MANEGMENT OF PANCREATIC TRUMA

Abstract

Pancreatic injury can pose a formidable challenge to the surgeon and failure to manage it correctly may have devastating consequences for the patient, detailed knowledge and correct application of the available operative choices is important. Injuries to the pancreas are uncommon, since the pancreas lies deep in the middle of the upper abdomen behind the stomach and other larger organs. The retroperitoneal location and character of the pancreas present a number of challenges to the trauma surgeon faced with a pancreatic injury Anatomy of the pancreas : The pancreas, named for the Greek words pan (all) and kreas (flesh), is a 12-15 – cm long J-shaped (like a hockey stick), soft, lobulated, retroperitoneal organ. It lies transversely, although a bit obliquely, on the posterior abdominal wall behind the stomach, across the lumbar (L1-2) spine Functions of the pancreas : The pancreas has digestive and hormonal functions:The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum.The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones). Mechanism of injury: Traumatic injuries to the abdomen are defined as either blunt force or penetrating . Blunt force trauma occurs when an object strikes the abdomen or the abdomen strikes against an object. A common example of this occurs during an automobile accident. During blunt trauma, the abdominal organs can be injured at three distinct times. Initial injury can occur during a rapid change in organ momentum and speed. When organs or adjacent structures suddenly decelerate at different speeds (often due to connective tissues), shearing forces can result in organs tearing at their bases or at the juncture between two organs. Solid and hollow organs and the vasculature are all at risk for shearing forces. Next, organs can be crushed as a blunt object presses against them, or as organs are compressed against rigid structures in the body. Finally, external compression from blunt trauma causes a rise of pressure inside an organ, particularly hollow organs. As a result, hollow organs rupture, spilling their contents into the abdominal cavity. Penetrating trauma occurs when an object physically enters through the skin and wall of the abdominal cavity. The most common mechanism for penetrating trauma is gunfire, followed by stabbing. Other causes include impalement and animal bites. As an object enters the abdominal cavity. Diagnosis: A diagnosis of pancreatic injury is made by imaging studies, typically computed tomography (CT) of the abdomen or exploratory laparotomy, as indicated by the clinical scenario. Laboratory studies such as serum amylase and lipase are typically performed as a part of routine trauma assessment. Serum amylase or lipase cannot be used to rule out or establish a diagnosis of pancreatic injury. the imaging diagnosis of blunt pancreatic and duodenal injury relies primarily on computed tomography (CT) of the abdomen and cholangiopancreatography (endoscopic or magnetic resonance). Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate imaging technique to detect and localize pancreatic ductal injury. Exploratory laparotomy in those patients who are taken emergently to the operating room for abdominal trauma, pancreatic injuries are diagnosed at exploration. Classification systems of Pancreatic Injury:There are three main classification systems for pancreatic injuries .All three address the key issues of treatment of parenchymal disruption and major pancreatic duct status in the more severe injuries by focusing on anatomical location. The latest system was proposed by the American Association for the Surgery of Trauma Committee on Organ Injury Scaling. Although injury management does not correlate exactly with grade, injury scales provide a practical means by which to communicate the severity of injury. The severity of injury is estimated based upon findings of computed tomography or during operative exploration. Complication of injuryTrauma to the pancreas: is relatively rare and is one of the most easily overlooked intrabdominal injuries. Delay in diagnosis leads to high morbidity.Major early complications are pancreatitis, pancreatic abscess/necrosis, pancreatic fistula and pseudocyst. Management: Nonoperative management of pancreatic injury is safe for patients with blunt Grade I or Grade II injuries of the pancreas (contusion, superficial laceration) Nonoperative management has not been reported for penetrating mechanisms. Patients found to have ductal