Evaluation of the Blunt Pancreatic Injury, a Long-Term Tertiary Care Center Study: An Original Research

ABSTRACT

Introduction:

Pancreatic trauma is uncommon and challenging to diagnose. Contrarily, severe injuries to the kidney, spleen, and liver are frequent and typically easy to detect with imaging methods. Pancreas injuries can cause a significant amount of morbidity and mortality. Reviewing the institution’s experience with this rather infrequent injury was the goal of this study.

Materials and Method:

The patients’ records were collected from the data records at the tertiary care center for patients who had pancreatic damage and were followed up for a year. The American Association for the Surgery of Trauma pancreatic damage grade scores were assigned to each patient using the radiologic and surgical findings. Clinical examination and CT results were predominantly used to make the diagnosis in patients who underwent non-operative treatment. The data are presented as descriptive statistics.

Results:

Only 2.2% of the total cases that presented to the trauma center were finalized as pancreatic injuries. Trauma to the abdomen was seen in nearly half the cases brought. Most of the subjects in pancreatic injuries were in grade 3. Mortality was noted maximum for the grade 3 and 4 cases.

Conclusions:

While high-grade pancreatic injury almost always requires an operational intervention, low-grade pancreatic injury with an intact main pancreatic duct may be effectively handled non-operatively. When possible, distal pancreatectomy with spleen preservation is the ideal procedure for distal pancreatic trans-action. A patient who is hemodynamically stable with complex pancreaticoduodenal damage, which is related to a high death rate, should undergo Whipple resection.

INTRODUCTION

Although rare, pancreatic injuries owing to trauma have a high possibility of disabilities. With blunt trauma, the pancreas is injured in 0.2% of patients. Penetrating injuries have a greater incidence, ranging from 1 to 12% in published data sets.[1,2] A pancreatic injury can result in an overall morbidity rate of 30% to 40%.[3] In different data sets, the mortality rate varies from 9% to 34%.[3,4] Uncontrolled bleeding is the primary cause of early mortality, whereas sepsis and the ensuing organ failure are typically the cause of late mortality. 2% to 17% of deaths are directly attributable to pancreatic damage.[3] When accompanied by duodenal perforation or closely linked arterial hemorrhage, pancreatic damage is potentially fatal.[5,6] In cases of acute pancreatic injuries, a physical exam is typically unreliable.[3] The risk of morbidity and death can be reduced with an early and correct diagnosis, and the identification of pancreatic injury is facilitated by a number of imaging modalities.[4,7] Serious problems, such as intra-abdominal collection, pancreatic fistula, and intra-abdominal hemorrhage, may result from a deferment in diagnosis or underestimating how severe it may turn.[8,9]

Prompt, early, and accurate diagnosis depend on understanding the time, ductal injury, processes of injury, other injuries, and diagnostic modalities. Because this disruption is the primary reason for delayed problems like pancreatic pseudocysts, early diagnosis of disruption of the main duct is crucial.[10] The intersection of the pancreas’ tail and body is where severe pancreatic damage most frequently occurs. Recovery of normal pancreatic physiology following pancreatic resection relies on the severity of the damage and the size of the organ that is ablated.[7,10] Generally, a resection of >90% is necessary to establish endocrine insufficiency if the pancreas is otherwise normal.[3] Patients with pancreatic surgery for reasons other than trauma frequently have severe pancreatic dysfunction caused by the underlying condition. Evaluation of the functional outcome following Whipple’s resection revealed a 20%–50% postoperative diabetes incidence.[11] Resection eases pain in cases of chronic pancreatitis, but exocrine and endocrine functioning is typically impaired. There are inconsistencies in the conclusions made about pancreatic injuries and their management.[7,12,13] Preoperative assessment of pancreatic function is impossible in the trauma group. Data on pancreatic function following trauma-related pancreatic damage or excision are scarce.[14] Hence the current study evaluates pancreatic injuries at a tertiary care center.

MATERIALS AND METHODS

A retrospective research was carried out from April 2020 to January 2022. The study comprised patients with abdominal injuries. All pancreatic injuries were assessed using the American Association for the Surgery of Trauma’s (AAST) organ injury scaling committee to categorize the severity of the pancreatic injuries for analysis. The first round of CPR was performed by the Advanced Trauma Life Support protocol. Patients with acute abdomen, symptoms of peritonitis, significant intraabdominal bleeding, or clinical suspicion of a serious pancreatic injury underwent urgent surgery. Surgery was done right away in patients whom we managed conservatively if there was a sign of clinical worsening or an increase in abdominal discomfort. CECT abdomen was used to evaluate each patient. Each patient’s AAST pancreatic injury grade score was assigned based on the radiologic and surgical findings.

Statistical analysis

Frequencies, ranges, and median were described as descriptive statistics.

RESULTS

From the data, the total number of cases admitted for trauma at the center was 4566, of which 2001 were abdominal traumas. Pancreatic injuries were seen in 102 cases. Male and female distribution was 83:19 [Table 1].

Table 1.

Incidence of all the trauma cases

Type	Number of cases
Total number of trauma patients	4622
Total number of abdominal trauma patients	2001
Total number of pancreatic trauma patients	102
Male	83
Female	19

Pancreatic injuries ranged from grade 1 to 5. The number of cases that were non-operative was 22; operative was 86; those who underwent pancreatic surgery were 70 and died after the surgery was 19 [Table 2]. One patient was admitted with grade 4 pancreatic damage and focal main pancreatic duct disruption after suffering a workplace injury. This level had a localized collection that reached the mesentery. He experienced fever spikes after being admitted, and his overall numbers were 21,500. Amylase levels in the ascitic fluid were 903. 800 cc of fluid was drained from the patient using a localized collection and a USG-guided pigtail insertion. After the operation, his fever spikes subsided, and his numbers were normal. The fluid’s culture exhibited no growth. The pigtail remained in place after his discharge. After 21 days, he reported abdominal distension and bleeding into the pigtail. Fluid collection and interior septations were discovered by CECT. After having a laparotomy, the patient was found to have a thinned-out proximal transverse colon, a pseudocyst with necrotic material from the perforation site, and D1 perforation. He underwent tube duodenostomy for hematoma evacuation and ileostomy for gastroduodenal artery ligation, both of which went well. On day 8, after surgery, the patient was released in a stable situation.

Table 2.

Distribution of pancreatic cases and their management

Grades	Non-operative cases	Operative cases	Operated due to pancreatic injury	Mortality
I	16	4	2	2
II	2	20	2	2
III	1	50	50	8
IV	2	10	10	6
V	1	2	4	1

In a patient who sustained a fall, a hematoma was noted and placed for surgery. The subhepatic space’s purulent fluid was removed during a diagnostic laparoscopy. He was released on day nine after surgery with a drain still in place. After three months, the patient returned with a daily drain of roughly 200–300 ml. An abdominal CECT exposed a pseudocyst and hypodense lesion in the head of the pancreas. He had a laparotomy, which revealed a cystic cavity in the head of the pancreas and a fistulous tube communicating from the skin to the ductal system. Fistulo-jejunostomy and cystojejunostomy were carried out. The drains were taken out and later discharged five days following the operation. Two of the 20 patients experienced problems related to the pancreas (pseudocyst). The laparoscopic cystojejunostomy procedure was later used to treat these two individuals. Despite the cumulative liver damage in ten patients, none required surgical intervention.

DISCUSSION

It might be difficult to diagnose and treat pancreatic trauma. The pancreas’ retroperitoneal position is frequently cited as the cause of the lack of initial physical symptoms and indications. According to some writers, pancreatic fluid output may diminish after injury, and pancreatic enzymes may continue to be inactive.[3] When a high-impact force is applied to the upper abdomen, tissues in the retroperitoneal area are crushed against the vertebra, resulting in blunt pancreatic injury that can range in severity from a slight bruise to a total cut.[3,4] Nearly 60% of pancreatic trauma in adults originates from car accidents.[3] In stab wounds, the knife induces pancreatic tissue damage along the path of the wound. In contrast, in gunfire/military operations, the passage of the bullets or the impact forces and the resulting pressure wave results in a broader area of harm.[4] When there are no indications for laparotomy, the decision of blunt trauma calls for a high index of suspicion.[3]

Nearly 70% of patients will have raised serum amylase; once 3 h have passed between the time of the injury and the time of the measurement, this percentage increases to 84%.[3,15] In the current investigation, a CT abdomen was performed on each patient to assess organ damage and grade the injury. According to reports, the newest generation of helical CT has good sensitivity and specificity.[3,15] Magnetic repulsion cholangiopancreatography (MRCP), a fast-developing non-invasive option to visualize the pancreatic duct, is said to be up to 97% accurate in the head and 83% accurate in the tail of the pancreas.[16,17] Nevertheless, in the current patient series, this method was not used. The degree and area of the parenchymal injury and the suspected or confirmed the integrity of the pancreatic duct all influence how the pancreatic trauma is surgically managed.[15,17]

The surgical strategy must also consider the patient’s stability and the severity of the afflicted organ harm. A comprehensive pancreatic inspection is required if the smaller sac contains bile, blood, or a central retroperitoneal hematoma. The pancreas must be completely exposed for evaluation. The Kocher maneuver must be used to mobilize the duodenum for a proper view of the uncinate process and pancreatic head. Additionally, opening up the hepatic flexure makes it easier to see and conduct a bimanual examination of the head and neck. To perform medial reflection, bimanual palpation, and posterior surface examination on the pancreas after injury to its tail, the spleen and the left colon must be moved. The surgeon has entrance to the inferior region of the pancreas through the division of the Trietz ligament and reflection of the fourth portion of the duodenum.[3,4,15]

Hemostasis, debridement of devitalized tissue, and sufficient external draining are used to treat grade I and II wounds.[3,4,15,17] There is a decreased frequency of infection problems when closed suction drainage is used as opposed to Penrose or sump drains.[3,15] The inclination to fix the capsular laceration should be resisted by the surgeon because doing so could lead to pseudocyst development.[3] A distal pancreatic transection typically takes place to the left of the superior mesenteric arteries and is seen with blunt injury when the pancreas is crumpled against the spinal column. The optimum treatment for this damage is a distal pancreatectomy. Whenever possible, the duct is ligated independently. Since pancreatic head injuries are commonly accompanied by further potentially fatal injuries, damage management measures, including packing and extensive external drainage, are usually necessary. If there are questions regarding ductal integrity or there is a chronic, high-output pancreatic fistula, postoperative MRCP or ERCP should be taken into consideration when the patient is stable.[2,4,15,17] Stenting is a viable alternative to a near-total pancreatectomy if proximal duct damage is diagnosed.[3,4] If the primary duct is unharmed, sufficient external drainage will suffice, and the wound will eventually heal. Less than 10% of pancreas injuries are combined pancreaticoduodenal injuries, which are extremely uncommon. These injuries are frequently accompanied by a superior mesenteric artery or vein injuries, so the surgeon should thoroughly investigate the retroperitoneum using the Cattell-Braasch procedure in this constellation of injuries. Damage-control strategies and gradual reconstruction are necessary for patients with these injuries.[17]

The surgical strategy will be determined by multiple factors. Primary repair and drainage will be sufficient if the distal common bile duct and ampulla are unharmed.[3,4,15,17] In this situation, duodenal repairs have a greater leakage that may lead to death. In 2%–10% of patients, a Whipple’s procedure may be necessary. After using damage-control methods to stabilize the patient, this should be done gradually.[3,15]

CONCLUSION

Pancreatic damage is rare and typically hard to identify. CT is the favored tool for detecting alleged pancreatic damage due to the complexity of the ultrasound results; nevertheless, pancreatic duct injury may not be identified on CT scans unless there is a through-and-through rupture. A patient who is hemodynamically stable can be treated minimally for low-grade injury. If high-grade traumas are hemodynamically stable, they can also be treated conservatively. They should, however, need ongoing monitoring because they are more likely to experience difficulties.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.