Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit

Table 2 Summary of cases: Blunt abdominal trauma resulting in high-grade pancreatic injuries

Patient		Mechanism	Pancreatic injury	Associated injuries	Vascular injury	AAST grade	Haemodynamic stability	Pre-operative transfusion requirements	Investigations prior to OT	Primary procedure, post-injury day	Other	LOS	Outcome
1	17F	Fall	Pancreatic body laceration	Splenic infarct	Nil	III	Stable; FAST positive	Nil	CTAP; MRCP; ERCP + Stent	DP and splenectomy, 10 d from injury (undetected injury on initial imaging)	Nil	20.8	Uncomplicated recovery
2	38F	MVA	Pancreatic head laceration; Associated with intraperitoneal haemorrhage	CBD avulsion; Liver laceration; Fractures–ribs; L2-3 transverse processes, right radius	Nil	IV	Stable	2U pRBCs	CTAP, MRCP	PD, 7 d from injury (transferred from regional centre, initially for conservative management)		17.8	Persistent intraabdominal collections requiring two CT-guided drainage procedures
3	36F	MVA	Transected pancreatic neck; Associated with large left retroperitoneal haematoma	Right tension pneumothorax; Left haemothorax; Multiple liver lacerations; Small and large bowel perforations; Left renal hilar laceration	Transection of left renal artery, suspected thoracic aortic injury	IV	Unstable	MTP, 26U pRBC, 18 FFP, 5 Plt, 47 Cryo, 1L albumin, 1g TXA	None	DP and splenectomy	Damage control surgery in hybrid theatre: Laparotomy with four quadrants packing and cross clamping of supracoeliac aorta. Angioembolisation of left renal artery performed; Pancreatic neck transection was noted and a temporary drain placed. Temporary abdominal closure with negative pressure dressing; Ongoing MTP and resuscitation for next 48 hours. Patient remained intubated; Definitive operative intervention 72 h from initial laparotomy: En block resection of distal pancreas and spleen, and distal transverse colonic resection without anastomosis.	3.1	In-hospital mortality (secondary to multi-organ failure)
4	29M	MBA	Transected head of pancreas	Liver laceration; Duodenal laceration; Radius and proximal phalanx fractures	Nil	IV	Unstable; FAST positive	7U pRBC	CTAP–deterioration en route to OT	Emergency PD, < 24 h from injury	Right wrist ORIF and closed reduction of 5th digit	15.0
5	20M	MVA	Transacted pancreas at junction of tail and body; Associated with major disruption of MPD	Splenic laceration	Nil	III	Stable	Nil	CTAP; ERCP and pancreatogram	DP and splenectomy, 2 d from injury	Nil	13.0	Uncomplicated recovery
6	19M	MBA	Transection of pancreatic tail and large pseudocyst	Chance injury to L1/2 with spinal canal stenosis; Avulsion of L2-4 right transverse processes	Nil	III	Stable; FAST positive	Nil	CTAP; ERCP + Stent	DP and splenectomy, 1 mo form injury (delayed presentation)	Spinal stabilisation, lumbar fusion L1-2	39.0	Uncomplicated recovery
7	20M	MBA	Transection to tail of pancreas; Associated with MPD rupture and retroperitoneal haematoma	Grade IV/V left renal injury; Splenic hilum laceration; Left ulnar fracture and multiple ribs; Penetrating wound to right knee	Left renal artery transection	III	Stable; FAST positive	Nil	MRCP; ERCP + stent	DP and splenectomy, 4 d from injury	Removal of Meckel’s diverticulum and appendicectomy; Left ulnar ORIF; Right knee wound washout and debridement	14.0	Uncomplicated recovery
8	17M	Sporting injury	Transected pancreatic neck and head; Associated with complete disruption of MPD	Liver laceration; Scaphoid fracture	Nil	IV	Stable	Nil	CTAP; ERCP	DP and splenectomy, 3 d from injury		12.0
9	18M	Sporting injury	Transected pancreatic body; Associated with large retroperitoneal collection	Nil	Nil	III	Stable	Nil	CT 3Phase	DP and splenectomy, 3 d form injury	Nil	15.5	Postoperative pancreatitis; Intraabdominal collection requiring CT-guided drainage
10	21M	Sporting injury	Transected pancreatic body; Associated with large intraperitoneal and retroperitoneal haematoma	Splenic laceration and infarct	Nil	III	Unstable; FAST positive	1U pRBC	CTAP	DP and splenectomy; Initial CT imaging demonstrating isolated splenic injury	Left hemicolectomy; Re-look laparotomy and colonic anastomosis	7.7
11	24M	Sporting injury	Transection at junction of pancreatic neck and body; Associated with complete disruption of MPD	Hepatic contusion	Nil	III	Stable; FAST negative	Nil	CTAP; MRCP; ERCP–Proceeded to laparotomy and DP	Subtotal pancreatectomy (spleen preserving), 3 d from injury; Missed ductal injury on initial CT	Nil	10.0	Uncomplicated recovery

AAST: American Association for the Surgery of Trauma; FAST: Focused assessment with sonography for trauma; MTP: Massive transfusion protocol; FFP: Fresh frozen plasma; Plt: Platelets; TXA: Tranexamic acid; Cryo: Cryoprecipitate; ORIF: Open reduction internal fixation; MVA: Motor vehicle accident; MPD: Main pancreatic duct; pRBC: Packed red blood cells; FAST: Focused assessment with sonography in trauma; CTAP: Computed tomography abdomen and pelvis; ERCP: Endoscopic retrograde cholangiopancreatography; MRCP: Magnetic resonance cholangiopancreatography; PID: Post injury day; OT: Operating theatre; PD: Pancreaticoduodenectomy; DP: Distal pancreatectomy; LOS: Length of stay.