Don’t mess with the pancreas! A multicenter analysis of the management of low-grade pancreatic injuries

Abstract

INTRODUCTION:Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity. METHODS:Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression. RESULTS:Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intraabdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584). CONCLUSION:The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma.

Time to update the American Association for the Surgery of Trauma pancreas injury grading lexicon?

“…This includes not only the patency of the duct but also its alignment. More specifically, injury to the main pancreatic duct results in the leakage of significant volumes of pancreatic enzymes into the surrounding tissues 3–5 . This injury-related morphology is fundamentally different from lower-grade injuries to the pancreatic parenchyma that disrupt only minor ducts 5 .…”

“…The ubiquitous screening computed tomography (CT) remains insufficient to reliably and accurately identify main pancreatic ductal injuries in the immediate setting (Table 1). 2,5 This challenge is also influenced by the observation that the pancreas-specific experience of the CT-interpreting clinician strongly impacts their ability to detect an associated pancreatic main duct injury 7 …”

“…[2][3][4] Although minor pancreatic duct trauma typically follows a less complicated course that is defined by time-limited sealing of these lower volume leaks (and therefore resolution of the leak itself), release of pancreatic enzymes remains a clinically important problem in subsets of these patients as well. 5 Benign small duct injury outcomes assume synchronous integrity and continuity of the main duct.…”

“…1 This lexicon has remained helpful within numerous domains including clinical management, education, and research. Unfortunately, imprecise grading, [2][3][4][5] limitations in imaging fidelity, [6][7][8][9] and confusion over contemporary terminology 4,5 have hampered the ability to refine grade-specific clinical care guidelines.…”

“…Pancreas trauma remains a challenging disease that frequently requires multidisciplinary care and prolonged patient follow-up 2,3 . Individual patient courses following pancreatic injury are dependent on multiple factors such as synchronous injuries, preexisting medical comorbidities, physiologic presentation, and associated upper abdominal vascular trauma 2–5 . Although the AAST pancreas injury grading scale offers clinicians and researchers a common language, it remains limited by a lack of granularity, as well as inadequate distinction between blunt and penetrating mechanisms (i.e., contusions vs. lacerations).…”