Le diagnostic precoce des traumatismes pancreatiques est marque par une absence frequente de correlation entre la gravite des lesions et la semeiologie initiale. Le retard au diagnostic peut etre responsable de complications graves, dont le traitement peut etre difficile. La pancreatite aigue post-traumatique en est une, qui est associee a un risque eleve de deces tardif. Les decisions dependent des circonstances de ce diagnostic. Chez un blesse hemodynamiquement instable, les procedures les plus efficaces s'imposent pour le traitement de l'hemorragie, et une laparotomie doit etre realisee au plus vite. A ventre ouvert, une laparotomie ecourtee peut s'imposer dans certains cas. Si l'hemodynamique est controlee, on doit reconnaitre la lesion, son site et sa gravite, qui repose sur l'existence d'une rupture du Wirsung et de l'association a une lesion duodenale. Les contusions benignes, sans rupture canalaire, relevent le plus souvent du drainage au contact. En cas de lesion corporeale ou caudale avec rupture du Wirsung, la resection du pancreas est proposee, d'autant plus que la resection est inferieure a 50-60 %, car ses suites sont simples : splenopancreatectomie ou pancreatectomie gauche. En cas de lesion pancreatique droite avec Wirsung rompu, on proposera le plus souvent le drainage, car la duodenopancreatectomie (DPC) est un geste lourd aux mauvais resultats, et parce que la mise en place d'une prothese par catheterisme retrograde endoscopique peut etre decidee en postoperatoire, et enfin parce que la gestion d'une fistule pancreatique pure est souvent simple. Si une DPC est inevitable, il faut penser a la possibilite de repousser le retablissement des continuites a j1 ou j2. Lorsqu'il existe une atteinte duodenale associee, elle est traitee par suture si elle est simple, par anastomose duodenojejunale sur anse en Y si elle est plus importante, gestes associes a une gastrostomie de decharge et a une jejunostomie d'alimentation, voire a une exclusion duodenale en cas de contusion pancreatique serieuse. Une DPC peut, la aussi, s'imposer. A ventre ferme, il faut faire appel a la tomodensitometrie (TDM) multibarrettes, la pancreatographie par resonance magnetique ou la cholangio-pancreatographie retrograde endoscopique a la recherche de la rupture canalaire. Si le Wirsung est intact, la surveillance est clinicobiologique et radiologique (TDM). Si le Wirsung est rompu, il existe une indication de pose de prothese par voie endoscopique. En cas d'echec, la decision peut etre difficile : la resection gauche evite le risque de complications, mais il est certain que l'option non operatoire peut etre un succes, et notamment chez l'enfant... La decision s'appuie sur le site de la lesion, l'etat clinique, et l'age du blesse.
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.