Selective nonoperative management of low-grade blunt pancreatic injury: are we there yet?
BACKGROUND
Nonoperative management (NOM) of low-grade blunt pancreatic injuries (LGBPI) diagnosed by computed tomographic (CT) abnormalities of the pancreas in the adult hemodynamically stable (HDS) patient has not been previously defined. We report our experience of patients with LGBPI at a single Level I Trauma Center.


METHODS
Adult HDS patients during a 5-year period with blunt pancreatic injuries with an abbreviated injury score of </=2 were identified through the hospital trauma registry. Management, complications, and outcome were reviewed. Patients who underwent initial emergency laparotomy, died on hospital day one, or had a Glasgow Coma Scale of three were excluded. Failure of NOM was defined by need for subsequent exploratory laparotomy or development of a pancreatic complication. Data are reported as mean +/- SEM.


RESULTS
A total of 120 patients were identified as having blunt pancreatic injury of which 35, with pancreatic abbreviated injury score of </=2, were blunt HDS patients with abdominal CT evidence of pancreatic injury. Amylase elevation was noted in 23 of 35 (68.5%) patients with positive CT scan findings of LGBPI. Study population consisted of 20 male patients and 15 female patients, age 32 +/- 13.22, injury severity score 21 +/- 10.08, systolic pressure 123 +/- 27.06 with mean base deficit -3.78 +/- 2. Of these 12 (34.28%) patients had an associated intra-abdominal solid organ injury. Five patients failed NOM (F-NOM), one had missed small bowel injury, three had pancreatic abscess, of which one developed a pancreatic fistula which resolved with medical management, and one F-NOM for blunt liver injury with missed bowel injury. No death in the F-NOM group and two deaths (5.71%) in the successful NOM (S-NOM) group unrelated to the pancreas. The average length of stay was 11 days +/- 9.71 days.


CONCLUSIONS
NOM of LGBPI diagnosed by CT was successful in the majority of HDS patients, with low morbidity and mortality. We propose a management algorithm for NOM of LGBPI in which the role for early ductal injury detection with endoscopic retrograde cholangio-pancreatogram or magnetic retrograde cholangio-pancreatogram should be incorporated to better analyze the most appropriate treatment.
Duchesne
Juan C
JC
Section of Trauma and Critical Care Surgery and Preventive Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA. jduchesn@tulane.edu
Schmieg
Robert
R
Islam
Saleem
S
Olivier
Jacob
J
McSwain
Norman
N
D000328:Adult; D000465:Algorithms; D001794:Blood Pressure; D015331:Cohort Studies; D003663:Decision Trees; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000293:injuries*; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*