HEPATIC AND PANCREATIC TRAUMA
| MANAGEMENT OF PANCREATIC TRAUMA —Norman E. McSwain, Jr, MD, Professor of Surgery, Tulane University
School of Medicine, New Orleans
|
| Background: hemorrhage from injuries to structures in vicinity of pancreas primary cause of death from pancreatic
injuries; maintaining energy production during hospital stay essential to patient survival; loss of energy production
permits infection and organ failure; speaker believes infection caused by ischemia to immune system within first
hour of patient care; inadequate energy production in trauma patients produces acute signs indicative of shock (eg,
shivering); main factors determining survival are control of hemorrhage and assessment for ductal injury
|
| Pancreatic anatomy and physiology: pancreas and duodenum have common blood supply; blood supply has dual
source (superior mesenteric artery and hepatic or other frontal artery), so subject to extensive bleeding; knowledge
of anatomy important in identifying location of duct and associated ductal injury; tail of pancreas receives blood
from splenic artery and returns it to splenic vein; Skandalakas described 17 to 25 connections between splenic artery
and pancreas, which need to be considered if tail of pancreas removed (simultaneous removal of spleen is option,
and data suggest infection after splenectomy in adults not problematic); pancreas has endocrine and exocrine
functions; saponification indicates splenic leak
|
| Mechanism of injury: blunt trauma—frequently produces crush injury when pancreas crosses vertebral body; in
adults, most injuries involve impact with steering column; in children, most injuries involve impact with handlebars;
patients may initially appear asymptomatic because injured pancreas does not produce signs detectable on
physical examination; penetrating trauma—injury to tail of pancreas most common; seatbelt injuries—contusion
transversely across abdomen above anterior superior iliac spine caused by seatbelt suggests crush injury to pancreas
|
| Assessment issues: increased complication rate if injury not recognized within 24 hr; only 15% of patients with injury
to pancreas have injury to duct; if no ductal injury, pancreas heals without intervention; Craig et al, 1995—only 5 of
13 patients with pancreatic injury had symptoms of intra-abdominal injuries; computed tomography (CT) sensitivity
75%; 78% of patients had elevated amylase; diagnostic peritoneal lavage positive in 5 patients, due to nonpancreatic
injury; 8 patients had nontherapeutic abdominal explorations because patient had pancreatic injury but
without significant problems; physical examination negative in 62% of cases; interpretation—amylase and lipase
not reliable or cost-effective assessment tools; many patients with elevated amylase do not have pancreatic injury;
elevated amylase often due to alcohol consumption (alcohol stimulates amylase production from parotid gland)
|
| Computed tomography: unreliable within first 24 hr; Federle et al, 1983—pancreatic injury missed because CT performed
too soon after injury, when plane of fracture difficult to identify; suggested that 75% of pancreatic injuries
could be diagnosed by identification of thickening of anterior renal fascia; Akhrass et al, 1996—CT missed 53% of
pancreatic injuries; European study—CT missed 37% of pancreatic injuries; Scalea et al, 2002—CT underestimated
presence of pancreatic injury by 31%
|
| Endoscopic retrograde cholangiopancreatography (ERCP): can be difficult to obtain during first 12 to 24 hr; good
intraoperative technique; performed intraoperatively from duodenal side by injecting dye through ampulla of Vater
into pancreatic duct or by cutting off piece of tail of pancreas to visualize duct and inserting catheter
|
| Laparotomy: reasons for missed pancreatic injuries include associated injuries, low injury score, and, most importantly,
delay in presentation; exploratory laparotomy frequently only good assessment tool; during operation, assess
for central hematoma posteriorly, bile staining near injury, pancreatic edema, intact capsule with hematoma,
parenchymal injury, and associated ductal injury
|
| Octreotide: not correct management; study—fistula formation worse in patients taking octreotide, compared to patients
not taking octreotide
|
| Operative management: use of Whipple procedure and drains for trauma injury becoming less common; distal
pancreatectomy—closed by stapling, using strong suture line, or both; if spleen to be preserved, need to tie off
blood vessels individually; know how to perform Kocher maneuver and mobilize and assess duodenum; failure to
open lesser sac and explore pancreas in patient with blunt trauma common mistake; to detect pancreatic injury,
slide finger along fourth portion of duodenum in one direction and under ligament of Treitz in other direction until
fingers touch; to protect pancreatic suture line, divert food stream away from duodenum by closing pylorus with
sutures or staples; Whipple procedure—technique used for trauma patient same as for any patient; to hook reconnect
duct, speaker uses technique of taking common duct just distal to gallbladder, leaving some of gallbladder, then
making onlay patch and sewing directly to jejunum; Whipple procedure performed less commonly because frequently,
injury to duodenum accompanies injury to pancreas, and holes can be sewn back together to give drainage
of pancreatic juice directly into gastrointestinal (GI) tract
|
| Infections: penetrating abdominal trauma has high infection rate and associated mortality; literature shows that colon
and small bowel injuries have similar infection risk
|
| Drains: no evidence drains provide benefit to patients, prevent infections (likely cause infections), remove unwanted
fluid accumulations, or prevent hematomas
|
 | Therapeutic drains: drain pus from abscess
|
| Decompressive drains: used in GI tract, eg, after duodenal injury, retrograde catheter can be inserted up through jejunum
to decompress duodenum; can decompress air or fluid
|
| Prophylactic drains: no data to suggest drainage of pancreas, liver, or spleen beneficial; “drains do little to prevent
infection, whether closed or passive little prophylactic value, especially with the use of antibiotics”;
Akhrass et al—external drains associated with higher morbidity in patients with grades I and II pancreatic injuries,
compared to patients without drains; Young et al—rate of fistula formulation significantly higher with
drainage, compared to without drainage; Wynn et al—pseudocyst accumulation associated with drainage; Fabian
et al—sump catheters source of intra-abdominal infection
|
| Summary: vascular injuries should be treated first, eg, packing, damage control; insert feeding jejunostomy and decompressive
tubes or divert food stream; do not use drains; ductal injuries need repair; if no ductal injury, probably
no action needed
|
| Summary: important to perform hemorrhage control first; ductal integrity important; minimal surgery desirable;
knowledge of anatomy critical; CT and amylase poor assessment tools; important to maintain energy production
|
| THE FRACTURED LIVER —David H. Wisner, MD, Professor and Vice-Chair, Department of Surgery, University
of California, Davis, School of Medicine
|
| North Carolina trauma registry: rate of nonoperative management increased significantly from 1988 to 1992
|
| Study: of ≈80 patients with liver injuries, 23 (≈30%) had emergency operation, half for liver problems (all involved
packing); of patients monitored, 8 required delayed operations, but none for liver problems
|
| Important caveats: history of hypotension or poor response to fluid management causes problems; patients often
look remarkably well but, in fact, have severe disease; deterioration with intubation indicates severe liver problem
(positive pressure ventilation can exacerbate bleeding from damaged hepatic veins)
|
| Study: 400 patients received initial nonoperative treatment; 2 deaths related to liver injury; 21 (≈5%) patients had
complications, eg, hemorrhage, biloma, abscess; CT showing free fluid in abdomen suggests missed small bowel injury;
6 patients required delayed operations
|
| CT showing blush on liver: suggests patient has serious bleeding problem; percutaneous techniques at embolization
may be beneficial
|
| Mobilization: speaker favors mobilization of liver if operation required; for penetrating injury, mobilization aids visualization
and repair of holes in diaphragm; for blunt-trauma injury, mobilization aids visualization and packing
|
| Pringle maneuver: unknown how long clamp can remain in place before safety compromised; data from elective
surgery suggest 15 to 20 min acceptable, but likely <15 min acceptable in trauma patients
|
| Packing: “if in doubt, pack the liver”; speaker does not believe in placing something between packs and liver parenchyma;
studies inconclusive, but speaker believes packing confers survival benefit
|
| Activated factor VIIa: complexes with tissue factor; localized at sites of tissue damage; induces coagulation; approved
for use in hemophilia; study—20 patients with severe hemorrhage in whom conventional measures failed;
within 30 min of activated factor VIIa administration, prothrombin time and partial thromboplastin time decreased;
volume of transfusion decreased significantly over 24 hr
|
| Removal of packing: study—70 patients packed and survived >24 hr; some patients had packs removed within 36
hr (earlier removal believed to be associated with fewer complications), others removed at 72 hr; complication
rates did not differ, but rebleeding rate much higher when packs removed earlier; suggests packs can be left in
place for 2 days
|
| PERCUTANEOUS CATHETER MANAGEMENT OF BILIARY TRAUMA —John T. Owings, MD, Professor of Surgery,
Chief of Surgical Critical Care, University of California, Davis, School of Medicine
|
| Hepatic injuries: most do not require treatment; “the liver is the honest organ,” so if bleeding stops, likely to stay
stopped; important to recognize that injuries come in clusters, so patient with documented liver injury also may
have bowel or other injury; bowel injuries most difficult to diagnose, and delay in diagnosis leads to significantly
increased mortality
|
| Signs of management challenge: blush on CT—area of haziness (feathered contrast) suggests bleeding into free
space or broadening of normal vascular structure that may be contained pseudoaneurysm; elevated bilirubin—
dramatic increase in bilirubin from 1 mg/dL on day 1 to 20 mg/dL on day 4 inconsistent with something, eg,
duodenal hematoma, pressing on biliary tree (biliary tree compression leads to increase in bilirubin of 3 mg/dL
per day); dramatic increase in bilirubin suggests biliary sepsis or biliary venous fistula, which can be treated
with transcatheter techniques
|
| Potential catheter targets: hepatic arterial bleeding; biloma; biliary tree leaks not contained in biloma; fistulae; abscess
|
| Angiographic control of hepatic artery bleeding: patient with major liver injury and hypotension should be operated
on immediately; angiography not helpful for parenchymal bleeding (packs more effective); can be useful as adjunct;
ineffective for portal or hepatic venous bleeding
|
| Strategy for treatment of severe hepatic bleeding: in cases of suspected hepatic arterial or portal venous bleeding,
attempt to control with sutures and, if successful, close with drains; if suture control unsuccessful, pack patient; if
packing unsuccessful, perform angiography
|
| Biliary tree complications: biloma—easily treated with transcatheter techniques; simple drainage of biloma frequently
adequate; biliary leak—drain area of gallbladder fossa and insert catheter (usually transhepatic catheter) using
ERCP; important to place stent across sphincter of Oddi to ensure path of least resistance in intestinal tract
instead of peritoneal cavity; during drainage, assess cavity where bile collected and biliary flow; stent indicated if
flow through biliary tree inadequate to allow for persistent drainage
|
Educational Objectives
| The goal of this program is to educate the listener about issues in hepatic and pancreatic trauma. After hearing and assimilating
this program, the clinician will be better able to:
|
| 1. Assess pancreatic trauma.
|
| 2. Describe the role of computed tomography in the assessment of pancreatic trauma.
|
| 3. Discuss the use of drains in the management of pancreatic trauma.
|
| 4. Manage the patient with a fractured liver.
|
| 5. Discuss percutaneous management of biliary trauma.
|
Discussed on This Program
Octreotide acetate [Sandostatin, Sandostatin LAR, Sandostatin LAR Depot]
Recombinant activated coagulation factor VIIa (rFVIIa) [NovoSeven]
Suggested Reading
Adamson WT et al: Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic
trauma. J Pediatr Surg 38(3):354, 2003; Asensio JA et al: Pancreaticoduodenectomy: a rare procedure for the management
of complex pancreaticoduodenal injuries. J Am Coll Surg 197(6):937, 2003; Chrysos E et al: Pancreatic trauma
in the adult: current knowledge in diagnosis and management. Pancreatology 2(4):365, 2002; Dutton RP et al: Recombinant
factor VIIa for control of hemorrhage: early experience in critically ill trauma patients. J Clin Anesth
15(3):184, 2003; Fabbro MA et al: Management of severe blunt pancreatic trauma in children. Personal experience.
Pediatr Med Chir 23(3-4):179, 2001; Ilahi O et al: Efficacy of computed tomography in the diagnosis of pancreatic injury
in adult blunt trauma patients: a single-institutional study. Am Surg 68(8):704, 2002; Martinowitz U et al: Possible
role of recombinant activated factor VIIa (rFVIIa) in the control of hemorrhage associated with massive trauma.
Can J Anaesth 49(10):S15, 2002; Mboyo A et al: Internal drainage into an Onlay-Roux-en-Y jejunal loop in isolated
pancreatic injury with ductal transection: short-term and long-term follow-up in two pediatric cases. Eur J Pediatr Surg
10(6):398. 2000; Misra S et al: Percutaneous management of bile duct strictures and injuries associated with laparoscopic
cholecystectomy: a decade of experience. J Am Coll Surg 198(2):218, 2004; Olah A et al: Pancreatic transection
from blunt abdominal trauma: early versus delayed diagnosis and surgical management. Dig Surg 20(5):408,
2003; Sicklick JK et al: Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy:
perioperative results in 200 patients. Ann Surg 241(5):786, 2005; Tsukamoto T et al: Percutaneous management of
bile duct injuries after cholecystectomy. Hepatogastroenterology 49(43):113, 2002; Vasquez JC et al: Management of
penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury 32(10):753, 2001; Velmahos
GC et al: High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg
138(5):475, 2003; Velmahos GC et al: Nonoperative treatment of blunt injury to solid abdominal organs: a prospective
study. Arch Surg 138(8):844, 2003; Wales PW et al: Long-term outcome after nonoperative management of complete
traumatic pancreatic transection in children. J Pediatr Surg 36(5):823, 2001.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. McSwain was recorded November 29, 2004, at Surgery Postgraduate Conference sponsored by the Department of
Surgery, University of Iowa Carver College of Medicine and held in Iowa City. Drs. Owings and Wisner were recorded
September 18, 2004, at General Surgery 2004—26th Annual Postgraduate Course sponsored by the University of
California, Davis, Health System and held in Olympic Valley, California. The Audio-Digest Foundation thanks the
speakers and the sponsors for their cooperation in the production of this program.
|
