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Pancreatic injury

  The pancreas is a retroperitoneal organ, located deeply, horizontally attached to the posterior peritoneum behind the upper middle abdomen. Due to its anatomical characteristics, it is well-protected, and injury to the pancreas can only occur when external factors directly act on the pancreas or blunt force is directly applied to the upper abdomen. Pancreatic injuries are often accompanied by injuries to adjacent organs, such as the duodenum, bile duct, stomach, colon, spleen, kidneys, and adjacent large blood vessels. Pancreatic injuries account for about 1% to 2% of abdominal injuries, but due to their deep and concealed location, they are not easily discovered in the early stage, and even there is a possibility of missed diagnosis during surgical exploration. After pancreatic injury, complications such as pancreatic juice leakage or fistula are common. Because of the strong erosive nature of pancreatic juice and its impact on digestive function, the mortality rate of pancreatic injury is about 20%.

Table of contents

1. What are the causes of pancreatic injury?
2. What complications can pancreatic injury lead to?
3. What are the typical symptoms of pancreatic injury?
4. How to prevent pancreatic injury?
5. What laboratory tests are needed for pancreatic injury?
6. Diet taboos for patients with pancreatic injury
7. Conventional methods of Western medicine for the treatment of pancreatic injury

1. What are the causes of pancreatic injury?

  Pancreatic injury accounts for about 1% to 2% of abdominal injuries, but its position is deep and concealed, making it difficult to detect early, and there is also a possibility of missed diagnosis during surgical exploration. After pancreatic injury, complications such as pancreatic juice leakage or fistula are often accompanied. Due to the strong erosive nature of pancreatic juice and its impact on digestive function, the mortality rate of pancreatic injury is about 20%.

  Firstly, etiology

  1. Closed injuries

  The position of the pancreas is relatively fixed, and its posterior part is adjacent to a rigid vertebral column. Therefore, when blunt violence is directly applied to the upper abdomen, the pancreas is easily prone to contusion or transverse laceration injury, such as when a car accident occurs and the patient is hit by the steering wheel or handrail on the upper abdomen without any preparation, or when the upper abdomen hits the crossbar during a high-altitude fall.

  2. Open injuries

  (1) Cutting injury: Sharp instruments such as knives directly cut the pancreas, often accompanied by injuries to other abdominal visceral organs such as the liver, stomach, and duodenum.

  (2) Gunshot wounds: More common in wartime, the upper abdomen or lumbar region is pierced by bullets or shell fragments, causing injury to the pancreas. Gunshot explosion or multiple fragments can cause fragmentation injuries of the pancreatic tissue, which are quite complex to treat and have a very poor prognosis.

  (3) Iatrogenic injury: Less common, certain abdominal organ surgeries such as stomach, duodenum, spleen, and colon surgery can cause pancreatic tissue damage.

  Secondly,Pathogenesis

  1. Degree of injury

  According to the degree of pathological injury of the pancreas, it can be divided into mild contusion, severe contusion, and partial or complete rupture injuries, etc. The degree of pathological injury of the pancreas is the basic basis for the pathological classification of pancreatic trauma.

  (1) Mild laceration injury: Only causes edema and slight bleeding of the pancreatic tissue, or forms a small subcapsular hematoma under the pancreatic capsule. Sometimes, a small amount of pancreatic acini and small pancreatic ducts may also be damaged, leading to slight exudation of pancreatic juice and mild self-digestion of the pancreatic tissue. Clinically, it can manifest as traumatic pancreatitis. Small superficial lacerations of the pancreas without significant pancreatic duct injury should be classified as mild laceration injuries. Such injuries generally do not cause serious consequences and can often heal spontaneously.

  (2) Severe laceration injury: The local laceration of the pancreas is severe, with part of the pancreatic tissue necrotic and losing vitality. At the same time, there is a relatively extensive or thick pancreatic duct rupture, leading to a large amount of pancreatic juice exuding outside. After the digestive enzymes in the exuded pancreatic juice are activated, they can further digest the pancreatic tissue itself, causing more pancreatic tissue to necrotize and the surrounding tissue around the pancreas to be corroded, saponified, etc. If the digestive enzymes corrode the larger blood vessels around the pancreas, severe internal hemorrhage may occur. If the exudation of pancreatic juice is relatively slow and is wrapped by surrounding tissue, a pseudocyst of the pancreas may form. For relatively large pancreatic lacerations or deep pancreatic lacerations with possible large pancreatic duct injuries (such as knife stab wounds), although there is no extensive and severe local laceration, necrosis of the pancreatic tissue, they should also be classified as severe laceration injuries.

  (3) Lacerations less than 1/3 of the circumference of the pancreas: classified as severe contusions and lacerations, lacerations more than 1/3 of the circumference of the pancreas as partial rupture injuries, and lacerations more than 2/3 of the circumference as complete rupture injuries. The broken part is generally located in front of the spine, on the left side of the superior mesenteric artery, that is, near the neck or body of the pancreas. Sometimes it can also occur at the junction of the body and tail of the pancreas. Partially broken parts can be on the dorsal or ventral side of the pancreas. If it is on the dorsal side, it is not easy to be discovered during surgery. The pancreatic tissue near the plane of the rupture may be contused and lacerated, with mild necrosis, showing a tidy fracture surface. It may also be more severe. The main problem of this type of pancreatic injury is the involvement of the large pancreatic duct (main pancreatic duct or a larger accessory duct), causing partial or complete rupture, resulting in a large amount of pancreatic juice extravasation. The more the rupture site is close to the pancreatic head, the more the pancreatic juice extravasation, and the more serious the secondary autodigestion and infection caused.

  2. Injury location

  Pancreatic injuries of the same pathological degree occurring at different parts of the pancreas have different degrees of threat to life, incidence of complications, and prognosis, so their severity is different, and the surgical procedures to be adopted are also different. For example, a severe laceration involving only the tail of the pancreas can be treated with a simple tail resection, with a good prognosis. However, the treatment of severe contusions and lacerations of the pancreatic head is more complex. According to the location of the pancreatic injury, it can be divided into pancreatic head injury, neck-body injury, and tail injury.

  3. Whether there is duodenal injury

  According to whether there is duodenal injury, it can be divided into simple pancreatic injury and combined injury of pancreatic head and duodenum. Combined injury of pancreatic head and duodenum is often caused by direct trauma to the upper right abdomen, commonly involving the pancreatic head and duodenum. It is a relatively serious condition among pancreatic injuries. After injury, the mixture of pancreatic juice, duodenal juice, and bile is extensively extravasated into the abdominal cavity. Pancreatic enzymes are rapidly activated, exerting a strong digestive effect on the surrounding tissues, resulting in a high mortality rate.

  The three factors mentioned above can be randomly combined, resulting in complex types.

2. What complications are easy to cause pancreatic injury

  The incidence of complications after pancreatic injury is relatively high, ranging from 20% to 40%. The occurrence of complications is mainly related to the location, extent, clinical pathological type, presence or absence of shock, whether there is injury to other organs and its severity, surgical method, the clinical experience and skills of the surgeon.

  The main complications include:

  1. Pancreatic fistula

  Pancreatic fistula is the most common complication after pancreatic injury, also known as extrapancreatic fistula or pancreatic skin fistula. The occurrence of pancreatic fistula in patients with pancreatic head injury is more common than in those with pancreatic body and tail injury. This is related to the relatively thicker main pancreatic duct in the pancreatic head, the large amount of pancreatic juice drained by the pancreatic duct, and the difficulty in completely removing the pancreatic head injury during surgery. Pancreatic fistula is more common after normal pancreatic injury, while it is relatively rare in patients with chronic pancreatitis or pancreatic fibrosis.

  2. Abdominal abscess

  The incidence of abdominal abscess is about 25%, and it is related to the degree, extent, and associated gastrointestinal injury of pancreatic injury, poor abdominal drainage, and pancreatic fistula.

  3. Intraperitoneal hemorrhage

  Recent bleeding often originates from bleeding from the pancreatic wound, while late bleeding is often due to the corrosion and rupture of abdominal large blood vessels by pancreatic juice. Occasionally, persistent pancreatic fistula and intraperitoneal infection may occur simultaneously with intraperitoneal hemorrhage, which is difficult to manage and has a very high mortality rate.

  4. Traumatic pancreatitis

  After pancreatic injury, patients may present with upper abdominal pain accompanied by signs of paralytic ileus, elevated serum amylase concentration, and should be considered for traumatic pancreatitis.

  5. Pancreatic pseudocyst

  The incidence is about 20%, mostly due to the failure to detect pancreatic duct injury during surgery or insufficient drainage of pancreatic juice accumulated in the pancreatic parenchyma of the laceration.

  6. Pancreatic dysfunction

  Pancreatic dysfunction may occur due to severe pancreatic injury or excessive resection. Deficiency of exocrine secretion is mainly manifested as abdominal distension and steatorrhea; deficiency of endocrine secretion is manifested as hyperglycemia and hyperglycosuria.

3. What are the typical symptoms of pancreatic injury?

  Isolated pancreatic injury is relatively rare in clinical practice, accounting for about 10% of pancreatic injury cases. Most pancreatic injuries are associated with injuries to other abdominal organs and other parts of the body, such as cranial and brain injuries, chest injuries, or injuries to large blood vessels. The symptoms and signs of pancreatic injury are often masked by those of other organ injuries, especially in cases with cranial and brain injuries or large blood vessel injuries, and are also related to the degree and pathological type of the injury.

  1. Mild pancreatic injury

  Most symptoms are mild. In cases of closed abdominal injury, local skin contusions and ecchymosis may be seen. In cases of open injury, abdominal wounds and bleeding may be observed, and patients may have mild upper abdominal discomfort and mild peritoneal irritation symptoms; or there may be no symptoms at all, but several weeks, months, or years later, symptoms such as upper abdominal masses or gastrointestinal obstruction (due to pancreatic pseudocysts) may appear, and some patients may have concurrent chronic pancreatitis, pancreatic fibrosis, and other symptoms such as long-term upper abdominal discomfort, low fever, and shoulder and back pain.

  2. Severe pancreatic injury

  Most patients experience severe upper abdominal pain, nausea, vomiting, hiccups, caused by the overflow of pancreatic juice into the abdominal cavity. In some patients, the overflowed pancreatic juice is confined to the retroperitoneum or lesser omental bursa, resulting in shoulder and back pain, while abdominal pain is not prominent. Pain and internal bleeding can cause shock, leading to restlessness, confusion, pale complexion, cold extremities, shortness of breath, rapid pulse, and decreased blood pressure. Physical examination may reveal abdominal distension, significant decrease or disappearance of abdominal breathing; abdominal tenderness, rebound tenderness, and muscle tension, positive shifting dullness, decreased or absent bowel sounds, and aspiration of unclotted blood from abdominal puncture.

  3. Penetrating pancreatic injury

  The possibility of pancreatic injury can be inferred according to the location, direction, and depth of the wound. Penetrating injuries often involve injuries to other organs, and pancreatic injuries may be overlooked. Therefore, if there is no significant blood loss but clear signs of shock in the upper abdominal injury, pancreatic injury should be considered.

  4. Pancreatic injury caused by surgery

  Diagnosis is difficult because its clinical manifestations are quite inconsistent. Most cases show persistent upper abdominal pain and vomiting early after surgery; fever, increased pulse rate; abdominal tenderness, muscle tension, delayed recovery of bowel sounds; a mass appears in the upper abdomen, there is a lot of wound drainage, skin erosion and ulceration. If the level of amylase in the drainage fluid or mass puncture fluid is very high, the diagnosis can be confirmed.

  

4. How to prevent pancreatic injury

  Since this disease is caused by trauma, there are currently no preventive measures.

  Postoperative prevention as follows:

  1. Traumatic pancreatic injury is mainly treated by surgery, and various drugs need to be used for adjuvant treatment, among which the main treatments are fluid therapy, antibiotics, and drugs to inhibit pancreatic secretion.

  2. Adequate fluid replacement is required before surgery, and blood transfusion may be necessary if necessary, to prevent and treat shock and electrolyte and acid-base disorders, and to improve the patient's resistance and tolerance to surgery.

  3. The time for fasting and gastrointestinal decompression after surgery should be longer than that of other abdominal trauma patients, generally requiring 4-5 days. It also needs to be infused with fluids, electrolytes, glucose, vitamins, etc., to maintain energy and electrolyte balance.

  4. Patients with severe illness who cannot eat after surgery and who have complications need to be actively given nutritional support.

  5. Traumatic pancreatic injury, the main serious complication is pancreatic fistula, with an incidence rate of 32%, and a high mortality rate. Therefore, drugs to inhibit pancreatic secretion should be used from the beginning of preoperative treatment.

  6. Antibiotics should be used before, during, and after surgery, especially in severe peritonitis or patients with other visceral injuries, more need to be combined with medication.

  7. Continue antibiotic treatment after surgery, and regularly check blood and urine routine tests until 2-3 days after the body temperature and blood count return to normal.

  If the body temperature does not gradually decrease but gradually increases 3-4 days after surgery, the cause should be investigated and appropriate treatment should be given, and antibiotics should not be used blindly.

  8. According to the postoperative laparotomy findings and the degree of abdominal contamination, postoperative exudate, drainage fluid bacterial culture and drug sensitivity results, sensitive drugs should be selected for anti-infection treatment.

5. What laboratory tests are needed for pancreatic injury

  The diagnosis of open pancreatic injury is not difficult. Gunshot wounds in the upper abdomen or near the umbilicus must consider the possibility of pancreatic injury. During laparotomy, it is not difficult to find the injured site. The diagnosis of closed pancreatic injury is very difficult, and fewer than half of the correct diagnoses are obtained before surgery. At this time, auxiliary examinations can be helpful for diagnosis.

  1. Laboratory examination

  1. Blood examination

  Red blood cell count decreases, hemoglobin and hematocrit decrease, while white blood cell count increases significantly, and the early increase in white blood cell count is due to inflammation.

  2. Serum amylase measurement

  Currently, there is no specific laboratory test that can accurately diagnose pancreatic injury. The increase in serum amylase in closed pancreatic injuries is more than in penetrating injuries, but there is still controversy in the literature regarding the value of serum amylase measurement for diagnosing pancreatic injury. In some cases of pancreatic injury, the early measurement of serum amylase may not be increased. It is generally believed that if the serum amylase exceeds 300 Somogyi units, or if there is a continuous dynamic increase in serum amylase after injury, it should be considered as an important basis for diagnosing pancreatic injury.

  3. Urinary amylase measurement

  After 12-24 hours of pancreatic injury, urinary amylase levels gradually increase. Although it is later than the increase in serum amylase, it lasts longer, so urinary amylase measurement is helpful for the diagnosis of pancreatic injury. For patients suspected of having pancreatic injury, long-term observation is recommended, and if urinary amylase is greater than 500 Somogyi units, it has certain diagnostic significance.

  4. Amylase measurement in abdominal puncture fluid

  In the early stage or mild injury of pancreatic injury, abdominal puncture may be negative. For patients with severe pancreatic injury, the abdominal puncture fluid is hemorrhagic, and amylase levels are elevated, which may be higher than the serum amylase value. Some people believe that amylase levels exceeding 100 Somogyi units can be used as a diagnostic criterion.

  5. Amylase measurement in abdominal lavage fluid

  For patients suspected of having pancreatic injury, abdominal symptoms and signs are not obvious, and the overall condition is stable. If abdominal puncture is negative, abdominal lavage can be performed after which the concentration of amylase in the lavage fluid can be measured, which has certain value for the diagnosis of pancreatic injury.

  Secondly, other examinations

  1. X-ray film

  It can be seen that there is a large area of dense soft tissue shadow in the upper abdomen, the left lumbar muscle and renal shadow disappear, the abdominal fat line is prominent or disappears, which is caused by pancreatic swelling and surrounding hemorrhage; if there is a rupture of the stomach and duodenum, there can be bubbles at the costovertebral angle or free gas under the diaphragm.

  2. Ultrasound examination

  It can judge the injury, location, degree, and range of solid organs in the abdomen (liver, kidney, pancreas, etc.), as well as localized abdominal infections, abscesses after trauma. It can detect localized or diffuse enlargement of the pancreas, increased or decreased echo, hematoma, and pseudocyst formation, and can also locate for diagnostic puncture. Linear or strip-like hypoechoic areas can be seen in laceration injuries, but this examination is easily affected by intestinal gas.

  3. CT examination

  CT has a high value for the early diagnosis of pancreatic injury, as it is not affected by intestinal distension. CT shows diffuse or localized enlargement of the pancreas, non-uniform fluid accumulation with unclear or incomplete encapsulation of the pancreatic edge, CT values between 20-50Hu, pancreatic edema or peripancreatic effusion, thickening of the left renal preperitoneal fascia. On enhanced CT images, low-density linear or strip-like defects can be seen at the fracture sites, and in patients with duodenal injuries, extraluminal gas or contrast medium can also be seen.

  4. Endoscopic Retrograde Cholangiopancreatography (ERCP)

  This examination has certain diagnostic value for pancreatic injuries caused by acute abdominal trauma, as it can detect extravasation of contrast medium or interruption of the pancreatic duct, which is a reliable method for diagnosing the injury of the main pancreatic duct. However, this examination can result in complications ranging from 4% to 7%, with a mortality rate of 1%. Moreover, patients who cannot tolerate the operation due to severe esophageal, gastric, and duodenal stenosis or critically ill conditions cannot undergo this examination. After the acute phase of abdominal closed injuries, this examination can clarify the pathological condition of the pancreatic duct, which is of great value in determining the surgical plan.

  5. Magnetic Resonance Cholangiopancreatography (MRCP)

  MRCP is a state-of-the-art, non-invasive technique for observing the anatomical and pathological morphology of the biliary and pancreatic systems. It can display the natural state of the morphology and tissue structure of the pancreatic and bile ducts without the influence of contrast medium injection, and it can complement ERCP, making it one of the important diagnostic methods for biliary and pancreatic diseases.

  6. Diagnostic laparoscopic exploration

  The advantages of laparoscopic exploration include the ability to directly observe the injured organs and determine the presence of active bleeding. It not only provides accurate diagnosis but also facilitates the selection of appropriate treatment plans, while avoiding unnecessary laparotomy. It can reduce complications and mortality associated with surgery, allowing 54% to 57% of patients to avoid exploratory surgery. However, it is still an invasive diagnostic and treatment method, and its diagnostic accuracy for retroperitoneal organs is not as good as that of CT scans. There is a possibility of missed diagnosis of intestinal injuries, and delays in surgical timing can occur in cases with significant internal bleeding and obvious peritonitis. Therefore, the rational selection of cases is very important. Reports suggest that video laparoscopic exploration is suitable for patients highly suspected of having abdominal organ injuries or those who have confirmed abdominal organ injuries but have relatively stable hemodynamics. Different degrees of consciousness impairment can lead to blurred clinical manifestations and signs, and severe abdominal organ injuries need to be ruled out. Unexplained hypotension and significant abdominal bleeding can lead to extremely unstable hemodynamics. Previous abdominal surgery history, pregnancy, and abdominal hernia are contraindications for abdominal trauma. The incidence of complications in general surgery diagnostic video laparoscopic exploration is 0% to 3%, with the main complications being hollow organ perforation, subcutaneous emphysema, omental emphysema, and incisional infection.

6. Dietary recommendations and禁忌 for patients with pancreatic injuries

  In addition to timely treatment for pancreatic injuries, we should not take the diet lightly.

  It is important to pay attention to a low-fat diet in terms of food consumption, as fats and greasy foods can stimulate the secretion of pancreatic juice, increasing the burden on the pancreas. Due to the high consumption of patients with pancreatitis, weight loss can be significant, so attention must be paid to the supply of nutrition.

  Diet should mainly consist of foods rich in carbohydrates, such as cakes, rice, and sweets. Protein should be consumed in high-quality forms, primarily from eggs, milk, meat, fish, and soy products.

  Drink plenty of water and avoid eating too much sugary food. Soy milk and milk are good choices, but they can produce more intestinal gas. For patients with pancreatitis, it is recommended to eat less greasy food and avoid overeating.

7. The conventional methods of Western medicine for treating pancreatic injuries

  Pancreatic injuries account for about 1% to 2% of abdominal injuries, but due to their deep and concealed location, they are often difficult to detect early, and there is even a possibility of misdiagnosis during surgical exploration. After pancreatic injury, complications such as pancreatic juice leakage or fistula are common. Because of the strong erosive nature of pancreatic juice and its impact on digestive function, the mortality rate of pancreatic injuries is about 20%.

  Therefore, for each case of upper abdominal injury, the possibility of pancreatic injury should be considered. Once the decision to operate is made, it is necessary to conduct a comprehensive examination first to clarify the condition of the pancreas. This includes exploring the ventral aspect of the pancreas by cutting the gastrocolic ligament, lifting the second part of the duodenum according to the Kocher method to explore the dorsal aspect of the pancreatic head and duodenum, and cutting the Treitz ligament if necessary to explore the body of the pancreas and the third and fourth parts of the duodenum. In addition to determining the location and extent of the pancreatic injury, it is more important to determine whether there is a rupture or break in the main pancreatic duct, so as to formulate the correct treatment plan.

  Treatment Methods:

  1. The purpose of the operation is to stop bleeding, debride, control the exocrine secretion of the pancreas, and deal with associated injuries.

  2. For pancreas contusions with intact capsules, only local drainage is needed.

  3. Partial rupture of the pancreas body without rupture of the main pancreatic duct can be repaired with silk suture.

  4. Severe contusion or transverse injury of the neck, body, and tail of the pancreas should be sutured at the proximal part of the pancreas and resected at the distal part.

  5. Severe contusion or fracture of the pancreatic head, in order to preserve the function of the pancreas, it is advisable to perform main pancreatic duct anastomosis at this time, or to ligate the proximal main pancreatic duct, suture the proximal gland, and perform anastomosis with the distal Roux-en-Y jejunum.

  6. Pancreatic head injury with duodenal rupture is the most serious. If the common bile duct at the head of the pancreas is ruptured while the pancreatic duct is intact, the two ends of the ruptured common bile duct can be sutured, and the duodenal and pancreatic incisions can be repaired. In addition, an anastomosis between the common bile duct and jejunum Roux-en-Y can be performed. If the common bile duct and the pancreatic duct are ruptured at the same time but the posterior wall of the pancreas is intact, an Roux-en-Y loop of the jejunum can be used to cover it and anastomosed with the pancreatic and duodenal incisions; pancreatectomy and duodenectomy should only be performed when the head of the pancreas is severely damaged and cannot be repaired.

  7. After various pancreatic surgeries, drainage materials should be left in the abdominal cavity because there is a possibility of concurrent pancreatic fistula after pancreatic surgery. The drainage materials must ensure unobstructed drainage and should not be removed prematurely, and it is best to use both cigarette drain and double-lumen negative pressure suction at the same time.

  8. Pancreatic fistula usually heals spontaneously within 4-6 weeks, and a few fistulas with large flow may need to be drained for several months, but rarely requires reoperation.

  Somatostatin has a strong inhibitory effect on the exocrine secretion of the pancreas and the entire gastrointestinal tract, and can be used for the prevention and treatment of traumatic pancreatic fistula. Pancreatic fistula should be fasting and given total parenteral nutrition treatment through the gastrointestinal tract.

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