Pancreatic Injuries in Deployed/Austere Settings

Anatomy

One of the challenges of pancreatic injuries lies in the complexity of its anatomy and relationship to surrounding structures. The head of the pancreas is closely associated with the C-loop of the duodenum and their shared blood supply.^[4]

Additionally, the proximity of the pancreas to the portal vein, mesenteric vessels, splenic vein, renal vessels, inferior vena cava, and aorta make intraoperative exsanguination a very real possibility with injury to the head of the pancreas.

Importantly, however, the surgical anatomy of the pancreas can be distilled down to a few critical maneuvers. Exposure of the head of the pancreas is performed by taking down the white line of Toldt of the ascending colon and mobilizing the hepatic flexure inferiorly and medially. A Kocher maneuver should be performed along the lateral aspect of the duodenum to mobilize the head of the pancreas as needed. The neck, body, and tail of the pancreas can be exposed by dividing the gastrocolic ligament and entering the lesser sac.

Diagnosis

Pancreatic injuries in deployed settings will frequently be discovered as part of exploratory laparotomy for penetrating abdominal or significant blast injury. Patients with significant injury to the lumbar spine or with direct trauma to the upper abdomen are at increased risk of blunt pancreatic injury. If available, CT scans can be helpful although a bit limited in their sensitivity for pancreatic injuries.^[5]

Findings on CT of note include free fluid in the lesser sac, peri-pancreatic hematoma, or development of a cystic fluid collection involving the pancreas. Trending serum amylase and lipase levels over 24 to 48 hours after injury can also be helpful in cases with diagnostic uncertainty.^[6] In general, one should have a low threshold to explore patients with possible pancreatic injuries. Missed pancreatic injuries can have significant consequences and as such should be explored in every laparotomy for trauma.

Management

Essentially any injury to the pancreas discovered during exploration requires drainage.^[7] While there is clearly a role for nonoperative management of pancreatic injury, the most conservative maneuver in austere settings without advanced adjuncts or imaging is often operative exploration. Additional management decisions should be based on injury to the main pancreatic duct as well as the location of destructive injuries. Lastly, the clinical status of the patient as well as the experience of the operating surgeon should be kept in mind.

Whenever experienced help is available, it should be sought after. If evacuation to a higher level of care is available, leaving the abdomen open after controlling bleeding and contamination should be strongly considered.

Clearly nonviable pancreatic body/tail tissue can be managed with a distal pancreatectomy. If available, this can be performed with a stapler. The splenic artery and vein can be taken in the same staple load after the short gastrics are divided to the spleen. The tail of the pancreas and spleen can then be removed en bloc with additional ligation of the splenic vessels and/or pancreatic duct as necessary. Although splenic-preserving distal pancreatectomy has been described in trauma, this can be time-consuming and should only be performed in optimal circumstances.^[8]

Destructive injuries to the pancreatic head can be particularly challenging and are often associated with injury to the duodenum. During the index operation, the general principles are to stop hemorrhage and lay drains. If evaluation to a higher level of care is expected, these types of injuries are certainly good candidates to leave open in a damage control setting for subsequent evaluation and more definitive management.

In later settings, more definitive operations can be performed to include pancreaticoduodenectomy in the rare circumstances it is truly indicated. Durable distal feeding access should be remembered in addition to an abundance of drains. As a rule of thumb, complex operations of the pancreatic head should be avoided during index traumatic operations.

Although pancreatic injuries are daunting challenges under any circumstances, much less in situations where resources are less than ideal, their management can be made easier by a few straightforward principles. This includes having a high index of suspicion and low threshold to explore patients in the operating room who may be at risk of pancreatic injury.

Surgically, any significant injury to the body or tail of the pancreas can be treated with distal pancreatectomy. In comparison, destructive injuries to the pancreatic should be drained extensively after hemorrhage control with resection deferred to later operations with experienced help whenever possible.

References

1. Hirshberg A, Mattox K. Top Knife: The Art and Craft of Trauma Surgery. (Allen M, ed.). TFM Publishing; 2014.
2. Vertrees A, Elster E, Jindal R, Ricordi C, Shriver C. Surgical Management of Modern Combat-Related Pancreatic Injuries: Traditional Management and Unique Strategies. Mil Med. 2014;179(3):315-319. DOI: 10.7205/milmed-d-13-00375.
3. Bozzay JD, Walker PF, Schechtman DW, Shaikh F, Stewart L, Tribble DR, Bradley MJ, Group IDCRPTIDOS. Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties. J Surg Res. 2021;257:285-293. DOI: 10.1016/j.jss.2020.07.075.
4. Ferrada P, Ferrada R, Feliciano D. Duodenum and Pancreas. In: Feliciano D, Mattox K, Moore E, eds. Trauma – 9th ed. McGraw Hill; 2021.
5. Biffl WL, Moore EE, Croce M, Davis JW, Coimbra R, Karmy-Jones R, McIntyre RC, Moore FA, Sperry J, Malhotra A, et al. Western Trauma Association critical decisions in trauma: management of pancreatic injuries. J Trauma Acute Care Surg. 2013;75(6):941-946. DOI: 10.1097/ta.0b013e3182a96572.
6. Brown TA. Pancreatic and Duodenal Injuries (Sleep When You Can…). In: Martin M, Beekley A, eds. Front Line Surgery: A Practical Approach – 1st ed. Springer; 2011.
7. Army USD of the. Emergency War Surgery. 3rd ed. Skyhorse Publishing; 2004.
8. Subramanian A, Dente CJ, Feliciano DV. The Management of Pancreatic Trauma in the Modern Era. Surg Clin N Am. 2007;87(6):1515-1532. DOI: 10.1016/j.suc.2007.08.007.