Management of Pancreatic Injuries

Annotation for Point G

Grade III. Distal transection or parenchymal injury with main pancreatic duct disruption are best managed operatively to prevent pancreatic ascites or a major fistula. Most ductal injuries can be identified by either preoperative studies in the stable patient or intraoperatively. The anatomic division between the head and body of the pancreas is the neck, where the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) pass behind the pancreas. This anatomic division will provide an estimated 50% of pancreatic tissue. Management decisions are based on the anatomic location of the parenchymal and duct injury (i.e., proximal vs. distal). Ductal injuries at or distal to the neck are treated definitively with distal pancreatectomy.^22,23 In the vast majority of patients, distal resection should leave no concern for later pancreatic endocrine or exocrine function. Intraoperative ductography does not seem to be warranted, as the Memphis group has recently demonstrated that clinical assessment can determine high versus low risk of main ductal injury.²³ Patients felt to be at high risk of ductal disruption undergo distal pancreatectomy, while those at low risk are managed with closed suction drains.²³  In the Memphis experience, morbidity seems to have decreased owing to a reduction in pancreatic resections.²⁴ The major morbidity following distal resection is pancreatic fistula, which is in turn associated with infectious and metabolic complications. The optimal surgical technique to avoid fistula has yet to be identified. In fact, a recent prospective randomized trial found equivalent rates of pancreatic fistula following stapled (36%) compared with hand-sewn (37%) resection.²⁵

Grade IV. The Memphis group has also promoted drainage alone for duct injuries in the pancreatic head.^23,24 Simple drainage is associated with pancreas-related morbidity rates of less than 15%. However, the effectiveness of this technique with major ductal injury remains to be established.