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PANCREATIC TRAUMA
Gustavo P. Fraga, MD, PhD, FACS
Associated Professor, Coordinator of the Division of Trauma Surgery, Department of Surgery,
School of Medical Sciences, University of Campinas (Unicamp)
Campinas, São Paulo, BRAZIL
Past President of SBAIT (Brazilian Trauma Society)
Past President of Panamerican Trauma Society
BRAZIL
• The world's fifth largest country
• Population with over 204 million people
• The only Portuguese speaking country in the
Americas
• The Brazilian economy is the world's seventh
largest economy by nominal GDP and one of the
world's fastest growing major economies
CAMPINAS is a city and
municipality located in
the coastal interior of the
state of Sao Paulo, Brazil
CAMPINAS
• Campinas' population is 1,080,999 (2010 census)
• Over 98.3% live in the urban region
• The city's metropolitan area contains 19 cities
and has a total population of 3.0 million people
• It is the third largest city in the state, after Sao
Paulo and Guarulhos
Hospital de Clinicas
University of Campinas (Unicamp)
Campinas, São Paulo
BRAZIL
OBJECTIVES
• Incidence x trauma mechanism
• Diagnosis
• Indications for surgical treatment
• Surgical management of pancreatic injuries
• Complications
PANCREATIC TRAUMA
• Uncomon injuries
• 3 - 12% of abdominal traumas
• 7% of patients submitted to laparotomy on
trauma
INCIDENCE
PANCREATIC TRAUMA
• Gunshot wounds
• Stab wound
MECHANISM
PENETRATING: 2/3
BLUNT: 1/3
• Car crash
• Assault
PANCREATIC TRAUMA
AMBULÂNCIA
PANCREATIC TRAUMA
• Penetrating abdominal trauma
• Blunt trauma with hemodynamic instability
DIAGNOSIS
INTRA OPERATIVELLY
PANCREATIC TRAUMA
• Clinical examination
• Amilasis
• FAST / ultrasound
• CT
• DPL
• ERCP
• Endoscopic ultrasound
BLUNT ABDOMINAL TRAUMA
DIAGNOSIS
PANCREATIC TRAUMA
A manejo vía aérea con control de la columna
cervical
B respiración / ventilación
C circulación con control de hemorragias
D déficit neurológicos
E exposición y prevenir la hipotermia
EVALUACIÓN PRIMARIA
RETROPERITONEAL
HEMATOMA
ACTIVE BLEEDING
Exposición quirúrgica del páncreas através de la
epiplón gastrocólico
Localización del páncreas en la bolsa omental
Localización del páncreas en la bolsa omental
Localización del páncreas en la bolsa omental
AAST grade III - GSW
KOCHER
KOCHER
CATTELL-BRAASCH
CATTELL-BRAASCH
MATTOX
MATTOX
Grado Descripción de la lesión ICD-9 AIS 90
I Hematoma
Laceración
Contusión menor sin lesión ductal
Laceración superficial sin lesión ductal
863. 81/84 2
2
II Hematoma
Laceración
Contusión mayor con lesión ductal o pérdida de tejido
Laceración mayor con lesión ductal o pérdida de tejido
863.81/84 2
3
III Laceración Transección distal o lesión de parénquima y ducto 863.92/94 3
IV Laceración Transección proximal o lesión que compromete la ampolla 863.91 4
V Laceración Disrupción masiva de la cabeza del páncreas 863.91 5
ESCALA DE LESIONES DEL PÁNCREAS
OIS - AAST
Moore et al., J Trauma, 1990
Duodenal and pancreatic grade IV injury
2013
Grau I eGrau II
drenagem externa
INTRAOPERATIVE TREATMENT
PANCREATIC TRAUMA
PANCREATIC TRAUMA: 131 cases (1994 - 2007)
pancreatectomia distal preservandoo baço + drenagem externa
paciente estável,baço sem lesão
drenagem externa
paciente instável
pancreatectomia distal comesplenectomia + drenagem externa
paciente estável,baço lesado
Grau III
PANCREATIC TRAUMA
INTRAOPERATIVE TREATMENT
Pancreatic grade III injury
Distal pancreatectomy
Hemostasis and Wirsung suture
Closed drain
Distal pancreatectomy with splenic preservation
drenagem externa
sem lesão ductal
pancreatectomia parcial
com lesão ductal
pancreatografia
paciente estável,ressecção viável
drenagem externa
paciente instável
drenagem externa com ousem exclusão pilórica
paciente estável,ressecção inviável
Grau IV
PANCREATIC TRAUMA
INTRAOPERATIVE TREATMENT
duodenopancreatectomiacom ou sem reconstrução
desvascularização completa dacabeça do pâncreas
drenagem externa comou sem exclusão pilórica
lesões associadasmoderadas ou graves
drenagem externa + "triplo tubo"gastrostomia
jejunostomia retrógradajejunostomia para nutrição
lesão pancreática menor comlesão duodenal
Grau V
PANCREATIC TRAUMA
INTRAOPERATIVE TREATMENT
Pancreaticoduodenectomy
• 15 patients (10 penetrating / 5 blunt)
• ISS average = 35
• 3 patients: Whipple
• 12 patients: Whipple + DCL
• Mortality: 13% (n = 2)
COMPLICATIONS
• Pancreatic fistulae: 7 - 20%
• Abscess: 10 - 25%
• Pancreatitis: 8 - 18%
• Hemorrage
• Pseudocyst
• Exocrine or endocrine insuficiency
PANCREATIC TRAUMA
Routine Postoperative Fistula
Prophylaxis With Octreotide
MORTALITY
Many factors such as:
• Patient stability
• Acuity of concomitant life-threatening injuries
• Need for damage control procedures
• AAST pancreatic grade of injury
9 - 34%
PANCREATIC TRAUMA
CONCLUSIONS
• Traumatic injury to the pancreas is rare
• High index of suspicion
• Evaluate the pancreatic major duct
• Treatment according to AAST injury grade and
patient stability
• High morbidity
PANCREATIC TRAUMA
