylase 312 • What next?

  14. Conservative treatment • Stable until day 4 • Tachycardia 110, T 37.8 • Bloods WCC 14 • Amylase 751 • What next?

  15. Repeat CT

  16. Options • Conservative • Surgery • Transfer to HPB unit

  17. RHH treatment • XRC review = transection of neck • Surgery • Questions • How to deal with : Head of gland Distal gland Any other injuries?

  18. Contrast swallow

  19. Operation • Complete transection of neck • Minimal contamination, 500ml fluid • Two ends of pancreas healthy • Head : Duct oversewn, end glued • Body/tail : debridement / mobilised - drained into roux loop

  20. Progress • Octreotide for 7 days • Minimal drainage • Allowed to E + D • Discharged day 9 • DNA’d clinic

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