Review Article
Current Diagnosis and Management of Pancreaticoduodenal Injury: A Concise Review
Xinlong Dai, Cheng Lu and Wentao Gao*
Department of Pancreas, The First Affiliated Hospital with Nanjing Medical University, China
*Corresponding author: Wentao Gao, Department of Pancreas, The First Affiliated Hospital with Nanjing Medical University, China
Published: 13 Feb, 2017
Cite this article as: Dai X, Lu C, Gao W. Current
Diagnosis and Management of
Pancreaticoduodenal Injury: A Concise
Review. Clin Oncol. 2017; 2: 1205.
Abstract
Owing to the proximity of the pancreas and duodenum, the pathogenesis, diagnosis, and
management of pancreaticoduodenal injury, while being distinct are all still interrelated. While
management of pancreatic injury is related to injury classification, which may vary greatly from
non-surgical intervention, operative therapy, or pancreaticoduodenectomy (PD), identification of
pancreatic duct injury is the top priority. Although Magnetic Resonance Cholangiopancreatography
(MRCP) and Endoscopic Retrograde Cholangiopancreatography (ERCP) are used as diagnostic
modalities for pancreatic duct evaluation, sphincterotomy or stenting by ERCP for duct injury are
still controversial. Non-surgical management is recommended for patients that do not have duct
injuries. Once duct injury has occurred, appropriate debridement, resection, and reconstruction
should be considered. Damage Control Surgery (DCS) is an option for critically ill patients
concurrently with appropriate initial treatment and delayed reconstructive procedures. Decisionmaking
of duodenal injury also depends on injury classification, and the consensus is primary repair
with adequate drainage in case of perforation. Combined pancreaticoduodenal injury is associated
with high morbidity and mortality. The effective prevention for pancreaticoduodenal injury-related
complications are significant including delicate operation, precise hemostasis, thorough irrigation,
and appropriate surgical options.
Keywords: Pancreaticoduodenal injury; Diagnosis; Operative management; Magnetic resonance cholangiopancreatography; Endoscopic retrograde cholangiopancreatography
Introduction
In two large retrospective studies of pancreaticoduodenal injury, pancreatic injury was seen in 58-69% cases; duodenal injury, in 24-26%; and combined injury, in 11–16% [1,2]. Early diagnosis and classification of pancreaticoduodenal injury is crucial for decision-making. Early treatment of pancreaticoduodenal injury requires either non-surgical or surgical approaches, aiming to improve patient outcomes and preserve the bodies’ and organs’ potential for recovery on the basis of the identified risks. Later treatment emphasizes multidisciplinary cooperation to seek and choose feasible approaches that could solve the existing problems in view of the patients’ condition and secondary manifestations [3,4]. In this study, we present a concise review of the management of traumatic pancreaticoduodenal injury, including diagnostic approaches, options for surgical determination, Damage Control Surgery (DCS) in pancreaticoduodenal injury, and treatment of complications.
Diagnosis
The retroperitoneal location of the pancreas and duodenum provides protection from blunt
and penetrating injuries; hence, the overall incidence of injury is low. However, this characteristic
can easily conceal the symptoms and signs of injury, resulting in delayed diagnosis and incorrect
classification, thereby leading to higher rates of morbidity and mortality [2,5]. For any upper
abdominal trauma, pancreaticoduodenal injury should be considered. Laboratory data such as
serum amylase levels have low sensitivity and specificity in the acute phase. An increase in amylase
levels after blunt pancreaticoduodenal injury is time-dependent, and a persistently increasing
amylase level is a more reliable indicator of pancreaticoduodenal injury, but it does not indicate the
severity of the injury. Diagnostic Peritoneal Lavage (DPL) can be useful in diagnosis, and amylase
detected in DPL fluid is a much more sensitive and specific indicator of pancreaticoduodenal injury
than serum or urine amylase estimations. Computed Tomography (CT) is the priority choice of
examination for hemodynamically stable patients, as it provides a safe and comprehensive means of
diagnosing traumatic pancreaticoduodenal injury [6,7].
The American Association for the Surgery of Trauma (AAST)
organizes pancreatic and duodenal injury patterns into five grades,
which are determined by the presence or absence of ductal disruption
and by the anatomic location of injury. Grades I and II injuries are
treated with non-surgical management techniques or simple drainage,
whereas grade III or higher injuries often require resection with
possible reconstruction and/or drainage procedures. For example,
pancreatic duct injury (Grade III) and duodenal perforation (Grade
II) form a crucial demarcation between non-surgical and surgical
management, respectively. Therefore, the identification of duct injury
and duodenal perforation are top priority.
Diagnosis of pancreatic duct injury
Signs of pancreatic injury on CT include intrapancreatic or
retroperitoneal hematoma, peripancreatic fluid, parenchymal
laceration, prerenal fascial thickening, and pancreatic laceration
and fracture. Both sensitivity and specificity of CT for pancreatic
injuries are greater than 85% [6]. Injury to the main pancreatic duct
occurs in up to 15% of all pancreatic injuries, and the majority is
penetrating trauma [8]. CT can detect main pancreatic duct injury
with a low accuracy of approximately 43% [9]. In early stages, a depth
of pancreatic laceration above 50% correlated with increased risk
of duct injury. In later stages, posttraumatic pseudocyst and distant
pancreatic duct dilatation are generally associated with a ductal leak
until proven otherwise [10,11].
Therefore, if pancreatic injury remains highly suspicious in a
hemodynamically stable patient without clear operative indications,
the surgeon should further investigate the potential for pancreatic
duct injury. This should be done with Magnetic Resonance
Cholangiopancreatography (MRCP) or Endoscopic Retrograde
Cholangiopancreatography (ERCP). The advantages of MRCP are its
noninvasive nature, shorter procedure time, and ready availability;
further, it allows observation of the entire duct as one continuous
image. However, MRCP cannot provide dynamic information as to
whether there is continuing leakage, pathologic fluid accumulation,
and ductal disruptions trafficked with pseudocysts [12]. Although
MRCP is used more frequently, ERCP is also increasingly being
used to help in both early and delayed diagnosis of pancreatic ductal
injury. However, the use of ERCP as a direct image-guided therapy is
still debatable.
Diagnosis of duodenal perforation
Sensitivity of CT for duodenal perforation is about 76% [9]. Free
air in the abdomen and pneumoretroperitoneum shown in CT are
indications for surgical intervention. However, oral contrast medium
does not increase the diagnostic accuracy.
Non-surgical and Surgical Management
Operative exploration
High-energy trauma, peritonitis, peritoneal effusion, abdominal
active bleeding, and hypodermal petechiae including emphysema
are surgical indicators. Regardless of whether there is radiographic
confirmation, timely operative exploration in such cases is imperative
as it also provides a direct and accurate diagnostic method.
Subsequently, pancreatic duct injury or duodenal injury may be
determined during the laparotomy.
Duodenal injury
Generally, operative indication for duodenal injuries depends on
duodenal perforation (Grade II and above). Duodenal contusion or hematoma and secondary obstruction can be equally well treated by
non-surgical management [13].
Pancreatic injury
Injury to the great vessels, hemodynamic instability, and main
duct injury (Grade III or above) are specific operative indicators.
Grades I and II can be treated with non-surgical management; only
10% cases will fail and present with complications. Failed non-surgical
management increases the incidence of complications by only 3% [1].
Whereas grade III or higher injuries often require surgical resection
with possible reconstruction or drainage procedures [14].
The accuracy of CT, which often fails to identify pancreatic duct
injury, is moderate at best. Damage to the ductal system, if ignored
or untreated, can result in fistula, traumatic pancreatitis, pseudocyst
formation, abdominal abscess, and other complications. Therefore,
if a CT scan cannot exclude ductal injury, investigation by MRCP or
ERCP should be considered. In addition, non-surgical management
of pancreatic injury, serial examinations, laboratory evaluation of
serum amylase levels, and CT are warranted. CT-guided abdominal
puncture and drainage or operative drainage should be performed
when abdominal signs get worse or peritoneal effusion is accompanied
with infection.
Conservative management of pancreatic injury (Grade III)
In children, non-surgical management of pancreatic injuries had
a few reported [15]. While operative management of pancreatic injury
(grades III-IV) remains controversial, conservative management
shows a trend toward a longer duration of hospital stay and a higher
rate of pseudocyst formation [16].
ERCP management of pancreatic injury (Grade III or IV)
ERCP as a therapeutic tool for pancreatic injury (Grade III or IV)
can be used for sphincterotomy, stent placement, and may help to
avoid unnecessary emergency operation. Stent therapy can improve
the clinical condition and resolve fistula and pseudocyst, but ductal
stricture is a major complication in the long-term.
Complications caused by stent or Endoscopic Nasopancreatic
Drainage (ENPD) although rare, have been reported, including
occlusion, migration, pancreatitis, duodenal erosion, and infection.
Stent exchanges may be required because of pancreatic ductal stricture,
which is almost inevitable. The diameter of the major pancreatic duct
is the most important factor in deciding ductal stricture [17].
Remarkably, despite the widespread notion that non-surgical
treatment of pancreaticoduodenal injuries that require surgical
intervention leads to disastrous outcomes, objective evidence is hard
to find. In a number of retrospective studies, missed diagnosis did not
affect mortality rates and length of hospital stay [1]. The feasibility
of non-surgical management or observation for pancreaticoduodenal
injury can be acceptable in the absence of hemodynamic instability,
peritonitis, and uncertainty of diagnosis and classification.
Although missed diagnosis can lead to fistula, pseudocyst, and other
complications, subsequently, delayed operation or non-surgical
management can be adopted.
Operative Decision-Making for Pancreatic Injury
Patients with peritonitis, active hemorrhage, intestinal spillage,
grade III or higher injuries, and hemodynamic instability with
a positive focused abdominal CT for trauma or pancreatic duct disruption require operative intervention [18,19]. The motives for
operation include hemostasis; wide drainage; debridement of necrotic
tissue; preservation of pancreatic function; and reasonable surgery
on the basis of grade of injury, additional injuries, and patients’
condition. Treatment strategy for the trauma is based on the grading
and traumatic status.
Delayed repair and DCS
The current concepts of DCS are based on the severity of
trauma and tolerance in patients, which has been applied to the
staged procedures to control hemorrhage, limit sepsis, and protect
from further injury. A simple and effective laparotomy is priority
for optimizing the physiological state and reducing disturbance of
homeostasis to the best extent in severely traumatized patients. After
the initial resuscitation is stable, the definitive repairs are completed
in a second surgery [20]. The principles of DCS are as follows:
Phase I: The use of rapid and temporary measures to control
bleeding and contamination and quick and temporary closure of the
abdominal cavity;
Phase II: Physiological resuscitation to correct hypothermia,
metabolic acidosis, and coagulopathy further;
Phase III: Planned reoperation for definitive repair of the
damaged organs [21].
For patients with severe trauma, damage control techniques
should subsequently be used (i.e., 48-96 h later), followed by definitive
operation [22]. The concepts of DCS should be applied to treat
pancreatic trauma from a perspective viewpoint that surgeons should
identify the main and secondary contradictions. Hypothermia,
hypoxia, and coagulopathy comprise a lethal triad. Before this triad
materializes, life-saving treatment should be initiated, because if the
patient dies, all efforts are in vain regardless of the perfection of the
chosen procedure. Thus, the ultimate objective should be to save the
patient’s life and improve survival rate.
Key points of operation
Patients who require laparotomy should undergo a systematic,
prompt, and rational exploration so that all areas of the abdomen
are assessed and injuries are not missed. Because of the adjacent
location of the pancreas and duodenum, injuries to the abdomen are
frequently associated with pancreaticoduodenal injuries. As standard
technique, management of solid organ injuries including liver and
spleen injuries is top priority, followed by hollow visceral injury
with contaminated fields, from the gastroesophageal junction to the
rectum. This process includes entering the lesser sac to evaluate the
posterior duodenum and pancreas.
No pancreatic duct injury (Grade I and Grade II): Pancreatic
contusion and superficial pancreatic lacerations without ductal
disruptions (Grades I and II) are treated with operative management
techniques, if non-surgical management proves ineffective [23,24].
Pancreatic injuries not involving the pancreatic duct, including
hematomas, parenchymal contusions, and lacerations of the capsule
or superficial parenchyma, can only be managed with external
debridement and simple repair. A fine lacrimal probe passed through
the papilla into the pancreatic duct for operative pancreatography
may provide sufficient information, but sometimes it is difficult
to find the papilla with this procedure and thereby, the risk for
duodenal fistulas increase. In rare cases, some centers recommend
intraoperative secretin, ultrasound (US), or ERCP, but these methods
are difficult to popularize. In damage control situations, the ductal
injury may be overlooked during a simple drainage of more complex
injuries that can cause postoperative pancreatic fistula and pseudocyst
formation, but endoscopic and interventional therapy and delayed
operation can be conducted subsequently in the hemodynamically
stable patient. The patients with pancreatic trauma (Grade III) with
high suspicion of injury to the pancreatic duct generally require distal
pancreatectomy and debridement [25].
Pancreatic injury (Grade III): The management of pancreatic
injuries with ductal involvement depends on the location of the
injury. Injuries to the left of the superior mesenteric vessels are
managed with a distal pancreatectomy with or without splenic
preservation. For life-threatening injuries, a closed suction drain
should be placed in the remaining proximal duct, then given delayed
pancreaticoenterostomy.
Pancreatic injury (Grade IV): Middle pancreatectomy and
debridement are recommended for injuries to the right of the superior
mesenteric vessels (grade IV).
Pancreatic injury (Grade V): Extensive damage to the
pancreatic head involving the duodenum and ampulla, combined
pancreaticoduodenal injuries, and uncontrollable bleeding of
pancreatic head may require a PD [26]. When the patient is
hemodynamically abnormal and unsuited for surgery, damage control
techniques should be used. Primary management of pancreatic injury
includes control of both hemorrhage and contamination, abdominal
packing, external drainage, and temporary abdominal closure with
plans for delayed PD. If the patient is hemodynamically unstable, PD
should be performed as a two-step procedure. After the initial damage
control surgery, reconstructions are completed during a second
surgery when the patient is stable. Even during a secondary operation,
reconstructions may not include pancreaticojejunostomy. Damage to
the pancreatic head and duodenum should be repaired rapidly during
operation. During the procedure, the common bile duct is ligatured
and biliary drainage is established by bile duct intubation and stoma.
Pancreatic secretion can be drained by pancreatic duct intubation,
and then mattress suture of distal pancreatic stump is accomplished.
The pancreatic bed is placed with a three-sump drainage tube, and
then rapidly temporarily closed. The patients are immediately
readmitted to the intensive care unit to ensure invasive monitoring,
cardiopulmonary support, aggressive rewarming, and replacement
of blood and clotting factors to correct any coagulopathy and/or
acid-base imbalance [21,27]. Furthermore, management of patients
include octreotide to control posttraumatic pancreatic fistula, enteral
and parenteral nutrition support, and prevention and control of
infection. The definitive operation should be completed after 72 h of
successful resuscitation. The definitive operation includes removal of
packing materials; exploration of the omitted trauma; management
of the remaining issues of DCS, such as pancreaticojejunostomy,
cholangioenterostomy, gastroenterostomy; and final closure of the
abdominal cavity.
Operative Decision-Making for Duodenal Injury
Management of duodenal injuries depends on the severity and
location of the injury. The consensus is a simple operation with
essential debridement, primary repair, adequate drainage, and lack of
complicated reconstruction. Treatment of the majority of duodenal
injury consists of primary repair, gastric decompression, initiation of total parenteral nutrition, and placement of drains [28]. If the existing
injury is in the first and second part of the duodenum that cannot
undergo primary repair, the Roux-en-Y jejunal limb to repair (serosal
or mucosal) a large defect is necessary. If the duodenal injury involves
the third or fourth part of the duodenum distal from the ampulla, a
local excision and duodenojejunostomy can be performed. Pancreaspreserving
duodenectomy is reserved for those patients with higher
duodenal injury (Grade IV) on the second part of the duodenum or
severe destruction of duodenum [29]. Surgical options when dealing
with the distal common bile duct injury include primary repair or
a delayed Roux-en-Y choledochojejunostomy. PD is indicated when
there is extensive trauma to the pancreatic head, a severe combined
pancreaticoduodenal injury, or destruction of the ampulla of Vater;
the reconstruction often depends on the severity of specific illness
[30].
Duodenal repair with pyloric exclusion or diversion procedure
remains a topic of contention. Duodenal diverticulization has been
replaced by pyloric exclusion. However, pyloric exclusion is relatively
more time-consuming and has greater complexity, and the associated
complications and prognosis are still controversial. Currently, this
method has only used for rare high-risk duodenal injuries [31].
Most (70%) pancreaticobiliary and duodenal injuries
or perforations often result from periampullary endoscopic
interventions, and their respective clinical outcomes and management
are varied. Most pancreatic and biliary perforations can be managed
nonoperatively; the requirement for operative treatment increases the
mortality rate.
Laparoscopic Operation for Pancreaticoduodenal Injury
Laparoscopic resection of the pancreas with Grade III or higher injuries under hemodynamically stable conditions can be performed safely and can lead to rapid recovery and reduced morbidity [32]. To the best of our knowledge, there are only a few cases of duodenal injury treated with laparoscopy.
Complications
Among cases treated surgically for pancreatic trauma, 20-
40% will present complications. The key is prevention, including
appropriate surgical options, delicate operation, definite hemostasis,
and adequate drainage. Common complications following
pancreaticoduodenal trauma include hemorrhage, pancreatic fistula,
pancreatitis, pseudocysts, and abscess that need to be managed by
multidisciplinary collaboration [14,25,33].
(1) Abdominal hemorrhage known as delayed hemorrhage can
originate from the pancreatic bed or the surrounding vessels as a
result of corroded fistulas. Control of pancreatic fistula can prevent
postoperative bleeding. The majority of arterial hemorrhage can be
diagnosed and treated by Digital Subtraction Angiography (DSA).
(2) The formation of pancreatic fistula is the most common
complication after surgical treatment for pancreatic trauma. Adequate
external drainage, control of infection and nutritional support are the
mainstays of management. Endoscopic management of disrupted
pancreatic ducts or strictures improves the outcomes of conservative
treatment. Upwards of 90% will be closed within 8 weeks while only
about 10% require surgical intervention [34].
(3) Pancreatitis is a complication of unrecognized pancreatic
duct injury. Reported incidence of pancreatitis is as high as 17%. The
majority of these can spontaneously resolve. Those with recurrent
episodes can be treated with ERCP-guided stent placement.
(4) Peripancreatic abscess occurs in around 20% of patients. These
cases usually can be treated percutaneously, while some patients need
surgical intervention.
(5) Regardless of the causes, almost 60% of pseudocysts will
spontaneously resolve in 6-8 weeks. ERCP can be used to determine
involvement of the main pancreatic duct. If there is no communication
of the duct with the pseudocyst, drainage can be carried out
percutaneously with CT or endoscopic US (EUS) guidance. When
communication with the main pancreatic duct exists, drainage with a
transpancreatic stent with or without intracavity drainage works well
with EUS. Endoscopic treatment with successful resolution occurs
in around 90% of patients with low recurrence rates [35]. Surgical
drainage is selected if the conditions for endoscopy are inappropriate.
Summary
The early diagnosis and grading of pancreaticoduodenal injury is important to guide individual management. In early stages, management of pancreaticoduodenal injuries should be based on the identified risks; surgeons typically strive to take simple approaches to treat life-threatening complications and restore the body’s and organ’s potential. In delayed stage, in view of the traumatic situation and secondary complications, multidisciplinary collaborations should be undertaken to ensure a practical approach and improve prognosis. It is necessary for a surgeon to treat and cure patients with the following understanding: “Performing the wonderful operation at the right time and place!”.
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