The management of pancreatic and pancreaticoduodenal injuries

Abstract

Abstract From 1969 to 1979 39 injuries of the pancreas and duodenum were treated at the Royal Victoria Hospital, Belfast. The mortality was 31 per cent. Twenty-six injuries were due to stab, bomb or bullet. Two of the 17 with low velocity gunshot wounds died, whereas all 5 cases of high velocity missile injury died (P < 0·001). Ten of the 13 cases of blunt trauma were due to road traffic accidents. In 21 cases the body and tail of the gland were injured, and in 13 the head and neck. There were 5 isolated duodenal injuries and in 7 a combined pancreaticoduodenal injury. The mortality was directly related to the number of other organs damaged. Three main methods of treatment were used—simple drainage, suture and drainage, and primary distal pancreatic resection. Serious complications, pancreatitis, fistula, secondary haemorrhage and sepsis were frequent after the first two methods but rare after distal resection. Diagnosis was delayed in 4 cases of closed injury and 1 of these patients died. Pancreatic injury was missed 6 times at operation; in 4 cases retroperitoneal haematoma was not explored and 2 of these patients died. Five of the 12 deaths were due to overwhelming bomb and bullet injury. In one case resuscitation was inadequate. The remaining 6 died of the complications of the original pancreatic injury, either because operation was delayed or because the injury was missed. Our management was deficient in three areas: awareness of the need for laparotomy, recognition of the injury at operation and inadequate surgery. All open abdominal injuries must be explored; suspicion and careful assessment are essential in closed trauma. At operation the pancreas must be carefully examined; an upper retroperitoneal haematoma is an absolute indication for this. Simple drainage is only sufficient for trivial injury; for major injury of the body and tail we prefer distal resection. Roux loop drainage is suggested for injury to the head and neck, especially when associated with duodenal injury.