Lesser-sac lavage for intraoperative detection of blunt pancreatic duct injury

Background/Aims: Blunt pancreatic duct injury is difficult to differentiate, especially during surgery. In terms of demonstration of pancreatic duct injury, endoscopic retrograde pancreatography (ERP) is the gold standard imaging study, however, availability can be problematic. Therefore, we have designed a method utilizing lesser-sac lavage to differentiate pancreatic duct injury. Methodology: Patients sustaining blunt pancreatic trauma treated at our institution over a two-year period were retrospectively enrolled in this study. Based on computed tomography (CT), these patients were divided into two groups: deep laceration or complete transection (Group 1) and superficial laceration (Group 2). Additionally, ten patients sustaining blunt abdominal trauma who had undergone emergency laparotomy for other visceral organ injury (Group 3) and four undergoing pancreatoduodenectomy (Group 4) were selected as controls. For laparotomy in Groups 1-3, the lesser sac was opened for lavage, with 50mL of 0.9% normal saline inserted, and 3mL of the sample fluid withdrawn at four time points (15, 30, 45 and 60 mins) with the fluid immediately replaced with 3mL of saline. Lavage-ascites amylase (LAA) and lipase (LAL) levels were measured. Serum amylase and lipase activities were measured intraoperatively from 3mL of the patient's blood. Results: Over the two-year study period, there were four pancreatic duct transections (Group 1), five partial pancreatic lacerations confirmed by post-ERP CT (Group 2), ten non-pancreatic traumas (Group 3), and four pancreatoduodenectomies due to pancreatic-head cancer (Group 4). The LAA and LAL for Group 1 were significantly higher than those for Group 2 or 3 at each of the four time points. The LAA and LAL ratios for Group 1 relative to Group 2 or 3 decreased gradually over time. These LAA ratios ranged from 7-13 for Group 1 to Group 2, 138-232 for Group 1 to Group 3, and 17-21 for Group 2 to Group 3. By contrast, the LAL ratio ranged from 3.0-3.4 comparing Group 1 to Group 2, 3180-29124 for Group 1 to Group 3, and 1058-8705 for Group 2 to Group 3. Conclusions: Using lesser-sac lavage for measurement of LAA and LAL constitutes a rapid, non-invasive and effective method for detection of pancreatic duct injury, especially transection of the main duct. LAA appears to be a better indicator for differentiation of minor (superficial laceration or side branch) or major (MPD) pancreatic injury at the first time point (15 minutes post lavage) compared to LAL. By contrast, LAL appears to be a better indicator with respect to differentiation of the injured pancreas from the normal organ at this time point.