Pancreatic injury accounts for approximately 1–2% of abdominal injuries and is often caused by external force impacting the upper abdomen or by strong compression of the pancreas against the spine. As a result, the neck and body regions of the pancreas are more commonly affected. Pancreatic injury may lead to pancreatic leakage or fistula formation. Due to the strong corrosive nature of pancreatic fluid, there is a high risk of abdominal infection and hemorrhage, with a mortality rate of approximately 20%.
Clinical Manifestations and Diagnosis
After pancreatic rupture or transection, pancreatic fluid may accumulate in the omental bursa, resulting in significant tenderness and muscle tension in the upper abdomen. Irritation of the diaphragm may cause referred pain to the shoulder. Leakage of pancreatic fluid into the abdominal cavity through the foramen of Winslow or a rupture in the lesser omentum often leads to rapid onset of diffuse peritonitis accompanied by severe abdominal pain. Isolated blunt pancreatic injuries with minimal or no leakage of pancreatic fluid may present with subtle clinical manifestations, making diagnosis prone to delay. In some cases, pancreatic fluid remains confined to the omental bursa until the formation of a pancreatic pseudocyst, which may then be detected.
Elevated serum amylase and amylase levels in peritoneal aspirates can provide diagnostic clues but require differentiation from amylase elevation caused by upper gastrointestinal perforations. It is noteworthy that some pancreatic injuries may not exhibit elevated amylase levels. Therefore, the possibility of pancreatic injury should be considered in all cases of upper abdominal trauma. Ultrasound imaging may reveal irregular pancreatic echogenicity and peripancreatic hematoma or effusion. For patients with unclear diagnoses who are clinically stable, CT or MRI can help assess the integrity of the pancreatic contour and the presence of peripancreatic hematoma or fluid collections.
Management
For upper abdominal trauma with a high suspicion or confirmed diagnosis of pancreatic injury, particularly in cases with significant peritoneal irritation signs, surgical exploration of the pancreas is indicated. Severe pancreatic contusion or transection can usually be confirmed during surgery, whereas minor injuries may be missed. During exploratory surgery, the retroperitoneum near the pancreas with hematoma, gas collection, fluid, or bile accumulation should be opened. This may include incising the gastrocolic ligament or mobilizing the duodenum using the Kocher maneuver to expose both the anterior and posterior surfaces of the pancreas to identify possible injuries.
The principles of surgery include achieving complete hemostasis, controlling pancreatic fluid leakage, and ensuring adequate drainage. For contusions with an intact pancreatic capsule, local drainage alone is sufficient. In cases of partial rupture of the pancreatic body with an intact main pancreatic duct, mattress sutures can be used to repair the injury. Severe contusions or transverse lacerations involving the neck, body, or tail of the pancreas may require proximal suture closure combined with distal pancreatectomy. The pancreas has sufficient functional reserve, and partial pancreatectomy generally does not lead to insufficiency of endocrine or exocrine function.
In cases of severe contusions or transections involving the pancreatic head, the main pancreatic duct at the proximal end of the head can be ligated, and the stump of the gland may be closed using sutures. A Roux-en-Y pancreatojejunostomy is performed to reconnect the distal pancreas with the jejunum. For cases where pancreatic head injury is associated with duodenal rupture, duodenal diversion techniques may be employed when necessary. Pancreaticoduodenectomy is reserved for pancreatic head injuries that are severely destructive and cannot be repaired.
Adequate drainage is critical for ensuring the success of pancreatic surgery and for preventing postoperative complications such as ascites, secondary bleeding, infections, and pancreatic fistula formation. Typically, 2–4 large-bore drainage tubes are placed around the pancreas, or dual drainage tubes are used with negative-pressure drainage. The drainage tubes should remain patent and are generally retained for approximately 10 days. Premature removal of the tubes is avoided as some pancreatic fistulas may develop over the course of the first week after injury.
In the event of a pancreatic fistula, maintaining appropriate drainage is essential. Most cases resolve spontaneously within 4–6 weeks, although some may persist for several months. Surgical reintervention is rarely required. Somatostatin can be utilized to prevent or manage post-traumatic pancreatic fistulas. In addition, patients may require fasting combined with total parenteral nutrition.