Pancreatic trauma
Key points
American association for the Surgery of Trauma (AAST) Pancreas Injury Scale
Grade I: Haematoma with minor contusion or superficial laceration without duct injury
Grade II: Major contusion or laceration without duct injury
Grade III: Distal transection or deep parenchymal injury with duct injury
Grade IV: Proximal transection or deep parenchymal injury involving the ampulla and/or intrapancreatic common bile duct
Grade V: Massive disruption of the pancreatic head ("shattered pancreas")
Management principles
Lacerations with no duct injury are managed conservatively
Grade 3 injuries
No need for MRCP/ERCP to investigate if CT confirmed ductal injury
Controversial as to whether conservative management or distal pancreatectomy is better
Lengths of stay (LOS) are generally similar between non-operative management (NOM) and operative management (OM) for pancreatic injuries
NOM is associated with higher rates of certain complications, such as pseudocysts
OM is preferred for more severe pancreatic injuries
Success rates for NOM are higher in lower-grade injuries
Injuries more than 48 hours old are associated with significant oedema and make surgery difficult
Some centres prefer distal pancreatectomy + drain for injuries <48h old, and conservative management for injuries >48h old
If >50% of the pancreas is resected, patient will have impaired glucose tolerance
Grade 4/5 injuries
Manage conservatively, can use stent +/- drain
If duodenum injured - may need Whipples procedure
Fistula is major post op complication
Follow up grade 3+ injuries for year for pancreatic insufficiency
Non-operative management principles
Feed after 1-2 days after resolution of epigastric tenderness
No evidence for prophylactic octreotide
Follow up imaging at 4-6 weeks for pseudocyst
MRCP at 6 weeks for duct continuity for severe injuries
References
Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum.
Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, McAninch JW, Pachter HL, Shackford SR, Trafton PG.
J Trauma. 1990 Nov;30(11):1427-9.
Naik-Mathuria, Bindi, and Nikhil R Shah. "Pancreatic Trauma." Pediatric Surgery NaT, American Pediatric Surgical Association, 2022. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829089/all/Pancreatic_Trauma.