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Chapter 22

Contents

CHAPTER XXII

Wounds of the Pancreas (62 Casualties)

H. Leon Poole, M. D.

The pancreas was wounded less frequently than any other major abdominal organ in the 3,154 abdominal injuries treated by the 2d Auxiliary Surgical Group in 1944-45 (table 76). The low frequency, 2.0 percent, parallels other reported experiences. In World War I, there were only 5 such injuries reported by British observers1in a series of 965 cases (0.5 percent), and the proportion in all abdominal injuries sustained by the American Expeditionary Forces was even lower (0.2 percent).2 Jolly3 reported 4 injuries of the pancreas in a series of 970 abdominal injuries observed in the Spanish Civil War.

TABLE 76.-Essential data in 62 wounds of pancreas

Type of wound

Cases

Frequency

Deaths

Case fatality rate


In 3,154 abdominal injuries

In 62 pancreatic injuries

 

 

Percent

Percent

 

 

Univisceral

1

0.03

1.6

1

100.0

Multivisceral

61

1.93

98.4

34

55.7


Total

62

1.97

100.0

35

56.5


The low frequency suggests that many of the patients who sustained such injuries did not survive to reach the hospital. The risk is not so much in the injury of the pancreas per se as in the almost inevitable damage to surrounding structures. This is borne out by certain facts:

1. Only 1 of the 62 injuries in this series was univisceral.

2. Thirteen of the casualties also suffered injury to a major blood vessel, in five cases the vessel being the vena cava.

3. Every patient was in shock when he was first seen. 

4. The case fatality rate was 56.5 percent (35 deaths).

The precise danger inherent in a wound confined to the pancreas cannot be determined from this series, in which, as just mentioned, there was only one univisceral injury. The relative surgical inaccessibility of the pancreatic

1History of the Great War Based on Official Documents. Medical Services Surgery of the War. London: His Majesty's Stationery Office, 1922, vol. I.
2The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1.
3Jolly, Douglas W.: Field Surgery in Total War. New York: Paul B. Hoeber. Inc., 1941.


286

region is attested by the fact that in three cases the wound was diagnosed only at autopsy.

NATURE OF INJURY

Agents causing injuries of the pancreas were of the same type, and acted with essentially the same frequency, as in other categories of abdominal injuries. Lacerations and perforations were the commonest type of wound. Penetrating wounds were present in 5 cases, and the organ was transected 3 times. In the 52 cases in which data concerning location were recorded, the head was involved 14 times, twice with involvement of the pancreatic duct also; the tail 24 times; and the body 14 times. Peritonitis caused by spill of pancreatic secretions was recorded in only one instance.

Thirty-two injuries, of which sixteen were fatal, were thoracoabdominal, and thirty, of which nineteen were fatal, were confined to the abdomen.

MULTIPLE AND ASSOCIATED INJURIES

Wounds of the pancreas were associated with wounds of other viscera in all except 1 of the 62 cases (tables 76 to 78, inclusive). The other damaged organs, in order of frequency of involvement, were the stomach, liver, spleen, kidney, colon, duodenum, and jejunum and ileum. Two or more other viscera were injured in almost three-quarters of all cases. Vascular injuries were associated in 13 cases, in every one of which other viscera were also injured.

Associated injuries, all of which were severe, were present in 16 cases (25.8 percent). Seven of these injuries were compound fractures or extensive soft-tissue wounds, and two patients had spinal-cord injuries.

TABLE 77.-Influence of multiplicity factor on case fatality rates in 62 wounds of pancreas

Organs injured

Cases

Deaths

Case fatality rate

Pancreas only

1

1

100.0

Pancreas and 1 viscus

15

5

33.3

Pancreas and 2 viscera

22

11

50.0

Pancreas and 3 viscera

15

9

60.0

Pancreas and 4 viscera

9

9

100.0

Total

62

35

56.6


CLINICAL FINDINGS

All 62 patients with injuries of the pancreas were in shock when they were first seen. In not a single instance were clinical findings such as to arouse suspicion that the pancreas had been injured.


287

TABLE 78.-Influence of specific additional organs wounded on case fatality rates in 61 multivisceral wounds of pancreas

Organs injured

Two organs only

Plus additional organs

Total

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Cases

Deaths

Case fatality rate

Pancreas and stomach

4

1

25.0

33

21

63.6

37

22

59.5

Pancreas and duodenum

0

0

(1)

11

9

81.8

11

9

81.8

Pancreas and jejuno-ileum

0

0

(1)

8

7

87.5

8

7

87.5

Pancreas and colon

3

2

66.6

14

10

71.4

17

12

70.6

Pancreas and liver

5

2

40.0

20

13

65.0

25

15

60.0

Pancreas and spleen

2

0

0

20

11

55.0

22

11

50.0

Pancreas and kidney

1

0

0

19

16

84.2

20

16

80.0

Pancreas and major vessels

0

0

(1)

13

11

84.6

13

11

84.6


1Not applicable.

All the men were seen too early for the effects of digestive secretions to have become apparent upon the skin. It was not possible by clinical methods to differentiate digestive peritonitis from peritonitis caused by fecal contamination. It was impossible to identify the pancreatic secretion in the discharge from the wound because of the admixture of blood and gastrointestinal contents. Laboratory facilities were not available for such determinations as the serum amylase test for pancreatitis. The sole clue to a pancreatic wound, in short, was the anatomic site of the injury.

TREATMENT

A transdiaphragmatic approach was used in 12 of the 32 thoracoabdominal injuries, and some type of abdominal incision in the other 48 cases in which this detail was recorded. Because the pancreatic wound was of secondary importance in all but one case in the series, the approach which afforded the greatest facility in the management of the other wounded viscera was always chosen.

Drainage of the site of the pancreatic injury was the only treatment in 24 of the 59 cases in which the diagnosis was made ante mortem. The wound was sutured in 17 cases, in 11 of which drainage was instituted. Packing was employed in 5 cases, in 1 of which drainage was instituted. The other 3 cases were managed by partial pancreatectomy, in 2 instances supplemented by drainage. Ligation of the pancreatic duct was performed in 1 of the 2 cases in which this structure was injured.


288

In three instances, as already mentioned, the injury was overlooked and an ante mortem diagnosis was not made. Four patients died on the operating table, and in the six remaining cases it was not possible to determine from the records why no active treatment had been instituted.

POSTOPERATIVE COMPLICATIONS

Shock which was present before operation and continued afterward was not listed as a postoperative complication. When it is excluded, postoperative complications occurred in 13 cases (21.0 percent). Anuria was present in five cases. Digestive peritonitis was observed in two instances; in one the diagnosis was made at operation and in the other at autopsy. Acute pancreatitis, jaundice, gastric hemorrhage, biliary fistula from an overlooked common duct injury, pulmonary edema, pneumonia and empyema, and femoral phlebitis occurred in one case each. Pancreatic fistula and its complications were not observed in forward hospitals, the patients being evacuated before these became manifest, but the records did not mention particular difficulties from pancreatic drainage.

CASE FATALITY RATES AND FACTORS OF MORTALITY

There were 35 deaths in the 62 pancreatic wounds (56.5 percent). Four, as already noted, occurred on the operating table, and an additional 15 occurred within the first 24 hours after operation. Two patients died on the first postoperative day, three on the second, one on the third, seven between the fifth and seventh days, and three after the seventh day.

Shock, hemorrhage, or both, were the primary causes of death in 21 of the fatalities (60.0 percent). Anuria was responsible for 5 other deaths and peritonitis for 3. The other six were variously caused by pancreatitis, gastric hemorrhage, atelectasis, pulmonary edema, pneumonia, and the vagovagal reflex following bronchoscopy.

The single patient with a univisceral pancreatic injury died on the eighth postoperative day, of pneumonia and empyema. In multivisceral injuries, the case fatality rate increased progressively as additional organs were involved (table 77) and reached 100 percent in the 9 cases in which 4 were involved in addition to the pancreas.

The cause of death was not stated in 1 of the 4 patients who died on the operating table. In the other three cases, the causes were, respectively, pancreatitis, hemorrhage and shock, and hemorrhage from an injured mediastinal vessel. All three patients whose pancreatic injuries were not discovered until autopsy had other serious visceral or vascular injuries. One of these three deaths was caused by anuria, one by peritonitis caused by an unrecognized lesion of the duodenum, and one by bile peritonitis arising from an overlooked injury of the common bile duct.


289

There were 11 fatalities in the 13 cases associated with vascular injury (84.6 percent). All five patients with injuries of the inferior vena cava died, as did each of the patients with injuries of the duodenal and pancreatic vessels and of the lumbar artery. One of the four patients with injuries of the splenic pedicle survived, as did one of the two with injuries of the renal pedicle.

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