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INTRODUCTION — Injuries of the pancreas and duodenum occur in about 3 to 5 percent of all traumatic abdominal injuries . The diagnosis can be challenging, particularly in the setting of blunt trauma, because symptoms and signs resulting from these injuries may not be obvious due to the retroperitoneal location of these organs. Initial evaluation of patients at risk for duodenal or pancreatic injury is focused on the earliest possible identification of high-grade injuries which often occur in the setting of other severe injuries, and are associated with high mortality rates [1-3]. For those patients who survive the early injury phase, high rates of late complications occur even when the injury is diagnosed and treated in a timely fashion . The majority of injuries to the pancreas and duodenum are of low grade and can be managed nonoperatively or using relatively simple surgical techniques but more complex injuries may require pancreatic and/or duodenal resection and reconstruction.
The mechanisms, associated injuries, diagnosis, and management of duodenal and pancreatic injury are reviewed here. The general approach to blunt and penetrating chest and abdominal trauma is discussed elsewhere. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults" and "Initial evaluation and management of blunt abdominal trauma in adults".)
DUODENAL AND PANCREATIC ANATOMY
Duodenum — The duodenum is primarily a retroperitoneal organ that begins at the pylorus and ends at the ligament of Treitz (figure 1).
The duodenum measures approximately 20 cm and consists of four segments. The first portion is transversely-oriented, beginning at the pylorus and ending at the common bile duct superiorly and the gastroduodenal artery inferiorly. The second portion runs inferiorly to the ampulla of Vater, the third portion runs transversely to the superior mesenteric artery and vein, and the fourth portion extends to the point where the duodenum emerges from the retroperitoneum to join the jejunum at the left border of the second lumbar vertebra.
Significant portions of the duodenum lie directly over the spinal column, and it is bordered anteriorly by the liver, colon, and stomach. The duodenal sweep is bordered by the gallbladder laterally and the head of the pancreas medially.
Pancreas — The pancreas is a compound exocrine and endocrine gland located in the retroperitoneum at the level of the second lumbar vertebrae (figure 1). Exocrine pancreatic secretion is composed of enzymes, water, electrolytes and bicarbonate, which are delivered to the duodenum via the pancreatic duct of Wirsung and aid with digestion. Insulin, glucagon and somatostatin are secreted by the islets of Langerhans, A cells and D cells, respectively. Removal of 90 percent of the mass of the pancreas can be performed without resulting in diabetes.
The pancreas is divided into five parts including the head, uncinate process, neck, body, and tail. The head of the pancreas lies to the right of the superior mesenteric artery. The uncinate process is a variable posterolateral extension of the head that passes behind the retropancreatic vessels and lies anterior to the inferior vena cava and aorta. The neck is defined as the portion of the gland overlying the superior mesenteric vessels. The body and tail lie to the left of the mesenteric vessels; there is no meaningful anatomic division between the body and tail.
Ductal anatomy — The pancreatic duct joins the common bile duct to drain into the duodenum via the major papilla (ampulla of Vater) (figure 2 and picture 1). The anatomy of these ducts can vary. In 85 percent of individuals, both the pancreatic duct and the common bile duct enter the duodenum through a common channel. In 5 percent of patients, both ducts enter the duodenum through the same ampulla but via separate channels. In the remaining 10 percent of patients, each duct enters the duodenum through a separate ampulla . The entry of the common bile duct into the pancreatic tissue posteriorly can also vary (figure 3).
Neurovascular supply — The arterial supply to the duodenum and pancreas (figure 4) is derived from the celiac artery providing the superior pancreaticoduodenal arteries (anterior and posterior branches), and the superior mesenteric artery providing the inferior pancreaticoduodenal arteries (anterior and posterior branches). The right gastric artery also gives branches to the duodenum and the splenic artery and supplies primarily the body and tail of the pancreas. The venous drainage (figure 5) follows the arteries to provide tributaries to the splenic vein and superior mesenteric vein which drain into the portal vein.
The duodenum and pancreas are innervated by sympathetic fibers from the splanchnic nerves (figure 6) and parasympathetic fibers from the vagus, both of which give rise to intrapancreatic periacinar nerve plexuses. The parasympathetic fibers stimulate exocrine and endocrine function, whereas the sympathetic fibers have an inhibitory effect.
TRAUMA EVALUATION — The initial resuscitation, diagnostic evaluation, and management of the patient with blunt or penetrating injury are based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma. The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal or thoracic trauma is discussed elsewhere. (See "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults".)
In the setting of acute trauma, many patients cannot relate their symptoms or medical history due to altered mental status (eg, neurologic injury, intoxication) or because they are intubated and sedated. Every attempt should be made to identify preexisting medical conditions by contacting the patient's primary care physician or family members. The presence of significant medical comorbidities and medical conditions requiring antiplatelet or anticoagulation should be determined. (See "Overview of inpatient management in the adult trauma patient", section on 'Patient assessment'.)
Although Focused Assessment with Sonography in Trauma (FAST) is a useful, validated test for detecting hemoperitoneum in the setting of blunt trauma, it is not reliable as a screening test for duodenal or pancreatic injury. Approximately one-third of patients with retroperitoneal injuries including injuries of the duodenum and pancreas will have normal FAST examinations [6,7]. Although diagnostic peritoneal lavage (DPL) does not sample the retroperitoneal space, most patients with duodenal or pancreatic injuries have associated injuries that may be detected by DPL; however, the test is not sufficiently specific for detecting duodenal or pancreatic injury . (See "Initial evaluation and management of blunt abdominal trauma in adults", section on 'Ultrasound' and "Initial evaluation and management of blunt abdominal trauma in adults", section on 'Diagnostic peritoneal lavage (DPL)'.)
Risk for injury — Duodenal and pancreatic injuries are uncommon, occurring in 3 to 5 percent of patients sustaining abdominal injuries . Injury to these retroperitoneal structures may be suspected based upon the injury mechanism and the identification of injury to organs in close proximity to the duodenum or pancreas.
Injury mechanism — Approximately 75 to 85 percent of blunt injuries to the duodenum and pancreas are caused by motor vehicle collisions [1,9]. The mechanism is typically due to crushing of these fixed retroperitoneal organs between the vertebral column and steering wheel or seatbelt. The remainder of blunt duodenal and pancreatic injuries results from falls and assaults [1,2,10]. Blunt duodenal and pancreatic injury can also be due to bicycle accidents in which the duodenum and pancreas are crushed between the spinal column and bicycle (or motorcycle) handlebar.
Any implement or missile that enters the abdomen can injure the pancreas or duodenum. Gunshot or shotgun wounds are more likely to result in injury compared with stab wounds because of their high energy. However, depending upon the girth of the victim and force applied, even a short implement that penetrates the upper abdomen can cause duodenal or pancreatic injury.
Associated injuries — The scope of injuries associated with pancreatic and duodenal trauma is illustrated in the following retrospective reviews:
●In a review of 1153 cases of duodenal injury, there were 3047 associated injuries . The liver was the most commonly injured organ, accounting for 17 percent of associated injuries. Other organs injured along with the duodenum included the pancreas (12 percent), small bowel (12 percent), colon (12 percent), and stomach (9 percent).
●In another review of 3465 injuries involving the pancreas, there were 7526 associated injuries . The liver was also the most commonly injured, accounting for 19 percent of associated injuries. Other organs injured along with the pancreas included the stomach (16 percent), spleen (11 percent), colon (8 percent), and duodenum (8 percent).
Because of the proximity of the major vascular structures including the aorta, vena cava, and portal vein, injury to the duodenum and pancreas can be associated with exsanguinating hemorrhage. In the first review discussed above, major abdominal veins were injured in 10 percent of patients, mostly involving the inferior vena cava, and major arteries were injured in 7 percent of patients, mostly involving the aorta . Penetrating injury is more likely to result in vascular injury, with one review documenting that 37 percent of patients with penetrating pancreatic injury had major vascular injuries . Major venous injuries were present in 20 percent of patients with blunt duodenal injury, but there were no associated arterial injuries .
CLINICAL EVALUATION — History and physical examination are nonspecific and are not reliable for detecting duodenal or pancreatic injury. A history of any blunt injury mechanism causing a blow or crushing injury to the midabdomen raises the suspicion for duodenal or pancreatic injury. (See 'Injury mechanism' above.)
Abdominal tenderness and peritoneal signs on initial evaluation may indicate the presence of intraabdominal injury but are not specific for duodenal or pancreatic injury. A physical exam finding of abdominal wall ecchymosis may be a sign that a crush injury has occurred. In a study of 117 blunt abdominal injuries due to motor vehicle accident, significantly more patients who presented with abdominal wall ecchymosis or the “seatbelt sign” had an intestinal injury (21 versus 2 percent), or intraabdominal injuries requiring surgery (36 versus 4 percent) compared with those who did not have ecchymosis .
The thoracic and lumbar spine should be carefully palpated for spinal tenderness which may indicate the presence of a spine fracture (image 1). Approximately one-third of patients with transverse vertebral body fractures (ie, Chance fracture) of the low thoracic or lumbar spine have intraabdominal injuries .
When patients are being observed following trauma, the following clinical symptoms and signs may suggest an undiagnosed duodenal or pancreatic injury [15,16]:
●Increasing abdominal pain
●Increasing abdominal tenderness
●Persistent emesis or inability to tolerate oral diet
●Proximal small bowel obstruction
DIAGNOSIS — A diagnosis of duodenal or 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. An elevated amylase or lipase can be present in patients with blunt abdominal trauma who do not have duodenal or pancreatic injury [17,18]. Alterations in serum amylase can be due to a variety of conditions not associated with trauma, many of which do not involve the pancreas (table 1), and many drugs affect serum amylase values (table 2). (See "Approach to the patient with elevated serum amylase or lipase".)
Imaging — The imaging diagnosis of blunt pancreatic and duodenal injury relies primarily on computed tomography (CT) of the abdomen and cholangiopancreatography (endoscopic or magnetic resonance).
Computed tomography — Abdominal CT findings of duodenal or pancreatic injury include the following:
●Duodenal – Duodenal wall thickening, peri-duodenal fluid, fluid in the right anterior pararenal space, diminished enhancement of the injured duodenal wall segment, and the “sentinel clot” sign, which is a highly attenuating, heterogeneous fluid (clot) accumulation near the site of injury . Findings of extraluminal air or extraluminal contrast indicate duodenal perforation .
●Pancreatic – Pancreatic laceration, pancreatic hematoma, active extravasation of contrast from the pancreas indicative of pancreatic bleeding, heterogenous pancreatic enlargement or edema, and low pancreatic attenuation [10,21,22].
In spite of advances in CT technology, missed injury (blunt) to the duodenum and pancreas continues to be a problem [22,23]. In retrospective reviews, the sensitivity of CT for detecting blunt small bowel injury is reported to be as low as 59 or as high as 92 percent [24-27].
The integrity of the pancreatic duct determines the course of treatment for injury to the pancreas, and a test with high specificity is desirable. In a multicenter study of 206 patients, the sensitivities of 16-channel and 64-channel multidetector abdominal CT were 54.0 and 52.4 percent, respectively, with specificities of 94.8 for 16-channel and 90.3 percent for 64-channel CT scanners . Highly specific findings include active hemorrhage and pancreatic laceration involving >50 percent of the parenchymal width . In spite of higher resolution scanning, between 5 to 10 percent of pancreatic ductal injuries are missed with abdominal CT. (See 'Nonoperative management' below.)
If the integrity of the pancreatic duct cannot be established with computed tomography, cholangiopancreatography can be performed. (See 'Endoscopic retrograde cholangiopancreatography' below and 'Magnetic resonance cholangiopancreatography' below.)
It is difficult to evaluate the impact of a missed diagnosis of duodenal or pancreatic injury on morbidity and mortality because injuries not initially apparent on CT are often diagnosed subsequently at exploratory laparotomy performed for other indications. In addition, missed blunt duodenal and pancreatic injuries tend to occur in patients who have other severe injuries, from which the patient often succumbs.
Endoscopic retrograde cholangiopancreatography — Endoscopic retrograde cholangiopancreatography (ERCP) is the most accurate imaging technique to detect and localize pancreatic ductal injury .
In patients with traumatic injuries, ERCP is indicated for hemodynamically stable patients with computed tomography (CT) of the abdomen that is inconclusive for pancreatic ductal injury, suspected pancreatic ductal injury based upon clinical findings during a period of observation or postoperatively, and findings in the operating room that are suspicious for pancreatic ductal injury when an intraoperative contrast study cannot be performed . (See 'Evaluating ductal anatomy' below.)
Some ductal injuries identified with ERCP may be conducive to management with percutaneous or endoscopic techniques (eg, biliary stent, pancreatic stent). (See "Endoscopic retrograde cholangiopancreatography: Indications, patient preparation, and complications".)
Magnetic resonance cholangiopancreatography — Like endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography (MRCP) is also sensitive for detecting pancreatic ductal injury and it also demonstrates parenchymal and peripancreatic abnormalities, such as pancreatic laceration, hematoma, contusion, and peripancreatic fluid [22,30,31]. Standard magnetic resonance cholangiopancreatography can also be augmented as a dynamic secretin-stimulated MRCP . (See "Magnetic resonance cholangiopancreatography", section on 'Secretin-enhanced MRCP'.)
An advantage of MRCP is that it is noninvasive. Disadvantages of MRCP for the diagnosis of pancreatic injury include that it is time-consuming, monitoring the injured patient while the test is being performed can be difficult, there is no opportunity for treatment, and it is not widely available. (See "Magnetic resonance cholangiopancreatography", section on 'Pancreatic duct disruption'.)
Diagnosis at laparotomy — For trauma patients with indications for emergent laparotomy, injuries to the duodenum and pancreas should be actively sought during abdominal exploration. Techniques for exposing the duodenum and pancreas and their intraoperative evaluation are discussed below. (See 'Abdominal exploration' below.)
If diagnostic imaging has not revealed a duodenal or pancreatic injury, the development of complications may require abdominal exploration. (See 'Complications of duodenal injuries' below and 'Complications of pancreatic injuries' below.)
INJURY GRADING — The most widely used injury classification system is from the American Association for the Surgery of Trauma (AAST) . 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.
Duodenal injury scale
●Grade I: Hematoma involving a single portion of duodenum or partial thickness laceration without perforation
●Grade II: Hematoma involving more than one portion or disruption <50 percent circumference or major laceration without duct injury or tissue loss
●Grade III: Laceration with disruption of 50 to 75 percent circumference of 2nd portion or disruption of 50 to 100 percent circumference of 1st, 3rd, 4th portion
●Grade IV: Laceration with disruption >75 percent circumference of 2nd portion or involving ampulla or distal common bile duct
●Grade V: Massive laceration with disruption of duodenopancreatic complex or devascularization of duodenum
Pancreas injury scale
●Grade I: Minor contusion without duct injury or superficial laceration without duct injury
●Grade II: Major contusion without duct injury or tissue loss, or major laceration without duct injury or tissue loss
●Grade III: Distal transection or parenchymal/duct injury
●Grade IV: Proximal transection or parenchymal injury involving ampulla
●Grade V: Massive disruption of the pancreatic head
NONOPERATIVE MANAGEMENT — Nonoperative management of duodenal and pancreatic injury is safe for patients with blunt Grade I or Grade II injuries of the duodenum (duodenal hematoma) or pancreas (contusion, superficial laceration) [34-37]. Nonoperative management has not been reported for penetrating mechanisms. Patients found to have ductal injury using computed tomography or cholangiopancreatography are not candidates for nonoperative management. (See 'Imaging' above.)
Nonoperative management consists of gastrointestinal decompression and nutritional support, as indicated. For patients with symptoms of proximal bowel obstruction due to duodenal hematoma, a nasogastric tube is placed for decompression and parenteral nutrition initiated. After five to seven days, imaging should be repeated to evaluate patency of the duodenum. If the obstruction has resolved, an oral diet can be initiated. However, if the obstruction persists after 10 to 14 days, exploratory laparotomy is indicated . (See 'Repair of duodenal injury' below.)
Careful follow-up is essential to monitor for complications that indicate the need for surgical exploration. A retrospective multicenter study evaluated the outcomes of 230 patients with blunt pancreatic and/or duodenal injury . Of the 97 patients managed nonoperatively, 10 patients (6 pancreatic, 3 duodenal) failed nonoperative management and required surgery.
Nutritional support — Early enteral nutrition is preferred over intravenous nutrition for most injured patients [34,39-45]. However, placing and maintaining enteral access in patients with blunt duodenal or pancreatic injury who are managed nonoperatively can be challenging. Postpyloric placement of a nasoenteric feeding tube may not be possible and surgical jejunostomy may become necessary. (See "Nasogastric and nasoenteric tubes" and "Overview of perioperative nutritional support", section on 'Indications'.)
Patients undergoing exploratory laparotomy and operative management of duodenal or pancreatic injuries can have a feeding jejunostomy placed prior to abdominal closure . There are insufficient data to recommend routine jejunostomy in all cases of operative duodenal or pancreatic injury given that about four percent of trauma patients will have complications related to surgical jejunostomy (eg, soft tissue infection, leak, enteric fistula, bowel obstruction) [46,47]. However, in patients with high grade injury (Grade III, Grade IV), the benefits of early enteral access and nutritional support likely outweigh the risk of complications related to the tube, and thus, prior to abdominal closure, we provide a decompressing gastrostomy, retrograde jejunostomy for duodenal decompression, and antegrade jejunostomy for enteral nutrition (known as “triple tube” or “triple ostomy.”) .
Abdominal exploration — Evaluation of the pancreas and duodenum is mandatory for injured patients who undergo exploratory laparotomy for other indications. A significant number of patients with other abdominal injuries will be diagnosed with duodenal or pancreatic injury at the time of exploratory laparotomy .
Following control of abdominal hemorrhage or gastrointestinal contamination, the visible areas of the retroperitoneum should be inspected for bile staining, entrapped air bubbles, and peri-duodenal or peripancreatic hematomas.
If there is a high suspicion of duodenal or pancreatic injury due to a missile or highly-associated injuries, each of the steps described below should be performed to mobilize and examine the retroperitoneum.
●Perform a Kocher maneuver (figure 7) by dissecting the lateral peritoneal attachments of the duodenum to expose the first, second, and third portion of the duodenum, and the head and neck of the pancreas.
●Divide the gastrocolic ligament to allow entry into the lesser sac and inspection of the posterior aspect of the first portion of the duodenum, the medial aspect of the second portion of the duodenum and the anterior surface of the pancreas.
●Divide the retroperitoneum inferior to the pancreas to inspect the posterior pancreas after mobilizing and lifting the inferior edge of the pancreas.
●Expose the third portion of the duodenum with a right medial visceral rotation.
●Mobilize the ligament of Treitz to expose the fourth portion of the duodenum and pancreas.
The duodenum should be examined thoroughly to evaluate for a full-thickness injury. When a duodenal hematoma is seen or palpated during emergent laparotomy, it should be left intact since a majority of these patients will heal with conservative management. Although it may be tempting to evacuate the hematoma, doing so can potentially convert a partial-thickness injury to a full-thickness injury. However, in patients who have failed conservative management of duodenal hematoma, the hematoma should be decompressed . (See 'Nonoperative management' above and 'Repair of duodenal injury' below.)
Most duodenal perforations are seen upon inspection. Subtle full-thickness injuries can be identified by instilling methylene blue through the nasogastric tube and looking for duodenal subserosal staining . Full-thickness duodenal injury in the region of the ampulla indicates a need to fully evaluate the ampulla, bile ducts, and pancreatic ducts using cholangiopancreatography. (See 'Evaluating ductal anatomy' below.)
Because the pancreas is highly vascular, transections and major lacerations of the pancreas are easily identified as a peripancreatic hematoma during visual inspection of the retroperitoneum. All peripancreatic hematomas should be explored. Once the hematoma is decompressed, the pancreas is examined for several minutes under loupe magnification to identify leakage of clear pancreatic fluid consistent with pancreatic duct injury .
If pancreatic ductal injury is suspected but is not immediately apparent, a dose of secretin (1 unit/kg intravenously) can be given to stimulate pancreatic secretion . Intraoperative ultrasound can also be used to detect pancreatic parenchymal or pancreatic duct injury . If a suspected pancreatic duct injury cannot be confirmed, cholangiopancreatography should be performed . (See 'Evaluating ductal anatomy' below.)
Evaluating ductal anatomy — During exploratory laparotomy for trauma, findings consistent with pancreatic ductal injury include direct observation of the injured duct, complete transection of the gland, laceration of >50 percent of the gland, central perforation, and severe maceration . In indeterminate cases, intraoperative cholangiopancreatography can determine the presence of ductal injury but can be technically difficult to accomplish.
Intraoperative cholangiopancreatography during trauma exploration is performed through an existing duodenal wound, or via anterior duodenotomy. A catheter is directed into the common bile duct or pancreatic duct injecting 2 to 5 mL of soluble contrast into the duct while imaging using fluoroscopy or shooting a plain film.
Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) can also provide the necessary imaging but would require the abdomen to be closed and the patient to be re-positioned in lateral decubitus position on a radiolucent table.
An alternative approach is to employ damage control techniques and obtain a postoperative study (ERCP or magnetic resonance cholangiopancreatogram [MRCP]) to evaluate the ductal anatomy. However, positive findings may indicate the need to return to the operating room to manage the identified injuries. (See 'Damage control' below.)
Damage control — Damage control surgery involves immediate control of bleeding sites (including those associated with duodenal or pancreatic injury) and gastrointestinal contamination with delayed management of injuries that are not immediately life-threatening including duodenal or pancreatic injuries. Intraperitoneal packing and temporary abdominal closure are followed by fluid resuscitation, patient warming and correction of coagulation deficits in the intensive care unit . (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury" and "Management of the open abdomen in adults".)
Damage control to manage duodenal injuries may involve rapid closure of the injured segment or resection of a full-thickness duodenal injury without reestablishing continuity . For suspected pancreatic duct injuries, wide drainage is used, but if the injury is distal, a quick distal pancreatectomy can be performed. (See 'Managing pancreatic injury' below.)
Bleeding from the pancreas distal to the head of the pancreas can usually be controlled with packing; however, high grade injuries to the head of the pancreas, which may also involve the duodenum, are often associated with bleeding that cannot be controlled by packing, and thus, resection without reconstruction may be needed. To resect the proximal duodenum and pancreas, the pylorus, pancreatic neck, and proximal jejunum are stapled across and transected, the common bile duct is ligated, and the biliary tract is drained using tube cholecystostomy . Closed suction drains are placed to control duodenal and pancreatic secretions. Following resuscitation and stabilization, definitive resection and reconstruction (Whipple) can be performed. (See 'Combined pancreaticoduodenal injuries' below.)
Repair of duodenal injury — The majority of duodenal lacerations can be managed by simple procedures such as debridement and primary repair, or resection and re-anastomosis . More complex procedures are rare, but are associated with a high risk of postoperative complications including suture line failure and anastomotic leak or small bowel fistula formation. Mortality is also increased, but is often related to associated injuries and not strictly a consequence of complications related to duodenal repair. (See 'Morbidity and mortality' below.)
●Low grade – Partial thickness injuries (Grade I) are repaired by suturing the serosa in a Lembert fashion. Full thickness duodenal lacerations (Grade II) are debrided and the duodenum is repaired with a tension-free primary closure in one or two layers. Longitudinal injuries should be closed transversely, if possible, to minimize the potential for luminal narrowing. If the injury is judged to be too extensive for primary repair (eg, >3 cm) after debridement, the injured segment should be resected and the duodenal ends brought together with a primary end-to-end duodeno-duodenostomy. Injuries to the 2nd portion of the duodenum may not be amenable to this approach if the common bile duct or ampulla is injured, or if resection would require removal of these structures. The treatment of ampullary injuries is discussed below. (See 'Combined pancreaticoduodenal injuries' below.)
●Intermediate grade – As with low-grade injuries, many intermediate (Grade III) injuries can also be treated with debridement and primary closure or resection and primary anastomosis.
●High grade – Injuries involving the ampulla (Grade IV, V) increase the complexity of duodenal repair. For limited injuries to the ampulla, management options include stenting or sphincteroplasty . Avulsion of the ampulla can occur and has been successfully managed with common bile duct reimplantation using choledochoduodenostomy [59,60]. Extensive periampullary injuries, such as intraduodenal bile duct injury, intrapancreatic bile duct injury, or Grade V injury often require staged pancreaticoduodenectomy . (See 'Combined pancreaticoduodenal injuries' below.)
Adjunctive techniques — Several adjunctive procedures have been used in conjunction with duodenal repair with a primary aim of decreasing the likelihood of leak following repair. There is no consensus on when these procedures are indicated and none of these techniques have demonstrated a clear benefit. Under most circumstances, these adjunctive techniques are not needed. Pyloric exclusion, duodenal decompression and duodenal diverticularization are described briefly below. Given a lack of data, we prefer pyloric exclusion because it is more easily performed in the face of severe traumatic injuries.
Pyloric exclusion — Pyloric exclusion refers to a procedure in which the pylorus is closed for the purpose of excluding gastric secretions from the duodenal repair. Pyloric exclusion is used selectively as an adjunctive procedure to manage intermediate or high grade duodenal or combined injuries. (See 'Repair of duodenal injury' above and 'Combined pancreaticoduodenal injuries' below.)
Following duodenal repair, the pylorus is sutured closed through a longitudinal antral gastrotomy using partial-thickness absorbable or nonabsorbable sutures placed proximally into the pylorus or alternatively using a noncutting linear stapler applied transversely just distal to the pylorus. Once the pylorus has been closed, a loop gastrojejunostomy is performed.
The pylorus will reopen spontaneously in the majority of patients within three to six weeks, even when nonabsorbable sutures or staples are used. In a small retrospective review of 29 patients with penetrating duodenal injuries, no significant differences in clinical outcomes were seen in patients who underwent pyloric exclusion compared with those who underwent primary repair alone . Although pyloric exclusion is a relatively straightforward procedure to perform, it is associated with a high incidence of marginal ulceration along the gastrojejunostomy.
Duodenal decompression — Following repair, the duodenum can be decompressed in an antegrade (duodenostomy) or a retrograde (jejunostomy) fashion. The rationale for duodenal decompression is to decrease the pressure and volume of secretions in the duodenum, thereby protecting the duodenal repair. In studies that have evaluated tube enterostomy, a serosal patch or mucosal graft taken from the jejunum or stomach has often been used to reinforce the duodenal repair.
There are no randomized trials evaluating the use of duodenal decompression in patients following duodenal injury and the outcomes of retrospective reviews are mixed. Given the lack of consistent results as illustrated in the following studies, and the risk of other complications such as duodenal fistula, we prefer not to use duodenal decompression following duodenal repair [34,39,63-65].
●One retrospective review of 276 patients with duodenal injuries repaired by primary closure compared 237 patients treated with tube decompression (mostly retrograde tube jejunostomy) and 57 who were not decompressed . Significantly more duodenal fistulas developed in patients who were not decompressed compared with those who were (11 of 57 versus 0 of 237).
●However, in another review of 247 patients, the incidence of duodenal fistula was the same whether or not duodenal decompression was performed . An increased incidence of complications was found in another study in patients with duodenal injury requiring repair and treated with duodenal decompression .
Duodenal diverticulization — Duodenal diverticulization refers to suture closure of the duodenal injury, antrectomy with end-to-side gastrojejunostomy, and tube duodenostomy . It is a complex, time-consuming procedure that is generally unnecessary.
Managing pancreatic injury — Most pancreatic injuries are low grade (Grade I or Grade II) and most can be managed nonoperatively (See 'Nonoperative management' above.)
When injury to the pancreas is identified during abdominal exploration, the integrity of the main pancreatic duct should be evaluated, and the location of the injury (proximal versus distal) (algorithm 1) ascertained. (See 'Evaluating ductal anatomy' above.)
Generally accepted principles of operative management of pancreatic injuries include control of bleeding, wide drainage to control potential pancreatic fistula, avoiding pancreaticoenteric anastomoses, and limiting the extent of procedures in the setting of damage control surgery. Perhaps the only consensus among trauma surgeons is that wide closed-suction drainage should be performed . When drains are placed, we prefer to use closed-suction drains rather than sump drainage, which has been associated with a greater incidence of septic pancreatic complications . Drains should be placed transversely, adjacent to the gland. When treating pancreatic injuries, a minimum of two drains should be placed, one superior to the pancreas and one inferior to the pancreas.
No pancreatic duct injury — Based upon injury grade, the operative management of pancreatic injuries that are not associated with ductal injury is as follows:
●Grade I injuries are minor contusions associated with small hematomas, minor capsular injury, and traumatic pancreatitis. When minor contusions are identified in the operating room, no specific intervention is needed (not even drainage) .
●Grade II injuries are pancreatic lacerations that do not involve the main pancreatic duct. Bleeding from the parenchyma is often apparent. Grade II injuries are treated with limited debridement and closed-suction drainage . Several procedures including suture repair of the capsule, omental plug, bipolar cautery, and tissue sealant have been advocated to decrease pancreatic fistula formation from minor pancreatic ducts injury, but there is no evidence to support these methods.
●Higher grade injuries (grades III, IV, V) include pancreatic ductal injuries and these injuries are often associated with duodenal injury. Multiple other traumatic injuries are often associated, necessitating a damage-control approach. (See 'Damage control' above and 'Combined pancreaticoduodenal injuries' below.)
Pancreatic ductal injuries — The management of pancreatic ductal injuries depends upon whether the main pancreatic duct is injured to the right or left of the superior mesenteric vein.
Pancreatic transection or parenchymal injury to the left of the superior mesenteric vein is managed with distal pancreatectomy (figure 8). Distal pancreatic resection can be accomplished without sacrificing the spleen (figure 9), or significantly prolonging operative time and should be considered in hemodynamically stable patients with isolated pancreatic injury [69,70]. To salvage the spleen, the splenic artery branches and venous tributaries draining the posterior surface of the pancreas are isolated and ligated, working from distal to proximal, followed by division of the pancreas (figure 9). The technical aspects of resecting the body and tail of the pancreas are discussed elsewhere. (See "Surgical resection of lesions of the body and tail of the pancreas", section on 'Distal pancreatectomy'.)
Management of pancreatic duct injury to the right of the superior mesenteric vessels depends upon the presence and extent of pancreatic tissue devitalization and concomitant duodenal injury. Options include debridement and wide suction drainage, extended distal pancreatectomy with division of the pancreas to the right of the superior mesenteric vessels, and pancreaticoduodenectomy. (See 'Combined pancreaticoduodenal injuries' below and "Surgical resection of lesions of the head of the pancreas".)
Due to the high incidence of endocrine insufficiency and diabetes with removal of >90 percent of the pancreas, some authors have advocated Roux-en-Y distal pancreaticojejunostomy (with oversewing of the proximal segment) for proximal duct transections (ie, central pancreatectomy) (figure 10). Central pancreatectomy has an advantage over distal or subtotal pancreatectomy in preserving the tail of the pancreas and its endocrine and exocrine function, as well as the spleen. However, the risk of anastomotic leak and morbidity are significant and some argue that a more conservative approach should be used. In a review of 134 patients with blunt pancreatic duct injury, 34 patients with proximal injuries (not Grade V) were treated with closed suction drainage alone . Complication rates were no different compared with more aggressive approaches. Favorable results have also been reported for proximal duct injury due to gunshot wounds using debridement, suture repair, and closed suction drainage . These considerations and the complexity of the procedure make central pancreatectomy unsuitable for many patients, particularly multiply-injured patients. The technical aspects of central pancreatectomy are discussed elsewhere. (See "Surgical resection of lesions of the body and tail of the pancreas", section on 'Central pancreatectomy'.)
Main pancreatic duct injuries with extensive injury to the pancreatic head can also be managed using anterior Roux-en-Y pancreaticojejunostomy for internal drainage provided there is sufficient parenchyma that is preserved . However, this procedure has been associated with a high incidence of pancreatic leak and abscess formation.
Combined pancreaticoduodenal injuries — Combined pancreatoduodenal injuries are associated with a high risk for morbidity and mortality. In some patients with combined pancreatoduodenal injuries, the duodenal injury and pancreatic injury can be approached separately using relatively simple procedures. (See 'Repair of duodenal injury' above and 'Managing pancreatic injury' above.)
When combined pancreatoduodenal injuries are more extensive, the risk of postoperative pancreatic and/or duodenal fistula is high. Adjunctive procedures should be considered to decrease the amount of secretions in the duodenum such as pyloric exclusion or tube decompression. Of these, pyloric exclusion is the most expedient and least complex option. (See 'Adjunctive techniques' above.)
For patients with severe, combined pancreatoduodenal injury, such as when the ampulla of Vater or intrapancreatic common bile duct has been destroyed, or the head of the pancreas has been devitalized, reconstruction is impossible and resection is needed. Fortunately, this rarely occurs. A damage control approach is often needed due to other associated injuries, which necessitates a staged procedure [49,56,74]. The head of the pancreas and proximal duodenum can usually be resected quickly (pancreaticoduodenectomy). At the initial exploration, the pylorus, proximal jejunum, and pancreatic stump are stapled and transected. The common bile duct is ligated or a drain placed within it. The patient is stabilized in the surgical intensive care unit and after 24 to 48 hours, brought back to the operating room for reconstruction (figure 11 and figure 12). (See "Surgical resection of lesions of the head of the pancreas", section on 'Pancreaticoduodenectomy' and "Surgical resection of lesions of the head of the pancreas", section on 'Gastrointestinal reconstruction'.)
An alternative pancreatic-enteric anastomosis in patients who will not tolerate an extended procedure is pancreatic duct ligation and drainage . The resulting pancreatic fistula is managed accordingly. (See 'Complications of pancreatic injuries' below.)
MORBIDITY AND MORTALITY — For both duodenal and pancreatic trauma, half of deaths are early, caused primarily by bleeding and hemorrhagic shock and half of deaths are late, due to complications including sepsis, fistula formation, and multiorgan failure [1,9]. Morbidity and mortality increases with increasing grade of injury for both duodenal and pancreatic injuries. High rates of late infectious complications occur even when the injury is identified early.
In a review of 15 case series describing more than 1400 patients, the mortality rate attributed to duodenal injury was 14 percent for penetrating injuries and 18 percent for blunt injuries . In a review of 76 case series describing nearly 5000 patients, the mortality rate attributed to pancreatic injuries was 20 percent for penetrating injury and 19 percent for blunt injury .
Complications of duodenal injuries — Duodenal injuries are associated with very high complications rates. In a systematic review of 15 case series describing more than 1400 patients with duodenal injuries, complications occurred in 64 percent of the patients . Complications related to duodenal injury include intraabdominal abscess, posttraumatic pancreatitis, and duodenal fistula, which are discussed below.
Risk factors for complications following duodenal repair include blunt mechanism or high-energy missile injury, injuries involving more than 75 percent of duodenal circumference, injury of the 1st or 2nd portion of the duodenum, delay in repair greater than 24 hours, and common bile duct injury .
●Intraabdominal abscess – The most common complication of duodenal injuries is intraabdominal abscess, which occurs in 11 to 18 percent of patients . Fluid collections are managed with antibiotics and percutaneous drainage. Reoperation is generally not needed.
●Post-traumatic pancreatitis – Post-traumatic pancreatitis complicates duodenal injury in 3 to 15 percent of patients . Management of post-traumatic pancreatitis is similar to the management of other forms of pancreatitis with bowel rest and nutritional support . (See "Management of acute pancreatitis".)
●Duodenal fistula – The most life-threatening complication of duodenal injury is duodenal fistula, which occurs in about 7 percent of patients . Management consists of drainage to control the fistula output, drainage of any associated intraabdominal abscesses, broad spectrum antibiotics, fluid therapy, and nutritional support. In patients who develop a high-output duodenal fistula, re-exploration should be performed, and pyloric exclusion should be considered if not previously performed . Managing patients who have undergone diversion already remains challenging. (See "Overview of enteric fistulas".)
Complications of pancreatic injuries — Complication rates for pancreatic injuries range from 24 to 50 percent [2,4,11,52,76]. Complications include pancreatic fistula, pancreatic pseudocyst and intraabdominal abscess, which typically do not require reoperation.
●Pancreatic fistula – Pancreatic fistula is the most common complication of a pancreatic injury. The incidence ranges from 5 to 37 percent of patients [4,11,29,52,69]. Pancreatic fistulas can be demonstrated with computed tomography or cholangiopancreatography (ERCP or MRCP) (image 2). Nonoperative management includes initial bowel rest, and total parenteral nutrition. Enteral nutrition can be initiated in patients with low-output fistulas (<20 mL daily) as long as the fistula output does not increase. Octreotide administration does not increase the rate of healing, but it does decrease the amount of fistula output, which may be useful in patients with high output fistulas with hypovolemia and electrolyte abnormalities . Patients with persistent fistulas may require reexploration . (See "Pancreatic fistulas: Management".)
●Pancreatic pseudocyst – The incidence of pancreatic pseudocyst formation is about 30 percent following blunt pancreatic injury . Early management consists of percutaneous drainage of fluid collections and treatment of infectious complications. Late management is similar to that of nontraumatic pseudocysts. Options include endoscopic retrograde cholangiopancreatography with pancreatic duct stenting , internal drainage, external drainage, and resection [50,77]. (See "Walled-off pancreatic fluid collections (including pseudocysts)" and "Endoscopic management of walled-off pancreatic fluid collections: Techniques".)
●Intraabdominal abscess – Intraabdominal abscess occurs in 7 to 18 percent of patients with pancreatic injuries [2,4,34]. The majority of posttraumatic intraabdominal abscesses can be treated with percutaneous drainage. The need for open surgical drainage is uncommon.
SUMMARY AND RECOMMENDATIONS
●Traumatic injury to the duodenum and pancreas occurs in 3 to 5 percent of patients with abdominal injury. The severity of injury correlates with the presence of associated injuries and increasing rates of morbidity and mortality. (See 'Introduction' above and 'Injury grading' above.)
●Signs and symptoms of duodenal or pancreatic injury may not be obvious upon presentation due to the retroperitoneal location of these organs. The diagnosis of low-grade injuries can be challenging, particularly in the setting of blunt trauma or when exploratory laparotomy is not immediately indicated to evaluate other injuries. (See 'Clinical evaluation' above and 'Diagnosis' above.)
●Computed tomography (CT) of the abdomen is the initial imaging test used to evaluate duodenal and pancreatic injury but has only moderate sensitivity for detecting these injuries. Specificity is higher but pancreatic ductal injuries will be missed in as many as 10 percent of patients. Cholangiopancreatography (endoscopic or magnetic resonance) may be needed to make a diagnosis of ductal injury. (See 'Diagnosis' above.)
●Low Grade (I or II) blunt injuries of the duodenum and pancreas are initially managed nonoperatively rather than with operative exploration and repair. Most of these injuries heal without the need for surgical intervention although about 10 percent of patients will fail nonoperative management. Nonoperative management includes bowel rest and nutritional support (enteral or parenteral). Nonoperative management has not been reported for penetrating mechanisms. (See 'Nonoperative management' above.)
●When duodenal or pancreatic injuries require operative intervention, relatively simple surgical techniques are often all that is needed. These include debridement of devitalized tissue, local repair of lacerations, closed-suction drainage and, for full-thickness duodenal injury, resection and primary anastomosis. Several adjunctive techniques have been described to decrease the potential for leak following duodenal repair, but no studies have proven any benefit. (See 'Repair of duodenal injury' above and 'Managing pancreatic injury' above.)
●The management of pancreatic ductal injuries depends upon the location of the injury. Distal main pancreatic duct injuries to the left of the superior mesenteric vein are managed with distal pancreatectomy. Proximal main pancreatic duct injury is managed primarily with wide closed-suction drainage. (See 'Pancreatic ductal injuries' above.)
●High-grade injuries to the pancreatic head or combined severe injuries of the duodenum and pancreas are managed with resection (pancreaticoduodenectomy) and interval reconstruction. Devitalized tissue is debrided and the pylorus, jejunum, and pancreatic stump are stapled closed. The common bile duct is ligated or drained. After an interval during which the patient is resuscitated, the patient is returned to the operating room for reconstruction (Whipple). (See 'Combined pancreaticoduodenal injuries' above.)
●Mortality following pancreatic and duodenal injury occurs in 15 to 20 percent of patients and is related to the severity of the duodenal or pancreatic injury and other associated injuries. Complications are common and include intraabdominal abscess, duodenal fistula, pancreatic fistula, pancreatitis and pancreatic pseudocyst. High rates of late infectious complications occur even if the injury is diagnosed and treated in a timely fashion. These complications can usually be managed without the need to return to the operating room. (See 'Complications of duodenal injuries' above and 'Complications of pancreatic injuries' above and 'Morbidity and mortality' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate, Inc. would like to acknowledge Dr. Ronald Jou and Dr. Susan Brundage, who contributed to earlier versions of this topic review.
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