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8/7/2019 Pancreatic Injuries
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PANCREATIC INJURIESPANCREATIC INJURIES
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Pancreatic traumaPancreatic trauma
Pancreatic trauma can occur after directPancreatic trauma can occur after direct
abdominal traumaabdominal trauma
Incidence 2Incidence 2--10% in major trauma10% in major trauma
Seen in 20Seen in 20--30% penetrating abdominal wounds30% penetrating abdominal wounds
Stabbing from back can cause itStabbing from back can cause it
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Pancreatic traumaPancreatic trauma
High mortality and morbidityHigh mortality and morbidity
Mortality 12Mortality 12--23%23% Mortality rises dramatically with shock and otherMortality rises dramatically with shock and other
organs traumaorgans trauma
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Pancreatic traumaPancreatic trauma
Morbidity 30Morbidity 30 49%49%
Necrosis, hemorrhage, abscess, fistula,Necrosis, hemorrhage, abscess, fistula,
pseudocystpseudocyst
Endocrine 20%Endocrine 20%
Morbidity >60% when diagnosis is delayedMorbidity >60% when diagnosis is delayed
Main pancreatic duct rupture seen in 1.6% bluntMain pancreatic duct rupture seen in 1.6% blunt
traumatrauma
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Associated injuriesAssociated injuries
9090--9595% have other injuries% have other injuries Liver 42Liver 42--32%32%
Spleen 25Spleen 25--40%40%
Stomach 20Stomach 20--40%40% Major vessel 25Major vessel 25--35%35%
Thorax 22Thorax 22--31%31%
Bowel 10Bowel 10--29%29%
CNS 25%CNS 25%
Duodenum 18%Duodenum 18%
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ANATOMYANATOMY
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Blood supplyBlood supply
ARTERIALARTERIALMultiple branches from celiac nd S.M.ArteryMultiple branches from celiac nd S.M.Artery
Pancreaticoduodenal arteriesPancreaticoduodenal arteries
Branches from Splenic arteryBranches from Splenic arteryVENOUSVENOUS
--Direct into PORTAL veinDirect into PORTAL vein
--pancreaticoduodenal vein join gastroepiploicpancreaticoduodenal vein join gastroepiploicvein to form common venous trunk TO SMVvein to form common venous trunk TO SMV
--Body and tail drain into splenic veinBody and tail drain into splenic vein
--Inferior arcade to IMVInferior arcade to IMV
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Pancreas with accessory pancreatic ductPancreas with accessory pancreatic duct
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ImagingImaging
CTCT
USUS
MRCPMRCP ERCPERCP
Serum amylase elevated in 73Serum amylase elevated in 73--82%82%
Amylase also elevated with bowel injury andAmylase also elevated with bowel injury andrenal failurerenal failure
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Acute CT findingsAcute CT findings
Direct findingsDirect findingsPancreatic enlargementPancreatic enlargement
LacerationLaceration
Inhomogeneous enhancementInhomogeneous enhancement Secondary findingsSecondary findings
Peripancreatic strandingPeripancreatic stranding
Peripancreatic fluid collectionPeripancreatic fluid collectionFluid between splenic vein and pancreasFluid between splenic vein and pancreas
HaemorrhageHaemorrhage
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Acute CT findingsAcute CT findings
Pancreatic duct disruption often not appreciatedPancreatic duct disruption often not appreciated
Sensitivity 40Sensitivity 40--69%69%
Other injury may obscure pancreatic findingsOther injury may obscure pancreatic findings
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GRADE-I Contusion Superficial laceration not involving duct
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GRADE - I
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GRADEGRADE -- II
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GRADE - II Laceration disrupting the main ductin the body or tail
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GRADE - II
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GRADE - III
Crushing or transection of the head Duodenum intact
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GRADEGRADE -- IIIIII
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GRADEGRADE -- IIIIII
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GRADE - IVCrushing or transection of Pancreatic head and
duodenum injury
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GRADEGRADE -- IVIV
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GRADEGRADE -- IVIV
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GRADEGRADE -- IVIV
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MANAGEMENT OFMANAGEMENT OF
PANCREATIC TRAUMAPANCREATIC TRAUMA
Depends upon location of injuryDepends upon location of injury[ BY CT ][ BY CT ]
Whether or not pancreatic duct is injuredWhether or not pancreatic duct is injured
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DIAGNOSING PANCREATICDIAGNOSING PANCREATIC
DUCT INJURYDUCT INJURY NO IDEAL METHOD EXISTS FORNO IDEAL METHOD EXISTS FOR
IDENTIFYINGDUCCTAL INURIESIDENTIFYINGDUCCTAL INURIES
Operative pancreatography throughOperative pancreatography through
duodenotomy or following resection of tail ofduodenotomy or following resection of tail of
pancreaspancreas
Passing of Coronary artery dilator into duct viaPassing of Coronary artery dilator into duct via
papillapapilla
ERPERP
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LOCATION OF PANCREATICLOCATION OF PANCREATIC
INJURYINJURYTAILTAIL
BODYBODY
NECKNECK
HEADHEAD
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TAIL,BODY AND NECK INJURIESTAIL,BODY AND NECK INJURIES
WITH DUCT TRANSECTEDWITH DUCT TRANSECTED
Distal pancreatectomy with splenectomyDistal pancreatectomy with splenectomy
Distal pancreatectomy with spleen perservationDistal pancreatectomy with spleen perservation
Conserving distal pancreas and spleen with RouxConserving distal pancreas and spleen with Roux--enen--Y LimbY Limb
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Pancreatic head andduct injuryPancreatic head andduct injury
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RouxRoux--enen--YY panreatojejunostomypanreatojejunostomy
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GRADEGRADE IV INJURYIV INJURY
HEAD OF PANCREAS AND DUODENALHEAD OF PANCREAS AND DUODENAL
INJURYINJURY
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GASTROJEJUNOSTOMY WITHGASTROJEJUNOSTOMY WITH
DUODENUM REPAIR AND FEEDINGDUODENUM REPAIR AND FEEDING
JEJUNOSTOMYJEJUNOSTOMY
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WHIPPLES PROCEEDUREWHIPPLES PROCEEDURE
INDICATIONS OF WHIPPLES ININDICATIONS OF WHIPPLES IN
PANCREA TIC TRAUMAPANCREA TIC TRAUMA
Injury to CBD and pancreatic duct in head ofInjury to CBD and pancreatic duct in head of
pancreaspancreas
A
vulsion of papilla of vater from duodenumA
vulsion of papilla of vater from duodenum Destruction of entire 2Destruction of entire 2ndnd part of duodenumpart of duodenum
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WHIPPLES PROCEEDUREWHIPPLES PROCEEDURE
INDICATIONS OF WHIPPLES ININDICATIONS OF WHIPPLES IN
MALIGNANCIESMALIGNANCIES
Malignant tumors affecting duodenumMalignant tumors affecting duodenum
Head of pancreasHead of pancreasDistal part of bile ductDistal part of bile duct
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WHIPPLES PROCEEDUREWHIPPLES PROCEEDURE
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WHIPPLE[ BEFORE ]WHIPPLE[ BEFORE ]
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WHIPPLE [ AFTER ]WHIPPLE [ AFTER ]
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COMLICATIONSCOMLICATIONS
NecrosisNecrosis
HaemorrhageHaemorrhage
AbscessAbscess PseudocystPseudocyst
FistulaFistula
Diabetes mellitusDiabetes mellitus Pancreatic insufficiencyPancreatic insufficiency
PSEUDOCYSTPSEUDOCYST
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PSEUDOCYSTPSEUDOCYST
WALLED OF COLLECTIONWALLED OF COLLECTIONOF SECRETIONSOF SECRETIONS
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CONCLUSIONCONCLUSION
Signs on admission CT may be easily overlookedSigns on admission CT may be easily overlooked
CT tends to under stage pancreatic injuriesCT tends to under stage pancreatic injuries Pancreatic duct disruption not well seen on CTPancreatic duct disruption not well seen on CT
Delayed diagnosis has worse prognosisDelayed diagnosis has worse prognosis
Surgery indicated for majorSurgery indicated for major splspl pancreatic headpancreatic headtraumatrauma
MRCP and ERCP useful to assess ductMRCP and ERCP useful to assess duct
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