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18 Decision-Making inHepatobiliary andPancreatic Surgery: Acute Care Surgeon’s Perspective
207
The treatment of choice for noninfected pancreatic pseudocysts is drainage via either transpapillary or transmural endoscopic approach. If
the pseudocyst is in direct approximation with
the gastric or duodenal wall, transmural drainage
is completed. Transpapillary drainage is rst-line
treatment if the pseudocyst comes into direct
contact with the pancreatic duct. Pseudocyst gastrostomy can be performed for pseudocysts
directly adjacent to the posterior wall of the
stomach. Pseudocysts that are smaller than 4cm
in size and are located in the head or uncinate
process of the pancreas can be approached by
pseudocyst duodenostomy [3].
Percutaneous drainage of pseudocyst is typically not recommended given the high risk of
associated complications including need for
repeat intervention, increased length of stay,
increased risk of pancreatic stula, and morbidity
and mortality. This treatment modality should be
considered in patients with infected pseudocysts
without pancreatic obstruction or large pseudocysts that are poor candidates for other interventions [1].
Pancreatic walled off necrosis (WON) occurs
relatively late, usually 3–5 weeks after onset of
AP.Asymptomatic WON does not mandate intervention and can resolve spontaneously; however,
symptomatic WON generally requires intervention. Secondary infection and pancreatic necrosis
result in increased morbidity and mortality for
patients, thus necrotic tissue should be removed
to prevent septic complications. Most commonly,
WON is treated with percutaneous drainage or
endoscopic drainage, reserving surgical drainage
for failure of one of the two previous modalities
[4].
In general, invasive intervention on NP uid
collection should be postponed until at least 4
weeks after initial presentation, even if percutaneous drains are placed, sooner collection should
be allowed to wall off and mature prior to any
further necrosectomy. The POINTER trial evaluated patients that underwent immediate drainage
and antibiotic use versus immediate antibiotic
use and delayed drainage of infected pancreatic
necrosis. This trial did not demonstrate any difference in complications between the two groups,
but demonstrated that 39% of patients in the
delayed intervention group were successfully
treated with antibiotics alone and required less
necrosectomy procedures (51% in the early
group versus 22% in the delayed group) [3, 11].
Necrotizing Pancreatitis
andTreatment Modalities
Pancreatic and peripancreatic necrosis are serious complications of AP with secondary infection of necrotic tissue remaining a leading cause
of mortality in patients with NP. Contrastenhanced CT is the preferred imaging modality
for diagnosis of NP as it can identify the presence
of gas in the necrotic collection. Magnetic resonance imaging may be used, but is less sensitive
than CT.Diagnosis of infected necrosis is based
on imaging ndings in conjunction with clinical
criteria including rising serum inammatory
markers and fever [12]. Historically, open surgical necrosectomy was the treatment of choice for
managing infected pancreatic necrosis.
Minimally invasive procedures, such as the step up approach, hybrid techniques, and endoscopic
approaches to debridement have become increasingly popular recently.
Patients that develop walled off pancreatic
necrosis (WOPN) after AP can be considered for
endoscopic necrosectomy. During endoscopic
necrosectomy, the endoscope advanced to the
level of the duodenum or stomach at the point
where necrotic tissue can be visualized adjacent
to the viscera. Transgastric or transduodenal
access is made, allowing for guidewire to be
inserted and coiled into the necrotic cavity. Serial
dilation occurs to dilate the wall of the stomach
or duodenum to at least 15mm, and the stent is
inserted across the length of the opening to the
point of the necrotic cavity [3]. The endoscopist
may choose to use a plastic double-pigtail stent, a
self-expandable metal stent (SEMS) or a lumenapposing metal stents (LAMS). The metal stents
are larger in diameter and provide access for
potential subsequent debridement. LAMS are
designed to be delivered via a single step delivery
platform resulting in shorter intervention time.
208
T. Thambi-Pillai et al.
Retrospective studies, as well as more recent randomized clinical trial, have mixed results regarding efcacy and complications between the 2
metal stent types, and more research is needed to
determine optimum stent type [12].
The Panter trial from the Dutch pancreatitis
group introduced a minimally invasive step-up
approach to the management of necrotizing pancreatitis. The step-up approach has 3 components. Initially, delaying timing for intervention
allows for encapsulation of the pancreatic collection and WOPN to optimize conditions for intervention. Next, use of a percutaneous or
endoscopic transgastric catheter is used to drain
the collection. After patients show clinical
improvement, debridement is required either via
endoscopic or surgical necrosectomy. Patients
should be reevaluated approximately 72 hours in
between steps, allowing for the least invasive
treatment approach possible with progressively
invasive procedures added to treat infected pancreatic necrosis [13, 14]. The step-up approach to
pancreatic debridement decreased the incidence
of new multi-system organ failure from 40 to
12% compared with laparotomy. The PENGUIN
trial demonstrated a reduced rate of pancreatic
stulas, no occurrence of new onset multi-system
organ failure, and reduced inammatory markers
in patients in the endoscopic arm as opposed to
the surgical necrosectomy group. The TENSION
trial did not demonstrate signicant difference in
mortality or major morbidity in patients undergoing an endoscopic versus surgical step-up
approach. However, fewer pancreatic stulas,
shorter length of stay, and decreased overall mean
cost were noted in the endoscopic step-up
approach. The MISER trial compared an endoscopic step-up approach to minimally invasive
surgery. There were no differences in mortality
rates among groups, but patients in the endoscopic approach were again less likely to develop
either enterocutaneous or pancreaticocutaneous
stulas, had a lower rate of complications, lower
rate of SIRS, lower cost, and less disease-related
adverse effects than those in the surgical group
[12].
Ultimately both endoscopic and surgical step up approaches to pancreatic debridement are
very effective. The endoscopic approach may be
superior in reducing major complications including pancreaticocutaneous stulas, cost, length of
stay, and increased quality of life with infected
pancreatic necrosis. However, the surgical step up approach may be superior to the endoscopic
approach in reduction of mortality and major
complications. While consensus varies, it seems
reasonable that endoscopic approach should be
considered rst in patients with infected pancreatic necrosis [4].
Minimally invasive methods for debridement
of infected NP are increasingly utilized.
Techniques include minimal access retroperitoneal pancreatic necrosectomy (MARPN) and
video-assisted retroperitoneal debridement
(VARD). The MARPN procedure begins with
placement of the 12 French catheter via CT guidance by interventional radiology. This access
tract is serially dilated up to 30 French during the
minimally invasive procedure so a rigid nephroscope can be advanced, serving as a visualization
instrument and working channel for necrosectomy. An irrigation drainage system for continuous lavage is placed at the end of the procedure
and lavage continues at the bedside. MARPN can
be performed multiple times until clinical
improvement is noted. The VARD is a hybrid of
the manual and laparoscopic necrosectomy. A
left ank subcostal incision is made allowing for
direct manual debridement followed by laparoscopic inspection and debridement with laparoscopic instruments of the tissue cavity.
Continuous lavage access is obtained to allow for
ongoing debridement [12].
Failure in minimally invasive treatment
modalities may lead to need for pancreatic open
necrosectomy. Pancreatic necrosectomy is performed through an open midline laparotomy or
subcostal laparotomy, and access is gained to the
area of pancreatic necrosis after dissection of the
gastrocolic ligament. Manual dissection and
debridement are completed, followed by lavage.
Open surgical necrosectomy can be performed
18 Decision-Making inHepatobiliary andPancreatic Surgery: Acute Care Surgeon’s Perspective
209
with open packing with reevaluation of the cavity
serially approximately every 48 hours until the
abdomen can be closed after inserting drains.
Alternatively, closed packing is performed when
multiple drains are placed in the residual cavity
after necrosectomy, the abdomen is closed, and
continuous lavage is performed via dual-lumen
saline slumps and silicone rubber tubes to allow
inow and outow of the lavage irrigant. Planned
repeat laparotomy provides continuous removal
of necrotic tissue over the upcoming days [12].
Open necrosectomy can be complicated by difculty in access to infected collections, need for
large laparotomy incision, hernia complications,
and possibility of enterocutaneous stula formation [3]. Open surgical necrosectomy for acute
pancreatitis historically was associated with elevated mortality rates as high as 50% or greater.
More recent studies demonstrate improvement in
mortality between 11 and 23% with complication
rates remaining high between 64 and 73%.
Minimally invasive procedures remain better tolerated than open necrosectomy procedures,
resulted in decreased postoperative multi-system
organ failure and improvement in treatment success rates [12]. Consideration of laparotomy and
open necrosectomy should be delayed for as long
as possible or avoided to decrease morbidity and
mortality rates [4]. Practice patterns remain variable but approaches starting with conservative
measures followed by endoscopic drainage or
percutaneous drainage, then minimally invasive
procedures produce superior outcomes to traditional open necrosectomy for patients with
infected pancreatic necrosis [4]. Despite signicant increases in morbidity and even mortality
with open necrosectomy, surgeons still need to
remain comfortable with this techniques for
patients who fail treatment with more minimally
invasive modalities.
We believe that the care needs to be individualized to each patient based on the clinical situation and local expertise available based on above
guidelines. In our experience, surgical necrosectomy requires less reoperations compared to
endoscopic or percutaneous approach but needs
to be weighed against patient’s operative risk and
complication rate.
Hemorrhagic Complications
Acute upper gastrointestinal bleeding can be
common in AP and frequently results from stress
ulcers, peptic ulcer disease, or hemorrhagic gastroduodenitis. Rarely, massive hemorrhage
occurs into the gastrointestinal tract or abdominal
cavity. Erosion of the splenic artery, pancreaticoduodenal, and gastroduodenal arteries can lead to
rupture or pseudoaneurysm formation. The
splenic artery is most commonly affected.
Pseudoaneurysm should be suspected if patients
have repeated episodes of gastrointestinal bleeding, bloating, or increasing abdominal pain (associated with a pulsatile mass). If patients develop
severe and life-threatening bleeding, arteriography with embolization of the bleeding vessel can
be effective, otherwise emergent exploratory
laparotomy is required [4].
Dicult Gallbladder
Cholecystectomy is one of the most common surgical procedures performed in the United States
with about 300,000 cholecystectomies performed
annually [15]. Despite the commonality of this
procedure, it can easily become one of the most
frustrating procedures performed even for the
most seasoned surgeon. Management of the difcult gallbladder is a controversial topic, and there
are multiple ways and opinions as to how best
deal with this situation. The goal of this section is
to provide insight into recognizing characteristics
of a difcult gallbladder and safely dealing with
technically difcult cholecystectomies and any
postoperative complications that may arise.
Preoperative ConsiderationsThe3P’s: Patient, Physician,
andPathophysiology
Making the decision on whether or not to proceed
with cholecystectomy can be a difcult one.
Factors that play into a difcult cholecystectomy
can be categorized into the 3P’s: the patient, the
physician, and the pathology.
210
T. Thambi-Pillai et al.
Patient characteristics that contribute to a
more difcult gallbladder include previous
abdominal surgeries, cirrhosis, advanced age
greater than 65, and pregnancy [16, 17]. Physician
experience also plays a role in whether or not a
cholecystectomy will be difcult. Undoubtedly,
what is considered a difcult gallbladder will
vary signicant from a newly minted attending
compared to a surgeon ready for retirement.
Despite the amount of experience one has, in the
setting of a difcult gallbladder, a surgeon should
seek help or guidance if there are any concerns
about how to proceed.
The pathophysiology of the disease will be the
most critical in dening the difculty of the surgery. The degree of inammation encounter is the
foremost contributor to the difculty of the surgery. Indicators of the severity of inammation
can be seen in lab work and on imaging. The
Tokyo Guidelines characterize moderate acute
cholecystitis as inammation for more than 72
hours, leukocytosis greater than 18k, and signs of
signicant local inammation such as gangrene
or emphysema [18]. Severe acute cholecystitis is
cholecystitis with end-organ dysfunction secondary to sepsis. Chronic cholecystitis, especially
with greater than 10 episodes of biliary colic and
signs of a retracted gallbladder on ultrasound are
also red ags. Furthermore, previous attempts at
cholecystectomy as well as previous percutaneous drainage tubes make subsequent dissection
more difcult.
By recognizing these warning signs of a difcult gallbladder, a surgeon can best prepare themselves and the patient for possible outcomes. It is
imperative that while obtaining informed consent, the patient is prepared to expect a possible
bailout procedure and the subsequent complications that may arise from them.
The Pregnant Patient
operative and medical management. However, up
to 50% of patients with recurrent symptoms
require hospitalization and about 23% of these
patients went on to develop acute cholecystitis,
cholangitis, or gallstone pancreatitis. Preterm
labor and fetal loss resulted in 20% and 10–60%
of cases, respectively, depending on severity of
disease [19]. No signicant increased risk of premature labor and maternal or fetal complications
have been observed in pregnant women undergoing lap cholecystectomy versus the general
obstetric population. Given the low risk of surgery to the mother and fetus, all pregnant women
regardless of trimester should be considered for
lap cholecystectomy for biliary disease. Women
past their rst trimester should be placed in the
left lateral decubitus position to improve cardiac
output and venous return. Subcostal entry via
Hasson or Veress needle is recommended, and
insufation should be kept between 10 and
15mmHg. It is highly recommended that obstetric services be available in the facility where the
procedure is being performed.
Cholecystectomy inCirrhotic Patients
Patients with cirrhosis pose a unique set of challenges due to portal hypertension, coagulopathy,
ascites, and hepatic insufciency. As a rst step,
it is important to evaluate the MELD (Model for
End-stage Liver Disease) score and Child-Pugh
(CPT) classication. Generally, MELD score
predicted postoperative morbidity better than
CPT classication. The published literature
shows that cholecystectomy is safe in patients
with MELD <13 or Child A or B classication.
Laparoscopic cholecystectomy can be safely performed in a tertiary care center with expertise in
caring for patients with end-stage liver disease.
Further details are beyond the scope of this
chapter.
Nonoperative management of symptomatic gallbladder disease has a high risk of recurrence,
with the highest risk if diagnosed in the rst trimester. If the disease remains uncomplicated,
rates of preterm labor and abortion are similar for
Choledocholithiasis
When considering taking the patient to the operating room for cholecystectomy, not only do sur-
18 Decision-Making inHepatobiliary andPancreatic Surgery: Acute Care Surgeon’s Perspective
211
geons need to consider the severity and timing of
intervention but also other confounders such as
common bile duct stones, that would limit the
ability for care at one’s home institution. This is
especially true for community surgeons who do
not have ready access to MRCP or ERCP especially on the weekends or have the equipment or
comfort level to explore the common bile duct.
This oftentimes will sway the decision if the
patient stays or gets transferred.
Four risks factors have been identied by the
AGSE for choledocholithiasis. These being
dilated common bile duct, total bilirubin >1.7,
presence of common bile duct stone on ultrasound, and acute cholangitis. MRCP/EUS or IOC
are recommended if there is 1 risk factor present.
There is greater than 50% chance if 2 or more of
these risk factors are present and the duct should
be evaluated preoperative with ERCP or intraoperative intervention. Without any of these risk
factors, there is less than 10% chance of choledocholithiasis [20].
If a stone is found intraoperatively, clearance
of the duct can be attempted by rst trying to
ush the stone or administering 1 gram of glucagon. Depending on the surgeon’s experience, a
laparoscopic transcystic vs transcholedochal
common bile duct exploration can be performed.
If a duct exploration is not possible, postoperative ERCP is a reasonable option however it is
recommended that the cystic stump be generously controlled with an additional endoloop or
extra clips. Leaving a drain by the cystic duct
stump in order to control for a possible bile leak
secondary to stump blowout is also
recommended.
Timing ofCholecystectomy
hours of admission [21]. However, oftentimes
this is not the case and surgeons must consider
the risks versus benets of surgical intervention.
After 72 hours, it is not uncommon to nd that
the plane has brosed, making the dissection
even more difcult, especially in the setting of an
intrahepatic gallbladder. Historically, most surgeons have opted to wait 6 weeks post onset of
disease to try and reduce the amount of inammation as much as possible to make dissection
easier. Caution must be taken in this scenario as
there can be a failure rate of up to 20% with medical management of cholecystitis [22]. Of note,
studies have shown that there is no difference in
conversion rate, morbidity, or mortality if a cholecystectomy is pursued with the 72-hour window, in between, or beyond the 6-week waiting
period.
In the case of patients that are too sick to tolerate surgical intervention bridging with a cholecystostomy tube is a reasonable therapy until the
patient is well enough for surgical intervention.
Prior to cholecystectomy, cholangiogram can be
performed to see if the cystic duct is patent as a
measure of residual inammation and also gives
the surgeon a chance to delineate out the anatomy
further. If a patient chooses to not undergo surgery, the cholecystostomy tube can be removed
however they must be cautioned that recurrent
cholecystitis can occur again especially if they
have gallstones. It is preferable that the cholecystostomy tube remains in place until surgery can
be performed.
In especially frail patients who will probably
never be surgically be optimized, cholecystostomy tubes can be left in place with occasional
exchanges and capped. Should they develop
another bout of cholecystitis, the drain can be
placed to gravity.
In the idea world, all patients would present for
cholecystectomy within 72 hours of onset of disease. Intervention within the rst 72 hours is
aided by having a plane in between the liver and
gallbladder secondary to edema. Furthermore,
early intervention has been shown to decrease
length of stay, costs, bile leak rates, and conversion rates to open if intervened on within 24
Intraoperative Conduct
No matter what technology or technique is
applied in performing a cholecystectomy, the tenants of a safe cholecystectomy must be followed.
The hepatocystic triangle must be adequately
cleared, and the cystic plate should be exposed by
212
T. Thambi-Pillai et al.
Fig. 18.1 The rst photo shows ICG view clearly highlighting the gallbladder, cystic duct, and the common bile
duct. Second photo shows the critical view of safety
dissecting out the lower third of the gallbladder.
Two and only two structures should be seen
entering the gallbladder. The critical view of
safety (CVS) must be obtained prior to transection
of structures [23]. If there are any doubts about
the anatomy, a cholangiogram or use of indocyanine green (ICG) uoroscopy can be performed
to help delineate out biliary anatomy. We use
0.625mg IV in the preoperative area. Rouviere’s
sulcus which is the cleft of the liver running anterior to segment 1 of the liver can be a helpful
landmark intraoperatively. This line of demarcation separates the cystic duct and artery superiorly and common bile duct inferiorly. In the case
of severe inammation or brosis in which the
critical view cannot be found, the surgeon must
be prepared to utilize bail out procedures in order
to avoid dreaded bile duct injuries. Options for
bail out include subtotal reconstituting cholecystectomy, fenestrated cholecystectomy, or surgical
drainage of the gallbladder (Fig.18.1).
With a subtotal fenestrated approach, the anterior wall of the gallbladder is resected, and gallstones are removed. The cystic duct may or may
not be ligated during the procedure. With this
approach, there is a higher chance of bile leak
and a drain should be left close to the gallbladder
remnant. If a persistent bile leak is still observed
3–5 days after surgery, the drain should be placed
to gravity until resolution of the leak which
should self-resolve in several weeks or the patient
can be referred for ERCP.Typically, a drain output of 200 mls or less per day will resolve within
2 weeks.
(CVS) on ICG mode, and third photo same CVS on normal laparoscopic view
In a reconstituting cholecystectomy approach,
the gallbladder remnant is sutured closed after
removal gallstones. The rates of bile leakage are
less with this technique; however, there is a
greater risk of recurrent gallbladder disease.
It is imperative that if bleeding is encountered
during dissection that endoclips are not red haphazardly. Placing pressure using a Kitner or using
small strips of surgicel can be used to slow or
stop the bleeding. Beware of Moynihan’s hump
which is a tortuous right hepatic artery that
approaches very close to the gallbladder and cystic duct. It occurs in 3–16% of cases and is more
likely to be seen in cirrhotic patients. In these
patients, the cystic artery can be very short and
sometimes there will not be a true main cystic
artery coming off but many small offshoots. The
right hepatic artery can be mistaken for the cystic
artery and ligated by mistake, or even worse torn.
Ductal injuries are oftentimes preceded by vascular injuries and if signicant bleeding is encountered, the surgeon should consider converting to a
“dome down” technique versus open
cholecystectomy.
Common Bile Duct Injury
Despite best efforts, common bile duct injuries
still do occur. A majority of the time this is due to
surgeon disorientation and misinterpretation of
aberrant anatomy as “normal.” Only 3% of the
time are injuries due to departing from orthodox
operative strategy or sloppy dissection. Generous
18 Decision-Making inHepatobiliary andPancreatic Surgery: Acute Care Surgeon’s Perspective
213
use of cholangiography can help reorient the surgeon. Of note, cholangiography will not prevent
a bile duct injury but will help to recognize an
injury sooner. If a bile duct transection is discovered intraoperatively, the surgeon should remember these three words: stop, drop, and roll.
Stoppage of the surgery is needed as this has now
become a highly emotional situation. Dropping
the instruments and also allow the heart rate to
slow down will allow you to make a more rational decision. Finally, roll the care of the patient to
another surgeon, ideally a hepatobiliary surgeon
at a tertiary care center. Studies have shown that
attempts by the index surgeon to repair the injury
resulted in an extremely low success rate and signicantly increased length of stay compared to
repairs performed by a hepatobiliary surgeon at a
tertiary care center.
In closing, recognizing a difcult gallbladder
preoperatively and planning subsequent intraoperative conduct with possible bailout techniques
are important. Being able to recognize when and
where to stop prior to biliary injury is key. And
above all, do not be afraid to ask for help.
Pancreatic Trauma
Pancreatic trauma is a rare but complex and challenging medical condition encountered by the
acute care surgeon. The pancreas is located deep
within the retroperitoneum overlying the aorta in
the upper abdomen and is divided into threethirds in relation to the superior mesenteric vessels, it is surrounded by vitals structures oriented
horizontally in the upper abdomen. It has a rich
and extensive blood supply which makes hemorrhage from this area difcult to control with simple suture ligation. Estimates for the incidence of
pancreatic injury range from 0.2% to 12% of
abdominal traumas; blunt trauma accounts for
the mechanism most frequently encountered and
to a lesser extent in penetrating trauma due to the
fatal nature of these penetrating injuries. Early
recognition and management of such injuries are
paramount to avoid the dreaded implications of
missed injury.
Pancreatic injury is rarely an isolated injury; it
can result from various mechanisms. Due to the
sometimes subtle presentation of pancreatic
injury, the trauma surgeon should have a high
index of suspicion-based mechanism. Incidents,
such as blunt trauma due to a forceful impact on
the upper abdomen, are commonly seen in car
accidents, falls, or physical assaults and from penetrating trauma such as stab or gunshot wounds
which can directly damage the pancreas.
Mortality of pancreatic injury is in the range
of 10–12%, morbidities can be up to 60%. The
key predictor of outcome is the integrity of the
pancreatic duct.
Early death is usually from the associated
injuries. It is estimated that 40% of cases are
associated with vascular, liver, or stomach injuries. Mortality is proportional to the number of
injured organs. When pancreatic injury is left
untreated, the mortality can be as high as 50–90%.
Survivors likely will have chronic pain, pancreatitis, and pseudocysts.
Clinical signs and symptoms are non-specic
and may include abdominal pain, nausea, vomiting, and epigastric tenderness. The biochemical
marker may aid in establishing the diagnosis if
used alone; serum amylase is neither sufciently
sensitive nor specic for the diagnosis of pancreatic injury in a report by Takashima etal., 83% of
patients with pancreatic injury showed elevated
serum amylase levels at least 3h after the initial
trauma; however, the levels did not correlate with
injury severity. Serum amylase is not specic to
pancreas injury and will also be elevated in hemorrhagic shock, and other internal organ injuries
such as the liver, bowel, and ovaries. In suspected
traumatic pancreatic injury, serial serum amylase
measurements are recommended. A normal level
has a high negative predictive value.
Imaging studies such as CT scans or MRIs
help assess the extent and nature of the injury.
Thin slices CT scan is considered the gold standard to diagnose pancreatic injury with sensitivity and specicity in the range of 80–90%. Signs
of injury include intrapancreatic split, complete
transection, or an enhanced pancreas with an
unenhanced hematoma.
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T. Thambi-Pillai et al.
Pancreatic injury on occasion can be difcult
to detect on a CT scan obtained in the trauma bay
and may take time to develop. The trauma surgeon should consider repeating the CT scan if
there is a high index of suspicion for pancreatic
injury particularly when the patient develops
unexplained or worsening abdominal pain or
upward trending serum amylase.
ERCP and MRI don’t play a signicant role in
the acute trauma setting. However, stable trauma
patients may add more information regarding the
integrity of the pancreatic duct.
Intraoperatively, if pancreatic injury is suspected, the pancreas should be evaluated by
opening the lesser sac and visually assessing the
gland, liberal kocherization of the duodenum can
facilitate exposure of the pancreatic head. The
tail of the pancreas can be assessed by mobilizing
the spleen from the lateral attachments and lifting
the pancreas from the retroperitoneal attachments. Hematoma involving the pancreas needs
exploration to ensure adequate visualization of
the gland. Complete transection of the gland or
laceration greater than 50% carries a high risk of
pancreatic duct disruption [24].
The patient’s hemodynamic stability and any
further potentially fatal injuries should be taken
into consideration by the trauma surgeon.
Damage control by widely draining the lesser sac
is a bailout maneuver with an acceptable
outcome.
Another tool in the armamentarium of the
trauma surgeon is intraoperative cholangiography. This tool can be useful for assessing pancreatic ductal disruption. The technique involves
surgical removal of the gallbladder and accessing
the cystic duct. inject contrast under uoroscopic
visualization. If the pancreatic duct is not visualized, 2mg of IV morphine can induce spasm of
the sphincter and facilitate a pancreatogram.
The American Association for the Surgery of
Trauma (AAST) published a grading system
classication system for pancreatic injury:
• Grade I: Hematoma with minor contusion or
supercial laceration without duct injury
• Grade II: Major contusion or laceration with-
out duct injury
• Grade III: Distal transection or deep parenchymal injury with duct injury
• Grade IV: Proximal transection or deep parenchymal injury involving the ampulla (and/or
intrapancreatic common bile duct)
• Grade V: Massive disruption of the pancreatic
head (“shattered pancreas”)
Grades I and II do not involve the duct and are
considered low-grade injuries. Grades III, IV, and
V involve the duct and constitute high-grade injuries. With this system, typically, higher-grade
injuries correlate with higher mortality and
complications.
Fortunately, the majority of traumatic pancre-
atic injuries are mild contusions that will resolve
with conservative measures and supportive care.
On the other hand, severe lacerations or complete
organ destruction (high-grade III–IV) blunt pancreatic injuries or involvement of the main pancreatic duct will require immediate surgical
intervention to repair the damage, remove dead
tissue, or, in extreme cases, partial or complete
removal of the pancreas.
Surgical Options
Surgical treatment for pancreatic injuries
demands a tailored approach, considering the
specic injury, the patient’s condition, and the
aim to restore both the organ’s function and the
patient’s overall health. Advancements in surgical techniques and postoperative care continue to
improve outcomes, making surgical intervention
more effective and safer for individuals facing
pancreatic trauma.
1. Observation and Nonoperative Management:
• Contusions or minor injuries (grade I/II
pancreatic injuries): Mild injuries often
don’t require surgical intervention. Close
monitoring in a hospital setting with
supportive care, pain management, and
ensuring proper healing might sufce.
• If there is concern for pancreatic duct disruption, studies like ERCP or MRCP could
considered as it may change the grade of
18 Decision-Making inHepatobiliary andPancreatic Surgery: Acute Care Surgeon’s Perspective
the injury and therefore the recommended
treatment plan. The use of octreotide is
controversial. Somatostatin analogues
have been used by many surgeons in an
attempt to reduce post-pancreatectomy stula. In elective pancreatic resection, pasireotide, a longer-acting somatostatin
analogue, has been shown to reduce postoperative pancreatic stula [25]. This analogue has not been studied in the trauma
patient population. Guidelines from the
Eastern Association for the Surgery of
Trauma recommend against the routine use
of octreotide for postoperative prophylaxis
related to traumatic pancreatic injuries to
prevent stula.
2. Distal Pancreatectomy
• Severe Injuries: If the injury affects the tail
or body of the pancreas extensively, distal
pancreatectomy of the damaged portion
might be necessary. Splenic preservation in
trauma situations can be technically challenging and is more time-consuming than a
distal pancreatectomy for this reason most
adult and pediatric surgeons favor distal
pancreatectomy and splenectomy and closure of the proximal stump to minimize
bleeding and operative time. There are different techniques for closing the pancreatic
stump, none is proven to be superior in
minimizing post- pancreatectomy stula.
Stapler closure and handsewn closure of
the pancreatic stump are the standard
methods described in the literature, other
studies have shown a lower incidence of
post-pancreatectomy stula when the main
pancreatic duct is identied and clipped
[26].
• Post-splenectomy vaccination in the
trauma patient population is recommended
during the patient’s hospital admission.
The lifetime risk of overwhelming postsplenectomy infection is approximately
5% for patients who receive splenectomy
for hematologic disorders and signicantly
lower for trauma patients (Fig.18.2) [27].
Fig. 18.2 CT scan of the abdomen with IV contrast demonstrating hematoma and disruption of the pancreatic
body. The patient was managed with distal pancreatectomy with splenic preservation
3. Pancreaticoduodenectomy (Whipple Procedure):
• Complex injuries: Severe trauma to the
head of the pancreas or duodenum is the
most challenging situation faced by the
trauma surgeon and may necessitate a
Whipple procedure. In hemodynamically
unstable patients, staging the resection and
reconstruction can be done to minimize
operative time and anesthesia exposure.
Whipple procedure should be carried out
within 24–48 hours following the patient’s
presentation to reduce the risk of traumatic
pancreatitis which will complicate the surgical resection. In unstable patients, the
surgeon may opt for hemorrhage control,
wide external drainage to manage uid
collections or leaks, and utilize postoperatively MRCP to evaluate the status of
the pancreatic duct, followed by ERCP and
stenting if a main pancreatic duct injury is
identied. Sharpe et Al published their
data on managing 87 patients with proximal pancreatic injuries by closed suction
drainage, in this group there were seven
stulas (8.1%) and ve abscesses (5.7%),
and no pancreatic-related mortality
suggesting the majority of these complex
injuries can be managed by widely draining the lesser sac. The downside to such an
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T. Thambi-Pillai et al.
approach is the risk of developing chronic
grade b pancreatic stula which will result
in a long hospital course and the need for
multiple interventions [28].
Post-Surgical Care
Pancreatic trauma can lead to complications,
such as infections, pancreatic insufciency,
bleeding, pancreatic stulas, and in severe cases
death. By far pancreatic stula is the most common complication encountered, fortunately
majority will resolve spontaneously.
Postoperative hemorrhage is a serious complication of pancreatic trauma. Although the mechanism remains unknown, it is thought to be
associated with pancreatic stulas and intraperitoneal abscesses.
Aggressive management of pancreatic stula,
early detection of infection, and ensuring adequate nutrition are vital for successful outcomes.
Dietary adjustments or enzyme replacements
might be necessary.
Management of this complex patient population usually requires a dedicated multidisciplinary team. The prognosis of such injuries
varies depending on the extent of the injury, the
promptness of treatment, and the patient’s overall
health.
Surgical treatment for pancreatic injuries
demands a tailored approach, considering the
specic injury, the patient’s condition, and the
aim to restore both the organ’s function and the
patient’s overall health. Advancements in surgical techniques and postoperative care continue to
improve outcomes, making surgical intervention
more effective and safer for individuals with pancreatic trauma.
Liver Trauma
with nonoperative management. About 1 in 7
hepatic injuries require operative intervention
[29].
Liver injury should be suspected when there is
blunt or penetrative trauma to the right upper
quadrant or right chest especially lower chest. In
a stable patient, CT scan with IV contrast is the
best way to evaluate the extent of livery injury.
Hepatic Injury Grading
The American Association for the Surgery of
Trauma (AAST) is the most commonly used
classication system, and it grades based on the
extent of hematoma and depth of laceration/
parenchymal disruption.
The imaging criteria of the AAST grades of
hepatic injury are as follows:
Grade I: Subcapsular hematoma <10 percent sur-
face area. Parenchymal laceration <1 cm in
depth.
Grade II: Subcapsular hematoma 10–50 percent
surface area; intraparenchymal hematoma
<10 cm in diameter. Laceration: 1–3 cm
parenchymal depth and ≤10cm in length.
Grade III: Subcapsular hematoma >50 percent of
surface area; ruptured subcapsular or paren-
chymal hematoma. Intraparenchymal hema-
toma >10cm. Laceration >3cm in depth. Any
injury in the presence of a liver vascular injury
or active bleeding contained within liver
parenchyma.
Grade IV: Parenchymal disruption involving
25–75% of a hepatic lobe. Active bleeding
extending beyond the liver parenchyma into
the peritoneum.
Grade V: Parenchymal disruption of >75 percent
of a hepatic lobe. Juxta hepatic venous injury
to include retro hepatic vena cava and central
major hepatic veins.
Liver is the most commonly injured abdominal
organ following a blunt trauma. Liver is a highly
vascular organ with dual blood supply with difcult to access venous drainage. Fortunately,
majority of the liver injuries are minor and heal
Management Options
The management approach to liver injuries
depends on: