Experiences in the management of pancreatic trauma

A 30-year experience in the management of 283 consecutive patients with acute pancreatic trauma was reviewed. Of these injuries 224 were penetrating; 59 were from blunt trauma. Diagnosis was made by laparotomy in all patients, although elevated serum amylase suggested this injury in 23 (56%) of 41 patients with nonpenetrating injuries. Operative measures were initially involved with correction of associated injury when present (961 organ injuries in 278 patients: 3.5 injuries per patient). During the earlier years, Penrose drains were placed to the site of injury. Significant pancreatic complications (fistula in 13, suppurative pancreatitis or abscess in six, pseudocyst in three) were noted in 19 (46%) of the 41 patients so managed. Routine sump drainage dramatically reduced the incidence of pancreatic complications to 2% in the 198 patients having external drainage alone. Distal resection was performed in 29 patients, without later pancreatic insufficiency. Most disappointing were the results from Roux-en-Y internal drainage: fistula developed in five and lethal bacterial pancreatitis in three of the seven patients so treated. Five patients died from exsanguination during exploration for major vascular trauma, and all three patients undergoing pancreaticoduodenectomy succumbed within 20 hours after operation. The overall mortality was 13.8%, with only seven deaths out of the last 100 patients treated. Profound hemorrhagic shock and its complications (19), suppurative pancreatitis (eight), and post-traumatic respiratory insufficiency (three) accounted for 30 of the 39 fatalities.