Injury to the pancreas was first recognized and reported in 1827. Since that time the problem has become more familiar, though compared with the incidence of injury to other viscera, it is still uncommon, and therefore is frequently overlooked. If the injury is not diagnosed initially it usually becomes apparent subsequently, as complications occur up to 6 weeks after the event. At this time treatment is much more difficult, morbidity is high, and the mortality rate is about 20 per cent.

The trauma may be either blunt or penetrating in nature: the latter type is about three times more common and is associated with a higher mortality rate. Up to 90 per cent of patients also have other serious injuries: these contribute to the high mortality. Other viscera which are particularly liable to be damaged in patients with pancreatic trauma are the liver, spleen, and small intestine.

Pancreatic trauma occurs in between 1 and 3 per cent of patients who have suffered blunt or penetrating abdominal injuries. This figure is low, but is increasing with the increase in numbers of high-speed motor vehicle accidents and in civil violence. It is most commonly seen in young adults, and in men more frequently than women. At present, however, the experience of any one surgeon will be small and successful management will therefore be based on the accrued published experience of others. The possibility of pancreatic injury should always be considered in patients who have suffered abdominal trauma. If there is sufficient concern the pancreas should be examined thoroughly, either through a laparotomy, which may be being performed for other injuries, or by careful investigation. Ductal injury in particular must be identified early if complications are to be avoided.

Serum amylase levels are elevated in 50 to 90 per cent of patients with pancreatic trauma, but false-positive results are also common. Trauma is a common cause of acute pancreatitis in children, accounting for one-third of all such cases in the United States. The pancreas of a child is vulnerable and easily damaged during sledging or bicycle accidents or by physical abuse. Children often present late, the accident having been regarded as trivial; in these patients hyperamylasaemia is always present.

Ultrasound is a simple method by which patients suspected of having sustained pancreatic trauma can be assessed. It may demonstrate pseudocysts but it is unreliable in detecting ductal injury. Computed tomography, if available, is more reliable and will successfully detect pancreatic fractures and contusions, as well as post-traumatic pseudocysts. However, ductal integrity can best be assessed by endoscopic retrograde pancreatography: this is the investigation of choice, when pancreatic injury is suspected. The classification of pancreatic injuries is shown in Table 1 391.

The majority of surgeons first encounter a pancreatic injury while performing a laparotomy for some more obvious coexisting injury. This is the best time to detect pancreatic injury, and correct treatment can avoid future complications and possible death. Examination of the pancreas in this situation is difficult however, particularly when other injuries seem more pressing and a planned approach is essential. Patients at risk are those who have received blunt trauma to the upper abdomen during a road traffic accident or who have an obvious penetrating injury to the upper abdomen. After other immediately life-threatening injuries have been dealt with, the pancreas should be examined. Clues to injury are the presence of blood in the lesser sac or, more commonly, a retroperitoneal haematoma in the upper abdomen that extends into the transverse mesocolon. There may be evidence of haematoma lateral to the second part of the duodenum. These findings demand thorough exploration and examination of the gland.

Access to the head of the gland is gained by dividing the peritoneum lateral to the second part of the duodenum and lifting the head away from the posterior abdominal wall and to the left (Kocher's manoeuvre) (1). The body and tail of the gland are best examined from within the lesser sac. Access is gained by detaching the greater omentum from its avascular attachment to the transverse colon (2). This allows access deep to the omentum and superior to the transverse mesocolon. The tail of the gland can be approached by deflecting the spleen to the right (3). This is neither particularly easy nor quick, and in emergency situations the tail can be examined adequately without the need for this manoeuvre. Division of the ligament of Trietz and mobilization of the duodenojejunal flexure allows examination of the third and fourth parts of the duodenum (4). This may be made easier if the hepatic flexure of the colon is mobilized to the left.

Injury to the gland may be identified by the presence of a capsular tear, by obvious haemorrhage from the gland or, rarely, by complete gland disruption. Ductal injury, however, may be very difficult to confirm, with nothing more obvious than some bruising in the gland. If facilities allow, a pancreatic ductogram should be obtained at the initial laparotomy: this can be done by intraoperative endoscopic pancreatography or by performing a transduodenal cannulation of the pancreatic duct. In practice, however, such refined endoscopic techniques are only available in a few specialized centres, and even satisfactory transduodenal pancreatograms are extremely difficult to obtain and interpret when performed in an emergency situation.

Grade I injuries can be safely managed by drainage of the pancreatic bed: this is best achieved by bringing large tube drains out posterolaterally through the loins. Unless there is definite evidence of ductal injury this is the treatment of choice.

If there is an obvious injury to the duct within the tail or body of the gland a distal pancreatectomy should be performed with ligation of the stump of the duct and drainage of the pancreatic bed. This approach in Grade II injuries carries fewer complications than drainage alone.

Grade III and IV injuries, in which the head of the gland is damaged, with or without trauma to the duodenum, may require a Whipple's pancreaticoduodenectomy to be performed. Fortunately this procedure is indicated only in 2 to 3 per cent of patients with pancreatic injuries. The operation is technically difficult, mainly because the very narrow calibre of the normal pancreatic and bile ducts makes reconstructions very difficult. In this situation the pancreatic anastomosis can be made by invaginating the stump of the gland into a loop of jejunum and the biliary anastomosis may be facilitated by ligating the distal common bile duct and anastomosing the gallbladder to an accessible loop of jejunum. Many authors have advocated drainage alone as the treatment for these severe injuries because of the technical difficulties of pancreaticoduodenectomy and the poor results of surgery. In critically ill patients with multiple trauma, it would seem prudent to institute drainage of the pancreas in the first instance. Appropriate investigations and secondary surgery can be performed at a later date in those patients who survive their other injuries. The results of surgical treatment of pancreatic trauma are disappointing: the overall mortality rate is about 20 per cent. The mortality associated with pancreaticoduodenectomy in these patients approaches 50 per cent, but the results of less radical treatment of these major injuries (Grades III and IV) are little better.

The prognosis of major pancreatic injuries (Grades III and IV) is unlikely to improve. However, with prompt diagnosis and early treatment, patients who have Grade I and II injuries should make a satisfactory recovery.

Lucas CE. Diagnosis and treatment of pancreatic and duodenal injury. Surg Clin N Am, 1977; 57: 49–65.