Management of Pancreatic Injuries

Introduction

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of pancreatic injuries in adult patients. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, the recommendations herein are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm (Fig. 1) and accompanying comments represent a safe and sensible approach that could be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols.

The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite the pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with pancreatic injuries.

Injuries to the pancreas present a significant challenge, for a number of reasons. First, while the deep, central position of the pancreas affords the organ some degree of protection, its retroperitoneal location confounds the clinical detection of injury. Second, physiologic functions contribute to a disturbingly high incidence of complications following injury, and morbidity is exacerbated by delays in diagnosis and treatment. Third, the infrequency of these injuries has resulted in a lack of significant management experience among practicing trauma surgeons. Consequently, trauma to the pancreas is associated with relatively poor outcomes that have not improved significantly during the past two decades, despite advances in trauma and critical care management.¹