Management of Pancreatic Injuries

Annotation for Point D

In between those with obvious indications for LAP and those with minor injuries, the paucity of data in this area hampers the creation of firm guidelines. The following several factors influence the decision making: (1) CT scan is not completely accurate in identifying duct injuries (Grade III);5 (2) higher-grade injuries are associated with greater morbidity and mortality;15 and (3) delays to intervention are associated with greater morbidity.15 Consequently, the most conservative approach would be to attempt to exclude main duct injury early; thus, patients with CT or clinical evidence suggesting possible ductal injury, if not undergoing LAP, should have MRCP or ERCP. As it is noninvasive, MRCP is preferred for diagnosis.12,16,17 If there is a Grade III injury or higher, the patient should undergo LAP. This recommendation is based on the better outcomes reported with surgery versus early endoscopic transpapillary pancreatic duct stenting14 and the possibility of missed hollow viscus injuries.10