Nonoperative Management of Pancreato-Duodenal Injuries

Abstract

Following injuries to the pancreas and duodenum (PDI) patients often present in extremis and undergo immediate laparotomy for hemodynamic instability and peritoneal signs. Nonoperative management (NOM) may be offered in selected patients with lowgrade injuries. Precise mapping of the injury, most commonly by computed tomography, is a prerequisite for NOM because clinical symptomatology can be variable and misleading. Additionally, delaying the treatment of PDI that should be corrected surgically may lead to significant complications. Therefore, NOM of PDI presents unique challenges, and the decision-making is not as straightforward as it is with NOM of other solid abdominal organs. Essentially, only duodenal hematomas without fullthickness wall perforation (Grade I and selected II) and pancreatic trauma without major duct involvement (Grade I and selected II) could be offered NOM. In these cases, the reported success rates vary from 74 to 95%. There are also a few severe pancreatic injuries that can be managed by stents with adequate reconstitution of the major pancreatic duct integrity and resolution of symptoms and without the need for operative management. Intensive monitoring and follow-up by clinical examination and repeat CT imaging is essential in these patients, as the risk of complications, and particularly a pseudocyst is high.

The current management of pancreatic trauma

“…Clinical findings that bear a high index of suspicion for pancreatic injury are lower rib fractures, soft tissue ecchymosis, supraumbilical seat belt sign and upper lumbar spine fractures [9]. The initial serum amylase level is not reliably accurate for the diagnosis of pancreatic trauma; its accuracy could possibly improve if amylase is measured more than three hours after injury [10].…”

“…The reported success rates vary from 74% to 95% [9]. Grade II injuries (no major duct involvement) can be managed conservatively with a higher incidence of complications, mainly pancreatitis and pseudocyst.…”

“…Grade II injuries (no major duct involvement) can be managed conservatively with a higher incidence of complications, mainly pancreatitis and pseudocyst. The pseudocyst formation rate after NOM for pancreatic trauma reaches 45-50% [9]. Simple superficial contusion or peripheral laceration with minimal parenchymal damage, any portion of the pancreas may be affected but intact main pancreatic duct Deep laceration, perforation or transection of the neck, body or tail of the pancreas, with or without pancreatic duct injury.…”

“…In Farrell's et al retrospective review of 51 patients with pancreatic trauma, 7 AAST grade IV and 7 AAST grade V injuries were identified: 2 involved The Current Management of Pancreatic Trauma providing the patient is haemodynamically stable and asymptomatic [11,21,33,34]; it is also a viable choice if surgical intervention is contraindicated due to the presence of comorbidities [9]. Patients with complete duct transection should be offered surgery [21].…”

Focus on Pancreatic and Duodenal Injuries

“…In this issue of the European Journal of Trauma and Emergency Surgery, well-known world experts explore the current management practices of pancreatic and duodenal injuries including the indications of nonoperative management as well as the current treatment of pancreatic fistulae, the most common complication following pancreatic injuries [6][7][8]. Albeit rare, all trauma surgeons should be familiar with the modern treatment options of these interesting and challenging injuries.…”