CHAPTER XXII
Wounds of the Pancreas (62 Casualties)
H. Leon Poole, M. D.
The pancreas was wounded less frequently than any other major abdominal organin the 3,154 abdominal injuries treated by the 2d Auxiliary Surgical Group in1944-45 (table 76). The low frequency, 2.0 percent, parallels other reportedexperiences. In World War I, there were only 5 such injuries reported by Britishobservers1in a series of 965 cases (0.5 percent), and theproportion in all abdominal injuries sustained by the American ExpeditionaryForces was even lower (0.2 percent).2 Jolly3 reported 4 injuries of thepancreas in a series of 970 abdominal injuries observed in the Spanish CivilWar.
TABLE 76.-Essential data in 62 wounds of pancreas
Type of wound | Cases | Frequency | Deaths | Case fatality rate | |
| In 62 pancreatic injuries | ||||
|
| Percent | Percent |
|
|
Univisceral | 1 | 0.03 | 1.6 | 1 | 100.0 |
Multivisceral | 61 | 1.93 | 98.4 | 34 | 55.7 |
| 62 | 1.97 | 100.0 | 35 | 56.5 |
The low frequency suggests that many of the patients whosustained such injuries did not survive to reach the hospital. The risk is notso much in the injury of the pancreas per se as in the almost inevitable damageto 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 thepancreas cannot be determined from this series, in which, as just mentioned,there was only one univisceral injury. The relative surgical inaccessibility ofthe pancreatic
1History of the Great WarBased on Official Documents. Medical Services Surgery of the War. London: HisMajesty's Stationery Office, 1922, vol. I.
2The Medical Department ofthe United States Army in the World War. Washington: U. S. Government PrintingOffice, 1927, vol. XI, pt. 1.
3Jolly, Douglas W.: FieldSurgery in Total War. New York: Paul B. Hoeber. Inc., 1941.
286
region is attested by the fact that in three cases the wound was diagnosedonly at autopsy.
NATURE OF INJURY
Agents causing injuries of the pancreas were of the sametype, and acted with essentially the same frequency, as in other categories ofabdominal injuries. Lacerations and perforations were the commonest type ofwound. Penetrating wounds were present in 5 cases, and the organ was transected3 times. In the 52 casesin 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 body14 times. Peritonitis caused by spill of pancreaticsecretions was recorded in only one instance.
Thirty-two injuries, of which sixteen were fatal, were thoracoabdominal, andthirty, of which nineteen were fatal, were confined to the abdomen.
MULTIPLE AND ASSOCIATED INJURIES
Wounds of the pancreas were associated with wounds of otherviscera in all except 1 of the 62 cases (tables 76 to 78, inclusive).The other damaged organs, in order of frequency of involvement, were thestomach, liver, spleen, kidney, colon, duodenum, and jejunum and ileum. Two ormore other viscera were injured in almost three-quarters of all cases. Vascularinjuries were associated in 13 cases, in every one of which other viscera werealso injured.
Associated injuries, all of which were severe, were presentin 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 multiplicityfactor 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 |
| 62 | 35 | 56.6 |
CLINICAL FINDINGS
All 62 patients with injuries of thepancreas were in shock when they were first seen. In not a single instance wereclinical findings such as to arouse suspicion that the pancreas had beeninjured.
287
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 digestivesecretions to have become apparent upon the skin. It was not possible byclinical methods to differentiate digestive peritonitis from peritonitis causedby fecal contamination. It was impossible to identify the pancreatic secretionin the discharge from the wound because of the admixture of blood andgastrointestinal contents. Laboratory facilities were not available for suchdeterminations as the serum amylase test for pancreatitis. The sole clue to apancreatic wound, in short, was the anatomic site of the injury.
TREATMENT
A transdiaphragmatic approach was used in 12 of the 32thoracoabdominal injuries, and some type of abdominal incision in the other 48cases in which this detail was recorded. Because the pancreatic wound was ofsecondary importance in all but one case in the series, the approach whichafforded the greatest facility in the management of the other wounded viscerawas always chosen.
Drainage of the site of the pancreatic injury was the only treatment in 24 ofthe 59 cases in which the diagnosis was made ante mortem. The wound was suturedin 17 cases, in 11 of which drainage was instituted. Packing was employed in 5cases, in 1 of which drainage was instituted. The other 3 cases were managed bypartial pancreatectomy, in 2 instances supplemented by drainage. Ligation of thepancreatic duct was performed in 1 of the 2 cases in which this structure wasinjured.
288
In three instances, as already mentioned, the injury wasoverlooked and an ante mortem diagnosis was not made. Four patients died on theoperating table, and in the six remaining cases it was not possible to determinefrom the records why no active treatment had been instituted.
POSTOPERATIVE COMPLICATIONS
Shock which was present before operation and continued afterward was notlisted as a postoperative complication. When it is excluded, postoperativecomplications occurred in 13 cases (21.0 percent).Anuria was present in five cases. Digestive peritonitis was observed in twoinstances; in one the diagnosis was made at operation and in the other atautopsy. Acute pancreatitis, jaundice, gastric hemorrhage, biliary fistula froman overlooked common duct injury, pulmonary edema, pneumonia and empyema, andfemoral phlebitis occurred in one case each. Pancreatic fistula and itscomplications were not observed in forward hospitals, the patients beingevacuated before these became manifest, but the records did not mentionparticular difficulties from pancreatic drainage.
CASE FATALITY RATES AND FACTORS OF MORTALITY
There were 35 deaths in the 62 pancreaticwounds (56.5 percent). Four, asalready noted, occurred on the operating table, and an additional 15 occurred within the first24 hoursafter operation. Two patients died on the first postoperative day, three on thesecond, one on the third, seven between the fifth and seventh days, and threeafter the seventh day.
Shock, hemorrhage, or both, were the primary causes of death in 21 of thefatalities (60.0 percent). Anuriawas responsible for 5 other deathsand peritonitis for 3. The other six were variously caused by pancreatitis,gastric hemorrhage, atelectasis, pulmonary edema, pneumonia, and the vagovagalreflex following bronchoscopy.
The single patient with a univisceral pancreatic injury died on the eighthpostoperative day, of pneumonia and empyema. In multivisceral injuries, the casefatality rate increased progressively as additional organs were involved (table77) and reached 100 percent in the 9 cases in which 4 were involved in additionto the pancreas.
The cause of death was not stated in 1 of the 4 patients whodied on the operating table. In the other three cases, the causes were,respectively, pancreatitis, hemorrhage and shock, and hemorrhage from an injuredmediastinal vessel. All three patients whose pancreatic injuries were notdiscovered until autopsy had other serious visceral or vascular injuries. One ofthese three deaths was caused by anuria, one by peritonitis caused by anunrecognized lesion of the duodenum, and one by bile peritonitis arising from anoverlooked 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 vesselsand of the lumbar artery. One of the four patients with injuries of the splenicpedicle survived, as did one of the two with injuries of the renal pedicle.
