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

Table 1 Study population and characteristics

	Blunt n = 11	Penetrating n = 3
Patient demographics
Age (yr, range)	20 (17 - 38)	32 (26 – 51)
Sex (male, %)	8	1
Injury characteristics
Mechanism
Motor vehicle accident	5	0
Gunshot	0	1
Stabbing	0	2
Sporting injury	5	0
Fall	1	0
Shock (BP < 90 mmHg)	3	1
Grade
III	7	0
IV	4	1
V	0	2
Associated abdominal injuries
Organ injuries	8	3
Vascular injuries	3	3
Intervention
Time to operation
< 12 h	4	3
> 12 h	7	0
Procedure
DP	9	0
PD	2	3
Outcomes
In-hospital mortality	1	0
Unplanned return to theatre	1	0
Length of stay	14.0 (3.1 – 39.0)	34.6 (19.7 – 40.4)
Postoperative complication
Postoperative pancreatitis / fistula	1	2
Haemorrhage	0	0
Intraabdominal sepsis	2	2

BP: Blood pressure; PD: Pancreaticoduodenectomy; DP: Distal pancreatectomy.

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.

Table 3 Summary of cases: Penetrating 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	Post-operative course
1	32M	Gunshot	Devascularisation of head of Pancreas, 4 cm defect	CBD; Duodenum, Right kidney (Grade III)	IVC, IPDA	V	Stable; FAST scan negative	Nil	CTAP	PD, < 24 h from injury	Right nephrectomy, IVC repair, Extended right hemicolectomy	19.7	Uncomplicated recovery
2	51F	Stabbing	Transection of head of pancreas	Renal hilum	PV; SMV; Middle colic vein	IV	Unstable; FAST positive	2U pRBC; 2U FFP; MTP activated	None	PD, < 24 h from injury	Extended to thoracotomy	34.6	Intraabdominal sepsis, collections requiring CT-guided drainage
3	26F	Stabbing	Head and uncinate of pancreas	Duodenum, Gallbladder	IVC	V	Stable; FAST positive	Nil	CTAP; Mesenteric angiogram (+ Pancreaticoduodenal pseudoaneurysm embolization)	PD, < 24 h from injury	IVC repair; Cholecystectomy	40.4	Intraabdominal collections, Splenic infarct

AAST: American Association for the Surgery of Trauma; FAST: Focused assessment with sonography for trauma; MTP: Massive transfusion protocol; FFP: Fresh frozen plasma; CBD: Common bile duct; IVC: Inferior vena cava; IPDA: Inferior pancreaticoduodenal artery; SMV: Superior mesenteric vein; pRBC: Packed red blood cells; CTAP: Computed tomography abdomen and pelvis; PID: Post injury day; OT: Operating theatre; PD: Pancreaticoduodenectomy; DP: Distal pancreatectomy; LOS: Length of stay.