Management of Pancreatic Injuries
Annotation for Point C
With liberal application of sensitive MDCT imaging, many low-grade injuries are diagnosed in patients who have no other indications for LAP. While recognizing thatmost of the related morbidity is caused by ductal disruption, nonoperative management (NOM) has been suggested for low-grade injuries. Most of the literature to date has been pertained to pediatric patients. A case series from Toronto reported feasibility and safety of the approach.6 Among 25 patients who presented early after injury, 14 had contusions (AAST-Organ Injury Scale grade was not reported, Table 17), of whom 2 developed pseudocysts, which resolved spontaneously. The other 11 patients had lacerations or transections; 5 of them developed pseudocysts, of whom 4 required drainage. More recently, studies have compared outcomes of patients managed with operation (OM) versus NOM, including Grade IV injuries.8,9 Overall length of stay did not differ in either series. Wood et al.8 reported that after OM, 21% had pancreatic complications, 57% had nonpancreatic complications, and 11% were readmitted. In contrast, in the group undergoing NOM, 73% had pancreatic complications, 20% had nonpancreatic complications, and 40% were readmitted. Complication rates were higher among those with endoscopic retrograde cholangiopancreatography (ERCP)Yproven duct injuries. In the multicenter experience reported by Paul and Mooney,9 length of stay was not different between OM and NOM. Morbidity was 45% after OM and 35% with NOM. Among the patients in the OMgroup, 15% developed pseudocysts, 10% developed fistulae, and 15% developed reoperations. In the NOM group, 35% developed pseudocysts. The interpretation of the data is confounded by selection bias, whereby the less severely injured were more likely to undergo NOM, and thus, prospective studies with long-term outcomes are warranted. There is not a great deal of literature in adults, but the approach seems safe. Duchesne et al.10 suggest that patients with apparent Grade I or II injuries could be managed nonoperatively if ductal disruption is excluded by magnetic resonance cholangiopancreatography (MRCP) or ERCP. Of 35 patients managed in this way, 5 (14%) failed, 3 with pancreatic abscess and 2 with missed bowel injuries. In the multicenter trial of New England trauma centers,11 69 (41%) of 170 patients with pancreatic or combined pancraticoduodenal injuries (96% were Grade I or II) were managed nonoperatively, with 7 (10%) failing. The recurring themes in the reports of NOM are that (a) it is safe to manage patients with Grade I and II injuries nonoperatively; (b) it is important to identify Grade III injuries or higher, that is, main pancreatic ductal disruption; and (c) distal main ductal disruptions are best managed operatively to avoid pancreatic duct-related complications.
In sum, with MDCT having a specificity of better than 90%,4,5 it seems reasonable to pursue NOM in the asymptomatic or minimally symptomatic patientwith no or nonspecific findings of pancreatic injury on CT scan. Worsening symptoms or clinical condition warrants repeat CT scanning, and new evidence of high-grade pancreatic injury or other operative lesions should prompt consideration of LAP. Peripancreatic fluid collections or other nonspecific findings should be addressed based on the expertise and resources of the trauma team and institution. Peripancreatic fluid collections may be drained operatively or percutaneously. Evaluation of the pancreatic duct may reveal a Grade III injury. The decision to proceed to LAP versus endoscopic management depends on local expertise and resources. Several small case series have suggested encouraging results of early endoscopic transpapillary pancreatic duct stenting;12,13 however, Lin et al.14 identified a consistent occurrence of major ductal strictures and noted that in their institution, operative management had a lower complication rate. In contrast, endoscopic transpapillary pancreatic duct stenting may be effective in managing later complications of duct injuries.12 Large pancreatic pseudocysts may be treated with endoscopic stenting or cyst enterostomy. Pancreatic fistulae will require drainage.