Pancreatic Trauma
Unlike ‘Liver’ and ‘Splenic’ trauma where rapid strides have been made in understanding, ‘Pancreatic trauma’ still remains a relative enigma, inspite of advances in diagnostics and surgical techniques. Largely, it is injury to the main pancreatic duct, it
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Pancreatic Trauma K.J. Singh, Ashwin Galagali, Rajan Chaudhry, and Giriraj Singh
5.1
Introduction
Unlike ‘Liver’ and ‘Splenic’ trauma where rapid strides have been made in understanding, ‘Pancreatic trauma’ still remains a relative enigma, inspite of advances in diagnostics and surgical techniques. Largely, it is injury to the main pancreatic duct, its timely diagnosis and appropriate management which decides the mortality and morbidity. Most pancreatic trauma scores including the widely followed ‘American Association for the Surgery of Trauma (AAST)’ focus on injury to the pancreatic duct in grading pancreatic trauma. Pancreatic trauma causes higher morbidity and mortality than that observed in injuries to other intraperitoneal organs because of three reasons [1]. • First, the pancreas anatomically resides in a relatively protected position high in the retroperitoneum. This results in it being infrequently injured in blunt abdominal trauma (BAT) such as vehicular accidents especially when compared to the spleen and liver and is often ignored. Further, it can be easily missed on clinical K.J. Singh (*) Department of GI Surgery and Liver Transplant, Army Hospital (R&R), New Delhi 110010, India e-mail: [email protected] A. Galagali Department of Surgery, Armed Forces Medical College, Pune, Maharashtra 411040, India e-mail: [email protected] R. Chaudhry AVSM VSM (Retd), Tata Main Hospital, Jamshedpur, Bihar 831001, India e-mail: [email protected] G. Singh Department of Radiodiagnosis and Intervention Radiology, Command Hospital, Kolkata, West Bengal 700027, India e-mail: [email protected] © Indian Association of Surgical Gastroenterology 2017 P. Sahni, S. Pal (eds.), GI Surgery Annual, GI Surgery Annual, DOI 10.1007/978-981-10-2678-2_5
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examination. There are no reliable serum markers. Imaging such as focused assessment by sonography for trauma (FAST), regular ultrasound (USG) and computerized tomography (CT) also may miss or under-diagnose pancreatic trauma. • Second, as other abdominal organs, the pancreas can be injured in BAT and penetrating abdominal trauma (PAT). While in PAT, emergency exploratory laparotomy is usually done, BAT today is likely to be managed conservatively if the patient is relatively stable. This results in ‘missing’ or a delay in recognizing pancreatic injuries. Even if a laparotomy is done, unlike other intraperitoneal organs, physical evaluation and examination of the pancreas in the operating room may miss an isolated pancreatic ductal injury. Adjunctive intraoperative tests such as endoscopic retrograde cholangio-pancreatography (ERCP) may be required, the expertise for which may not be available at a particular centre. • Third, the pancreas shares an intricate relation with the duodenum and biliary system. Severe trauma usually results in complex injuries to these organs as well thus increasing the morbidity and mortality.
5.2 5.2.1
Aetiology Anatomical Considerations
The pancreas is located in a relatively protected area of the abdominal c
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