Pancreatic and Duodenal Injury

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How common are pancreatic and duodenal injuries?

Injury to the pancreas and duodenum remain uncommon, likely because of the intimate association with other vital structures within the retroperitoneum. The recently documented incidence of duodenal injury is 0.2%–0.3%, followed by 0.004%–0.6% for pancreas injury. In patients undergoing laparotomy for trauma the incidence is 3%–6%. Traditionally, the incidence of pancreatic injury is higher in penetrating trauma; however, recent experience has suggested a reversal of this with the majority of pancreatic injuries resulting from a blunt mechanism.

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What other injuries are typically associated with penetrating pancreatic trauma?

Isolated injuries to the pancreas and duodenum are the exception rather than the rule, with more than 90% being associated with a concomitant injury. Liver injury is the most frequent concomitant injury, with a reported incidence of 50%. Other commonly associated injuries include the stomach (40%), large abdominal vessels such as the aorta and vena cava (40%), spleen (25%), kidney (2%), and duodenum (20%).

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How are pancreatic injuries diagnosed preoperatively?

Penetrating trauma to the pancreas is usually discovered during exploration for associated injuries. Such patients may present with hemodynamic instability from bleeding, positive focused abdominal sonography in trauma examination, or peritonitis. Patients with blunt injury who are hemodynamically stable should undergo abdominal computed tomography (CT) scan, and possible endoscopic retrograde cholangiopancreatography (ERCP) if proximal ductal disruption is suspected. The sensitivity for detecting pancreatic injury and pancreaticoduodenal injury is low for both 16- and 64-multidetector CT scan; however, the specificity is >90%. ERCP is the most accurate method of identifying an injury to the pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) is a useful modality to identify pancreatic injury with ductal involvement, and has an added advantage of evaluating the duct distal to a transection; however, therapeutic maneuvers are not possible with MRCP. Elevated serum amylase concentrations are nonspecific for pancreatic injury and can be normal initially in a high proportion of patients.

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