Traumatismes du pancréas. Principes de techniques et de tactique chirurgicales

Abstract

Early diagnosis of a pancreatic trauma (PT) is challenging due to discrepancies between severity of the lesions and initial symptomatology. Delayed diagnosis may be responsible for severe complications, the treatment of which is often difficult. A severe acute post-traumatic pancreatitis, for instance, is often associated with late death. The decisions depend on the circumstances in which the PT has been identified. If the patient is haemodynamically unstable, control of the haemorrhage is the priority, and immediate laparotomy must be undertaken, during which a damage control procedure must be decided if necessary. In the haemodynamically controlled patient, the surgeon has enough time to recognize the PT, its location and its severity. The main severity criteria are the disruption of the pancreatic duct and the association to a duodenal lesion. Minor injuries without ductal disruption are treated by external drainage. In case of distal injury with ductal disruption, resection of the distal segment is generally proposed, all the easier since the resection is less than 50-60 %. Drainage by a Roux-en-Y is actually not applicable to situations of emergency. In case of proximal pancreatic contusion with ductal injury, sump drainage will often be the best solution, because of the difficulties and bad results related to the Whipple procedure, because of the ability to complete such an option by complementary post-operative Endoscopic-Retrograde-Cholangio-Pancreatography (ERCP) with intra-ductal stent insertion, and because of the relative simplicity of the management of a pancreatic fistula. If, exceptionally, a pancreaticoduodenectomy is unavoidable, one must keep in mind the possibility to delay the reconstruction to the first or second postop day. An injury of the duodenum associated to a benign PT is treated by suture if simple and by a Roux-en-Y duodenojejunal diversion if severe. A venting gastrostomy, a feeding jejunostomy and possibly a stappled simplified duodenal exclusion can be performed if the duodeno-pancreatic lesions are very serious, and we recommend avoiding the pancreaticoduodenectomy, if possible. If the patient is haemodynamically stable, and the laparotomy not indicated, the best diagnosis tools are Computed Tomodensitometry, Magnetic Resonance Pancreatography and Endoscopic-Retrograde-Cholangio-Pancreatography. If these exams show a disruption of the main pancreatic duct, endoscopic transpapillary stent insertion may be successful. In case of failure, the management follows the same rules than those described in the operative treatment. Nonoperative management is appropriate for patients without any main pancreatic duct disruption, but it is obvious that this nonoperative option may eventually succeed, even if a disruption has been found, especially in children. The decision is based on the topography of the lesion, the clinical status, and the age of the patient.