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Clinical update on management of pancreatic trauma

  • Kjetil Søreide
    Correspondence
    Correspondence: K. Soreide, Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK.
    Affiliations
    Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK

    Clinical Medicine, University of Bergen, Norway

    Department of Gastrointestinal Surgery, Stavanger University Hospital, Norway
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  • Thomas G. Weiser
    Affiliations
    Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK

    Stanford University Department of Surgery, Section of Trauma and Critical Care, Stanford, CA, USA
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  • Rowan W. Parks
    Affiliations
    Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK
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Open ArchivePublished:July 11, 2018DOI:https://doi.org/10.1016/j.hpb.2018.05.009

      Abstract

      Background

      Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma.

      Methods

      Systematic literature review until May 2018.

      Results

      Pancreas injury is reported in 0.2–0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90–100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50–75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries.

      Conclusion

      Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.

      Introduction

      Pancreatic trauma is rare compared to other solid organ injuries of the abdomen.
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      Surgical management of solid organ injuries.
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      A population-based study of pancreatic trauma in Scotland.
      • Parks R.W.
      Hepatobiliary and pancreatic trauma.
      Incidence is difficult to properly calculate, but a Scottish population-based study found pancreatic injury to occur in 0.21% of over 52,000 trauma patients.
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      • Yip V.S.
      • Garden O.J.
      • Parks R.W.
      A population-based study of pancreatic trauma in Scotland.
      In the UK Trauma And Research Network (TARN) database there were 0.32% pancreatoduodenal injuries detected among over 356,000 injured patients.
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      The epidemiology of and outcome from pancreatoduodenal trauma in the UK, 1989-2013.
      A similar pancreatic injury incidence of 0.3% was noted in children in the United States National Trauma Data Bank.
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      • Rice H.E.
      • Scarborough J.E.
      • Adibe O.O.
      Management of blunt pancreatic trauma in children: review of the National Trauma Data Bank.
      While injuries to the liver, spleen and kidneys are far more common, pancreatic injury occurs in less than 10% of all abdominal injuries,
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      • Guillamondegui O.D.
      • Dennis B.M.
      • Stassen N.A.
      • Bhullar I.
      • et al.
      Surgical management of solid organ injuries.
      depending on evaluation of the population at risk and the underlying aetiology. Penetrating injuries are far more common in regions with a high prevalence of gunshot wounds, such as in North America and South Africa.
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      • Kobusingye O.
      Injuries.
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      • Nicol A.
      Surgical management and outcome of civilian gunshot injuries to the pancreas.
      In most other regions, a blunt aetiology following motor vehicle crashes or falls, or ‘insignificant’ trauma sustained during leisure activities are the prevailing mechanism leading to this rare injury.
      Notably, pancreatic trauma may frequently be overlooked or not readily appreciated on initial clinical examination and investigation. A delayed presentation or clinical deterioration of the patient may in some instances be the first clue of an underlying occult or undetected injury. Few centres have vast experience in managing pancreatic injury, but recent database reports, studies from high-volume centres and consensus reports have cast new light on the treatment and outcomes related to pancreatic injuries. The aim of this manuscript is to present an updated clinical analysis of the available knowledge for detection, classification and management of pancreatic trauma.

      Methods

      A systematic review of the PubMed/Medline literature available in the English language, was undertaken. Search words included wildcard search of ‘pancrea*’ OR ‘pancreas’ OR ‘pancreatic’ AND ‘trauma’ AND ‘injury’ combined with other key search words such as ‘injury severity’, ‘severity scoring’, ‘mortality’, ‘imaging’, ‘surgery’, ‘endoscopy’, and ‘outcome’. As there were several possible diagnostic and therapeutic modalities for consideration, the PRISMA guidelines
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      • Ioannidis J.P.
      • et al.
      The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
      for any given intervention was not formally applied. Rather, published guidelines, consensus reports, or systematic reviews and meta-analyses on all aspects of injury of the pancreas after blunt or penetrating trauma were reviewed. A predominant focus on the most recent 5 years (January 2013 to May 2018) was applied in order to present the most updated and recent data. There was no restriction of reports to any gender, age-group or region of origin, as long as published in the English language. Larger case series or registry data were included when available. Case reports and small case series were not considered unless representing unique examples or important deviations from standard practice. Further studies or references found through search of reference lists were included ad libitum for the topic under discussion.

      Results

      The literature search identified several systematic reviews, consensus reports, registry studies and larger single and multicentre studies (Supplemental Figure 1). A systematic review was identified on the use of amylase as a laboratory test to diagnose pancreatic injury,
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      • Kadavigere R.
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      • Rodrigues G.S.
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      Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review.
      and on early use of endoscopic management,
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      • Kullman E.
      • Gasslander T.
      • Sandstrom P.
      Early endoscopic treatment of blunt traumatic pancreatic injury.
      and there were three consensus reports for management in adults.
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      • Henry S.
      • Scalea T.M.
      • Shanmuganathan K.
      • et al.
      Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: results from an International Consensus Conference.
      • Ho V.P.
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      • Hambley J.E.
      • Yon J.R.
      • et al.
      Management of adult pancreatic injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma.
      • Biffl W.L.
      • Moore E.E.
      • Croce M.
      • Davis J.W.
      • Coimbra R.
      • Karmy-Jones R.
      • et al.
      Western Trauma Association critical decisions in trauma: management of pancreatic injuries.
      Two systematic reviews
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      • van Poll D.
      • Goslings J.C.
      • Busch O.R.
      • Rauws E.A.
      • Oomen M.W.
      • et al.
      Operative versus nonoperative management of blunt pancreatic trauma in children: a systematic review.
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.
      and one consensus report
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      • Rosenfeld E.H.
      • Gosain A.
      • Burd R.
      • Falcone Jr., R.A.
      • Thakkar R.
      • et al.
      Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.
      on diagnosis and management in children were also identified. In addition, recent reports from the National Trauma Databank (NTDB) in the USA were identified and reviewed.
      • Englum B.R.
      • Gulack B.C.
      • Rice H.E.
      • Scarborough J.E.
      • Adibe O.O.
      Management of blunt pancreatic trauma in children: review of the National Trauma Data Bank.
      • van der Wilden G.M.
      • Yeh D.
      • Hwabejire J.O.
      • Klein E.N.
      • Fagenholz P.J.
      • King D.R.
      • et al.
      Trauma whipple: do or don't after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB).
      • Mora M.C.
      • Wong K.E.
      • Friderici J.
      • Bittner K.
      • Moriarty K.P.
      • Patterson L.A.
      • et al.
      Operative vs nonoperative management of pediatric blunt pancreatic trauma: evaluation of the national trauma data bank.
      • Phillips B.
      • Turco L.
      • McDonald D.
      • Mause E.
      • Walters R.W.
      A subgroup analysis of penetrating injuries to the pancreas: 777 patients from the National Trauma Data Bank, 2010-2014.
      • Mohseni S.
      • Holzmacher J.
      • Sjolin G.
      • Ahl R.
      • Sarani B.
      Outcomes after resection versus non-resection management of penetrating grade III and IV pancreatic injury: a trauma quality improvement (TQIP) databank analysis.
      • Schellenberg M.
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      • Cheng V.
      • Bardes J.M.
      • Lam L.
      • Benjamin E.
      • et al.
      Spleen-preserving distal pancreatectomy in trauma.
      • Siboni S.
      • Kwon E.
      • Benjamin E.
      • Inaba K.
      • Demetriades D.
      Isolated blunt pancreatic trauma: a benign injury?.
      Further, a multicentre study in adults
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      • Tabbara M.
      • Gross R.
      • Willette P.
      • Hirsch E.
      • Burke P.
      • et al.
      Blunt pancreatoduodenal injury: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).
      and a multicentre study in children
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      • Rosenfeld E.H.
      • Gosain A.
      • Burd R.
      • Falcone Jr., R.A.
      • Thakkar R.
      • et al.
      Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.
      and several larger single, dual, or multi-centre cohorts were included.
      • Addison P.
      • Iurcotta T.
      • Amodu L.I.
      • Crandall G.
      • Akerman M.
      • Galvin D.
      • et al.
      Outcomes following operative vs. non-operative management of blunt traumatic pancreatic injuries: a retrospective multi-institutional study.
      • Das R.
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      • Chennat J.
      • Malin J.
      • et al.
      Endotherapy is effective for pancreatic ductal disruption: a dual center experience.
      • Lissidini G.
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      • Piccinni G.
      • Gurrado A.
      • Giungato S.
      • Prete F.
      • et al.
      Emergency pancreaticoduodenectomy: when is it needed? A dual non-trauma centre experience and literature review.
      • Rosenfeld E.H.
      • Vogel A.M.
      • Klinkner D.B.
      • Escobar M.
      • Gaines B.
      • Russell R.
      • et al.
      The utility of ERCP in pediatric pancreatic trauma.
      • Naik-Mathuria B.
      Practice variability exists in the management of high-grade pediatric pancreatic trauma.
      • Westgarth-Taylor C.
      • Loveland J.
      Paediatric pancreatic trauma: a review of the literature and results of a multicentre survey on patient management.
      • Girard E.
      • Abba J.
      • Arvieux C.
      • Trilling B.
      • Sage P.Y.
      • Mougin N.
      • et al.
      Management of pancreatic trauma.
      • Mansfield N.
      • Inaba K.
      • Berg R.
      • Beale E.
      • Benjamin E.
      • Lam L.
      • et al.
      Early pancreatic dysfunction after resection in trauma: an 18-year report from a level I trauma center.
      • Krige J.E.
      • Spence R.T.
      • Navsaria P.H.
      • Nicol A.J.
      Development and validation of a pancreatic injury mortality score (PIMS) based on 473 consecutive patients treated at a level 1 trauma center.
      • Krige J.E.
      • Kotze U.K.
      • Setshedi M.
      • Nicol A.J.
      • Navsaria P.H.
      Prognostic factors, morbidity and mortality in pancreatic trauma: a critical appraisal of 432 consecutive patients treated at a level 1 trauma centre.
      • Dai L.N.
      • Chen C.D.
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      • Liu P.
      • et al.
      Abdominal injuries involving bicycle handlebars in 219 children: results of 8-year follow-up.

      Diagnostic modalities and investigation

      Initial investigation and diagnosis in an acute setting should follow the general principles for all trauma patients, including an updated ATLS™ protocol,
      Advanced trauma life support (ATLS(R)): the ninth edition.
      with imaging and monitoring according to need and vital signs on presentation. For most patients with hemodynamic stability at presentation, initial imaging is done by either ultrasonography (Focused Assessment with Sonography for Trauma; FAST) or more usually by multidetector computed tomography (MD–CT) – both of which have low sensitivity for pancreatic injury, typically reported at 40–60%.
      • Moschetta M.
      • Telegrafo M.
      • Malagnino V.
      • Mappa L.
      • Ianora A.A.
      • Dabbicco D.
      • et al.
      Pancreatic trauma: the role of computed tomography for guiding therapeutic approach.
      • Melamud K.
      • LeBedis C.A.
      • Soto J.A.
      Imaging of pancreatic and duodenal trauma.
      • Bates D.D.
      • LeBedis C.A.
      • Soto J.A.
      • Gupta A.
      Use of magnetic resonance in pancreaticobiliary emergencies.
      Patients who present with unstable vital signs or in extremis may be taken immediately to the operating theatre for exploration and resuscitation, thus, foregoing any imaging as diagnostic support. Diagnosis of a pancreatic injury may then first be detected at the time of laparotomy.
      It is important to note that early clinical signs of pancreatic injury are vague, laboratory tests are nonspecific and imaging results may be subtle and overlooked. Thus, a high degree of clinical suspicion is needed to ensure the potential of such injury is not overlooked. In blunt injury, a ‘seat belt’ sign over the abdomen after a motor vehicle crash, or a history of a handle bar injury in children presenting with abdominal symptoms may raise the suspicion of an underlying pancreatic injury.
      Elevations of lipase and amylase are generally mild and non-specific less than 6 h after injury, but the sensitivity increases with time and with consistent elevation in enzymes.
      • Mahajan A.
      • Kadavigere R.
      • Sripathi S.
      • Rodrigues G.S.
      • Rao V.R.
      • Koteshwar P.
      Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review.
      However, it should be noted that these enzymes can also be elevated for other abdominal injuries,
      • Kumar S.
      • Sagar S.
      • Subramanian A.
      • Albert V.
      • Pandey R.M.
      • Kapoor N.
      Evaluation of amylase and lipase levels in blunt trauma abdomen patients.
      and higher enzyme levels are not associated with higher grades of pancreatic injury.
      • Mitra B.
      • Fitzgerald M.
      • Raoofi M.
      • Tan G.A.
      • Spencer J.C.
      • Atkin C.
      Serum lipase for assessment of pancreatic trauma.
      Thus, increased levels of amylase or lipase are not specific for pancreatic injury, but may raise diagnostic suspicion to pursue further imaging in patients with equivocal clinical findings.
      In general, US and CT are reported to have an overall low sensitivity for pancreatic injuries.
      • Vasquez M.
      • Cardarelli C.
      • Glaser J.
      • Murthi S.
      • Stein D.
      • Scalea T.
      The ABC's of pancreatic trauma: airway, breathing, and computerized tomography scan?.
      CT findings of pancreatic trauma can be broadly categorized as direct or “hard” signs, such as a pancreatic laceration, which tends to be specific but lacks sensitivity, or as indirect or “soft” signs, such as peripancreatic fluid, which tends to be sensitive but lacks specificity.
      • Melamud K.
      • LeBedis C.A.
      • Soto J.A.
      Imaging of pancreatic and duodenal trauma.
      • Rekhi S.
      • Anderson S.W.
      • Rhea J.T.
      • Soto J.A.
      Imaging of blunt pancreatic trauma.
      • Kumar A.
      • Panda A.
      • Gamanagatti S.
      Blunt pancreatic trauma: a persistent diagnostic conundrum?.
      However, newer multidetector CT may have sensitivities approaching 80% and higher specificity for ductal injury.
      • Velmahos G.C.
      • Tabbara M.
      • Gross R.
      • Willette P.
      • Hirsch E.
      • Burke P.
      • et al.
      Blunt pancreatoduodenal injury: a multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT).
      • Kumar A.
      • Panda A.
      • Gamanagatti S.
      Blunt pancreatic trauma: a persistent diagnostic conundrum?.
      A CT-based score proposed that parenchymal transection of over 50% of the pancreatic gland had a high risk of ductal disruption,
      • Wong Y.C.
      • Wang L.J.
      • Lin B.C.
      • Chen C.J.
      • Lim K.E.
      • Chen R.J.
      CT grading of blunt pancreatic injuries: prediction of ductal disruption and surgical correlation.
      but was based on CT-technology that is currently surpassed. Current MD–CT is both faster and has higher resolution and is therefore the primary imaging modality in trauma patients.
      • Grunherz L.
      • Jensen K.O.
      • Neuhaus V.
      • Mica L.
      • Werner C.M.L.
      • Ciritsis B.
      • et al.
      Early computed tomography or focused assessment with sonography in abdominal trauma: what are the leading opinions?.
      Due to the rarity of pancreatic injuries, studies reporting actual sensitivity data for CT are lacking. However, both MRCP and ERCP have higher sensitivity (approaching 100%) and each have their own indications when pancreatic injury and ductal disruption is suspected.
      • Melamud K.
      • LeBedis C.A.
      • Soto J.A.
      Imaging of pancreatic and duodenal trauma.
      • Bates D.D.
      • LeBedis C.A.
      • Soto J.A.
      • Gupta A.
      Use of magnetic resonance in pancreaticobiliary emergencies.
      • Kokabi N.
      • Shuaib W.
      • Xing M.
      • Harmouche E.
      • Wilson K.
      • Johnson J.O.
      • et al.
      Intra-abdominal solid organ injuries: an enhanced management algorithm.
      MRCP has the advantage of being non-invasive and is the first choice in a stable patient with suspicion of a pancreatic injury and to diagnose any injury to the pancreatic duct. Intraparenchymal hematoma may cause duct compression (showing as loss of duct on imaging). Differentiation from a true duct disruption may require ERCP to demonstrate contrast extravasation from side- or main-duct injuries. In theory, secretin-enhanced MRCP should improve the diagnostic yield, but there are only a few case series of its use for pancreatic trauma,
      • Hellund J.C.
      • Skattum J.
      • Buanes T.
      • Geitung J.T.
      Secretin-stimulated magnetic resonance cholangiopancreatography of patients with unclear disease in the pancreaticobiliary tract.
      • Gillams A.R.
      • Kurzawinski T.
      • Lees W.R.
      Diagnosis of duct disruption and assessment of pancreatic leak with dynamic secretin-stimulated MR cholangiopancreatography.
      so no current valid recommendation can be made for this technology. Consideration of the use of secretin-enhanced MRCP must be based on the quality of other imaging available (ie the type of CT or MR) and radiological recommendation and institutional experience with this technology. For equivocal findings on MRCP, the current approach would be to proceed to ERCP. Although an invasive test, ERCP remains the ‘reference standard’ and also has the advantage of facilitating therapeutic intervention, by insertion of a stent as an initial temporary attempt at management in otherwise stable and well patients.

      Scoring of injury types and severity

      A common nomenclature for defining injury severity is important for comparison of results and defining treatment strategies for specific injury types. The Organ Injury Scale
      • Moore E.E.
      • Cogbill T.H.
      • Malangoni M.A.
      • Jurkovich G.J.
      • Champion H.R.
      • Gennarelli T.A.
      • et al.
      Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum.
      (OIS) score is universally used by trauma registries as a standard for reporting type and severity of pancreatic injury (Fig. 1). Other available scoring systems exist,
      • Oniscu G.C.
      • Parks R.W.
      • Garden O.J.
      Classification of liver and pancreatic trauma.
      such as the Frey & Wardell
      • Parks R.W.
      Hepatobiliary and pancreatic trauma.
      or the Lucas score
      • Lucas C.E.
      Diagnosis and treatment of pancreatic and duodenal injury.
      that take into account associated duodenal injuries, but these are rarely, if ever, used for reporting in the literature with no major series or authoritative review published over the past decade suggesting any of these scores used to assess combined pancreatoduodenal injuries.
      • van der Wilden G.M.
      • Yeh D.
      • Hwabejire J.O.
      • Klein E.N.
      • Fagenholz P.J.
      • King D.R.
      • et al.
      Trauma whipple: do or don't after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB).
      • Girard E.
      • Abba J.
      • Arvieux C.
      • Trilling B.
      • Sage P.Y.
      • Mougin N.
      • et al.
      Management of pancreatic trauma.
      • Chinnery G.E.
      • Madiba T.E.
      Pancreaticoduodenal injuries: re-evaluating current management approaches.
      • Antonacci N.
      • Di Saverio S.
      • Ciaroni V.
      • Biscardi A.
      • Giugni A.
      • Cancellieri F.
      • et al.
      Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome?.
      • Ragulin-Coyne E.
      • Witkowski E.R.
      • Chau Z.
      • Wemple D.
      • Ng S.C.
      • Santry H.P.
      • et al.
      National trends in pancreaticoduodenal trauma: interventions and outcomes.
      • Subramanian A.
      • Feliciano D.V.
      Pancreatic trauma revisited.
      • Rickard M.J.
      • Brohi K.
      • Bautz P.C.
      Pancreatic and duodenal injuries: keep it simple.
      • Krige J.E.
      • Kotze U.K.
      • Setshedi M.
      • Nicol A.J.
      • Navsaria P.H.
      Surgical management and outcomes of combined pancreaticoduodenal injuries: analysis of 75 consecutive cases.
      However, the combined grading of pancreas and duodenal injury together may have some clinical value for practical decision-making. Currently, most series describe these rare combined injuries by the OIS score for pancreas and duodenum.
      • Moore E.E.
      • Cogbill T.H.
      • Malangoni M.A.
      • Jurkovich G.J.
      • Champion H.R.
      • Gennarelli T.A.
      • et al.
      Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum.
      Notably, such combined injuries occur in a rare minority of patients, reported to occur in less than 8% of all children with pancreatic injury
      • Katz M.G.
      • Fenton S.J.
      • Russell K.W.
      • Scaife E.R.
      • Short S.S.
      Surgical outcomes of pancreaticoduodenal injuries in children.
      and in just over 8% in all patients with pancreatic trauma.
      • Ragulin-Coyne E.
      • Witkowski E.R.
      • Chau Z.
      • Wemple D.
      • Ng S.C.
      • Santry H.P.
      • et al.
      National trends in pancreaticoduodenal trauma: interventions and outcomes.
      As such, it is recognized that for this select patient group, the severity scoring may have less validity and precision for therapeutic decision-making. Largely, experience stems from institutional series with high-volume trauma related to penetrating mechanisms.
      • van der Wilden G.M.
      • Yeh D.
      • Hwabejire J.O.
      • Klein E.N.
      • Fagenholz P.J.
      • King D.R.
      • et al.
      Trauma whipple: do or don't after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB).
      • Chinnery G.E.
      • Madiba T.E.
      Pancreaticoduodenal injuries: re-evaluating current management approaches.
      • Rickard M.J.
      • Brohi K.
      • Bautz P.C.
      Pancreatic and duodenal injuries: keep it simple.
      • Krige J.E.
      • Kotze U.K.
      • Setshedi M.
      • Nicol A.J.
      • Navsaria P.H.
      Surgical management and outcomes of combined pancreaticoduodenal injuries: analysis of 75 consecutive cases.
      • Krige J.E.
      • Navsaria P.H.
      • Nicol A.J.
      Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries.
      Figure 1
      Figure 1The organ injury scale (OIS) by American Association for Surgery of Trauma (AAST) for pancreatic injury severity
      Tabled 1Legend:
      GRADE*Injury Description
      IHematomaMajor contusion without duct injury or tissue loss
      LacerationMajor laceration without duct injury or tissue loss
      IIHematomaInvolving more than 1 portion
      LacerationDisruption <50% of circumference
      IIILacerationDistal transection or parenchymal injury with duct injury
      IVLacerationProximal (to right of superior mesenteric vein) transection or parenchymal injury
      VLacerationMassive disruption of pancreatic head
      *Advance one grade for multiple injuries to same organ, from Moore et al.
      • Moore E.E.
      • Cogbill T.H.
      • Malangoni M.A.
      • Jurkovich G.J.
      • Champion H.R.
      • Gennarelli T.A.
      • et al.
      Organ injury scaling, II: pancreas, duodenum, small bowel, colon, and rectum.
      .
      The OIS scoring system describes the anatomical relation of the injury with a focus on the location (head, body, tail) and the duct (involved, non-involved). This system neglects the overall injury burden to the patient, including the physiological state at presentation, which is usually highly predictive of outcome. It has been suggested that a system that considers other injures and the presence of shock should be used to separate the ‘good’ from the ‘bad’ and the ‘ugly’ injuries, and to relate management to outcome (Table 1).
      • Søreide K.
      Pancreas injury: the good, the bad and the ugly.
      Krige et al.
      • Krige J.E.
      • Spence R.T.
      • Navsaria P.H.
      • Nicol A.J.
      Development and validation of a pancreatic injury mortality score (PIMS) based on 473 consecutive patients treated at a level 1 trauma center.
      suggested a Pancreatic Injury Mortality Score (PIMS) as a composite outcome score based on 5 variables (Table 2) and found an overall good prediction (AUC of 0.84) in a series of 473 patients with pancreatic injuries. Further external validation is needed to test the robustness of this score, but this may prove difficult given that few, if any centres, have the same experience as the vast numbers reported by the Cape Town group over the years.
      • Chinnery G.E.
      • Krige J.E.
      • Kotze U.K.
      • Navsaria P.
      • Nicol A.
      Surgical management and outcome of civilian gunshot injuries to the pancreas.
      • Krige J.E.
      • Spence R.T.
      • Navsaria P.H.
      • Nicol A.J.
      Development and validation of a pancreatic injury mortality score (PIMS) based on 473 consecutive patients treated at a level 1 trauma center.
      • Krige J.E.
      • Kotze U.K.
      • Setshedi M.
      • Nicol A.J.
      • Navsaria P.H.
      Prognostic factors, morbidity and mortality in pancreatic trauma: a critical appraisal of 432 consecutive patients treated at a level 1 trauma centre.
      • Farrell R.J.
      • Krige J.E.
      • Bornman P.C.
      • Knottenbelt J.D.
      • Terblanche J.
      Operative strategies in pancreatic trauma.
      • Krige J.E.
      • Kotze U.K.
      • Hameed M.
      • Nicol A.J.
      • Navsaria P.H.
      Pancreatic injuries after blunt abdominal trauma: an analysis of 110 patients treated at a level 1 trauma centre.
      • Krige J.E.
      • Kotze U.K.
      • Nicol A.J.
      • Navsaria P.H.
      Morbidity and mortality after distal pancreatectomy for trauma: a critical appraisal of 107 consecutive patients undergoing resection at a level 1 trauma centre.
      Table 1Classification of pancreas injury into good, bad and ugly
      Modified from Søreide
      • Søreide K.
      Pancreas injury: the good, the bad and the ugly.
      and reproduced with permissions from Injury, Elsevier© 2015.
      Pancreas injury grade
      OIS/AAST grade.
      PhysiologyOther injuriesTreatmentRisk of Morb.Risk of Mort.Classification
      Suggestion based on the subsequent risk of complications and/or mortality.
      Grade I–IINo shockAbsentNOM ± drain0–10%<5%Good
      ShockPresent>10%<10%Bad
      Grade IIINo shockAbsentNOM ± Resection10–50%<10%
      ShockPresent25–50%10–20%Ugly
      Grade IV–VNo shockAbsentResection, staged>50%<20%
      ShockPresent>50%20–50%
      NOM denotes non-operative management.
      a OIS/AAST grade.
      b Suggestion based on the subsequent risk of complications and/or mortality.
      Table 2Scoring rubric for the Pancreatic Injury Mortality Score (PIMS)
      Reproduced from Krige et al.
      • Krige J.E.
      • Kotze U.K.
      • Setshedi M.
      • Nicol A.J.
      • Navsaria P.H.
      Prognostic factors, morbidity and mortality in pancreatic trauma: a critical appraisal of 432 consecutive patients treated at a level 1 trauma centre.
      with permission from Pancreatology, Elsevier© 2017.
      Age>55 yearsPoints
      Yes5
      No0
      Shocked
      Yes5
      No0
      Major vascular injury
      Yes2
      No0
      Number of associated abdominal injuries
      None0
      11
      22
      ≥33
      AAST pancreatic injury scale
      I1
      II2
      III3
      IV4
      V5
      Total Scorex/20
      Risk GroupsPIMS scoreMortality estimates
      LOW0–4Low <1%
      MEDIUM5–9Medium 15–17%
      HIGH10–20High 50%

      Management

      As addressed in recent systematic reviews and consensus reports,
      • Cimbanassi S.
      • Chiara O.
      • Leppaniemi A.
      • Henry S.
      • Scalea T.M.
      • Shanmuganathan K.
      • et al.
      Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: results from an International Consensus Conference.
      • Ho V.P.
      • Patel N.J.
      • Bokhari F.
      • Madbak F.G.
      • Hambley J.E.
      • Yon J.R.
      • et al.
      Management of adult pancreatic injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma.
      • Koh E.Y.
      • van Poll D.
      • Goslings J.C.
      • Busch O.R.
      • Rauws E.A.
      • Oomen M.W.
      • et al.
      Operative versus nonoperative management of blunt pancreatic trauma in children: a systematic review.
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.
      • Naik-Mathuria B.J.
      • Rosenfeld E.H.
      • Gosain A.
      • Burd R.
      • Falcone Jr., R.A.
      • Thakkar R.
      • et al.
      Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.
      there is scant evidence on which to base current decision-making and management plans. The only two consensus reports that have formally graded the evidence by recognised methodology found weak evidence to make recommendations. In the Eastern Association of Surgery for Trauma (EAST) guidelines using the Population, Intervention, Control, Outcome (PICO) approach, the consensus panel found very low quality evidence with serious risk of bias across all studies used to make recommendations regarding operative versus non-operative management for both grade I/II injuries and for grade III injuries and above.
      • Ho V.P.
      • Patel N.J.
      • Bokhari F.
      • Madbak F.G.
      • Hambley J.E.
      • Yon J.R.
      • et al.
      Management of adult pancreatic injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma.
      Similarly, most statements from an International Consensus Conference
      • Cimbanassi S.
      • Chiara O.
      • Leppaniemi A.
      • Henry S.
      • Scalea T.M.
      • Shanmuganathan K.
      • et al.
      Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: results from an International Consensus Conference.
      using the GRADE
      • Guyatt G.
      • Gutterman D.
      • Baumann M.H.
      • Addrizzo-Harris D.
      • Hylek E.M.
      • Phillips B.
      • et al.
      Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force.
      system, were ‘weak recommendations (2B or 2C)’ based on ‘weak’ or ‘very weak’ evidence.
      • Cimbanassi S.
      • Chiara O.
      • Leppaniemi A.
      • Henry S.
      • Scalea T.M.
      • Shanmuganathan K.
      • et al.
      Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: results from an International Consensus Conference.
      This must be kept in mind when considering recommendations for any approach in management.
      In general, trauma to the pancreas may present in any form, ranging from the mildest type with symptoms resembling mild pancreatitis with transiently elevated serum amylase and lipase after a traumatic insult, to severe pancreatic parenchymal injury, sometimes causing extreme disruption or complete transection of the gland necessitating surgical intervention (Fig. 2). For adults, consensus guidelines have been put forward to suggest best management,
      • Ho V.P.
      • Patel N.J.
      • Bokhari F.
      • Madbak F.G.
      • Hambley J.E.
      • Yon J.R.
      • et al.
      Management of adult pancreatic injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma.
      but the evidence is scarce and the proposed strategies are based on scant data. As for children, there is controversy still to the best management in high-grade injuries.
      • Siboni S.
      • Kwon E.
      • Benjamin E.
      • Inaba K.
      • Demetriades D.
      Isolated blunt pancreatic trauma: a benign injury?.
      • Naik-Mathuria B.
      Practice variability exists in the management of high-grade pediatric pancreatic trauma.
      An outline for management has been suggested in Fig. 3.
      Figure 2
      Figure 2Intraoperative finding of a grade III pancreatic injury. Pancreatic injury sustained after blunt injury. A distal pancreatectomy and splenectomy was performed. Arrows point at pancreatic transection. “P” indicates the pancreas (Image courtesy Dr TG Weiser)
      Figure 3
      Figure 3A proposed, simple management outline for pancreatic injury. For details, see description in the main body of the text

      Conservative management

      For patients who present with a ‘traumatic pancreatitis’, management should commence in a conservative manner, with fluid support, pain control and monitoring of vital signs. These patients usually have no other signs and will likely have a transient increase in lipase levels, which may occur hours after the mechanistic injury and settle without further management. Typically, no specific signs of injury are seen on cross sectional imaging, other than possible signs of ‘pancreatitis’.
      For grade I-II injuries, the treatment would primarily commence with a non-operative, supportive management strategy (Fig. 3). Only for grades III-V injuries should resection, rather than conservative management, be considered. Based on available studies, there seems to be no benefit in terms of mortality with resection over conservative management, but a decrease in length of stay may be achieved with surgery.
      • Mohseni S.
      • Holzmacher J.
      • Sjolin G.
      • Ahl R.
      • Sarani B.
      Outcomes after resection versus non-resection management of penetrating grade III and IV pancreatic injury: a trauma quality improvement (TQIP) databank analysis.
      A recent paper has summarized the conservative strategies in pancreatic trauma in an acronym, dubbed as the acronym ‘SEALANTS’ approach
      • Abdo A.
      • Jani N.
      • Cunningham S.C.
      Pancreatic duct disruption and nonoperative management: the SEALANTS approach.
      based on use of Somatostatin analogues, External drainage, ALternative nutrition, Antacids, Nil per os status, Total parenteral nutrition, and Stenting of the pancreatic duct. The authors suggest that, rather than introducing these in a stepwise fashion, they should be delivered in a ‘shotgun’ approach, with all elements commenced at once. The SEALANTS approach to pancreatic duct disruption is based on extrapolation of results from diverse fields in pancreatology and is only based on anecdotal experience.
      • Abdo A.
      • Jani N.
      • Cunningham S.C.
      Pancreatic duct disruption and nonoperative management: the SEALANTS approach.
      Moreover, some of the elements of the SEALANTS approach, such as the recommended use of somatostatin-analogues, are in conflict with the EAST consensus,
      • Ho V.P.
      • Patel N.J.
      • Bokhari F.
      • Madbak F.G.
      • Hambley J.E.
      • Yon J.R.
      • et al.
      Management of adult pancreatic injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma.
      which does not support the use of octreotide. This highlights that opinions are based on weak data with variable interpretation, and thus institutional practice and extrapolation from other fields of medicine may influence interpretation of data and management preferences.

      Endoscopic management

      Endoscopy may have a central and early role in management and healing of minor duct leaks in some pancreatic injuries (Fig. 3) and facilitate non-operative management by stenting and drainage in patients with delayed presentation of pseudocysts and collections.
      • Bhasin D.K.
      • Rana S.S.
      • Rawal P.
      Endoscopic retrograde pancreatography in pancreatic trauma: need to break the mental barrier.
      Based on data in a systematic review,
      • Bjornsson B.
      • Kullman E.
      • Gasslander T.
      • Sandstrom P.
      Early endoscopic treatment of blunt traumatic pancreatic injury.
      it is suggested that early ERCP and ductal stenting may lead to resolution of symptoms and healing of the injured duct in selected cases (30–100%), even for grade III injuries, thus avoiding major laparotomy and resection.
      • Bjornsson B.
      • Kullman E.
      • Gasslander T.
      • Sandstrom P.
      Early endoscopic treatment of blunt traumatic pancreatic injury.
      Notably, data are based on case series with variable outcome, but endoscopic management has gained both popularity and success, even for main duct disruptions.
      • Bjornsson B.
      • Kullman E.
      • Gasslander T.
      • Sandstrom P.
      Early endoscopic treatment of blunt traumatic pancreatic injury.
      • Rosenfeld E.H.
      • Vogel A.M.
      • Klinkner D.B.
      • Escobar M.
      • Gaines B.
      • Russell R.
      • et al.
      The utility of ERCP in pediatric pancreatic trauma.
      • Bhasin D.K.
      • Rana S.S.
      • Rawal P.
      Endoscopic retrograde pancreatography in pancreatic trauma: need to break the mental barrier.
      • Thomson D.A.
      • Krige J.E.
      • Thomson S.R.
      • Bornman P.C.
      The role of endoscopic retrograde pancreatography in pancreatic trauma: a critical appraisal of 48 patients treated at a tertiary institution.
      • Krige J.E.J.
      • Kotze U.K.
      • Navsaria P.H.
      • Nicol A.J.
      Endoscopic and operative treatment of delayed complications after pancreatic trauma: an analysis of 27 civilians treated in an academic level 1 trauma centre.
      • Delcenserie R.
      • Ricard J.
      • Yzet T.
      • Rebibo L.
      • Regimbeau J.M.
      Conservative endoscopic management for pancreatic trauma.
      • Kim S.
      • Kim J.W.
      • Jung P.Y.
      • Kwon H.Y.
      • Shim H.
      • Jang J.Y.
      • et al.
      Diagnostic and therapeutic role of endoscopic retrograde pancreatography in the management of traumatic pancreatic duct injury patients: single center experience for 34 years.
      Specific endoscopy-based scoring systems for pancreatic duct disruption after blunt trauma have been proposed in a small series from Kanagawa, Japan
      • Takishima T.
      • Hirata M.
      • Kataoka Y.
      • Asari Y.
      • Sato K.
      • Ohwada T.
      • et al.
      Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas.
      and a later modified version from Cape Town, South Africa.
      • Thomson D.A.
      • Krige J.E.
      • Thomson S.R.
      • Bornman P.C.
      The role of endoscopic retrograde pancreatography in pancreatic trauma: a critical appraisal of 48 patients treated at a tertiary institution.
      These scores are quite detailed, with 4–5 categories and several subcategories, thus questioning the robustness of each subcategory. Furthermore, only a proportion of patients undergo ERCP so this restricts the generalizability of the score. Also, none of the scores have been validated in larger, external series. However, both scores point to a high success rate for conservative management of ductal injuries restricted to involve side-branches only. Thus, the scores may be used in patients who proceed to ERCP based on suspicion of, or confirmation of, ductal involvement on MRCP.
      Another more generic endoscopy-based classification system
      • Mutignani M.
      • Dokas S.
      • Tringali A.
      • Forti E.
      • Pugliese F.
      • Cintolo M.
      • et al.
      Pancreatic leaks and fistulae: an endoscopy-oriented classification.
      that may also be applied to ductal leaks caused by injury to the pancreas has been suggested (Table 3). Notably, the system is largely based on development of a fistula or leak after elective pancreatic surgery, so extrapolation of the findings to the trauma setting run the risk of bias or lack of validity. However, in the setting of isolated injuries to the pancreas, the same principles may apply as for post-operative pancreatic fistulas. In this system, type I leaks occur after injury to the pancreatic parenchyma with leaks from small side braches or from the very distal end of the pancreatic duct (tail, IT). The leaks are usually minor with low output and usually heal after pancreatic stenting or nasopancreatic drainage followed by stenting that bridges the leak or at least crosses the sphincter of Oddi enabling decompression of the pancreatic duct. Successful endoscopic stenting as a final therapy is usually reported to be associated with a relatively low prevalence of trauma-related leaks in these series.
      • Das R.
      • Papachristou G.I.
      • Slivka A.
      • Easler J.J.
      • Chennat J.
      • Malin J.
      • et al.
      Endotherapy is effective for pancreatic ductal disruption: a dual center experience.
      Table 3Endoscopy-oriented classification of pancreatic leaks and suggested management
      Reproduced from Mutignani et al.
      • Mutignani M.
      • Dokas S.
      • Tringali A.
      • Forti E.
      • Pugliese F.
      • Cintolo M.
      • et al.
      Pancreatic leaks and fistulae: an endoscopy-oriented classification.
      with permission from Digestive Diseases and Sciences, Springer Nature© 2017.
      Leak typeSubtypeEndoscopic intervention
      IHead (IH)Bridging stent or nasopancreatic drain
      Body (IB)Bridging stent or nasopancreatic drain
      Tail (IT)Bridging stent if duct caliber allows or
      Cyanoacrylate/fibrin glue/other polymer injection at pancreatic tail/fistulous tract
      IIOpen proximal stump (IIO)Bridging stent or
      Nasopancreatic drain or
      Extrapancreatic transpapillary protruding stent
      Closed proximal stump (IIC)EUS + transmural drain of fluid collection from the distal gland into stomach/intestine or
      EUS-guided pancreaticogastrostomy or
      Conversion to open + bridging stent/nasopancreatic drain
      IIIProximal (IIIP)Transpapillary protruding stent to drain the collection
      Distal (IIID)Drain the CBD and the jejunum at the level of anastomosis EUS for transmural drain of peripancreatic collections or pancreaticogastrostomy
      According to the anatomic location, type I fistulas are further classified as H (head), B (body), and T (tail).

      Surgery and resection

      When laparotomy is indicated for other reasons, such as damage control surgery in hemodynamically challenged patient, a pancreatic injury may be found as part of the injury spectrum (Fig. 3). Decisions to drain, repair or resect may be determined based on the perceived benefits or risks of management of the concomitant injuries, e.g. a splenectomy may be done as part of a distal pancreatectomy if the patient is unwell and the risk of organ-salvage outweighs the benefit of immediate surgery.
      • Ho V.P.
      • Patel N.J.
      • Bokhari F.
      • Madbak F.G.
      • Hambley J.E.
      • Yon J.R.
      • et al.
      Management of adult pancreatic injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma.
      • Schellenberg M.
      • Inaba K.
      • Cheng V.
      • Bardes J.M.
      • Lam L.
      • Benjamin E.
      • et al.
      Spleen-preserving distal pancreatectomy in trauma.
      • Potoka D.A.
      • Gaines B.A.
      • Leppaniemi A.
      • Peitzman A.B.
      Management of blunt pancreatic trauma: what's new?.
      Spleen-preserving distal pancreatectomy for trauma is more likely to occur in younger patients with a lower injury score after blunt trauma.
      • Schellenberg M.
      • Inaba K.
      • Cheng V.
      • Bardes J.M.
      • Lam L.
      • Benjamin E.
      • et al.
      Spleen-preserving distal pancreatectomy in trauma.
      Advice on whether to routinely perform splenectomy or splenic salvage remains equivocal in the EAST consensus based on the scant data available.
      • Ho V.P.
      • Patel N.J.
      • Bokhari F.
      • Madbak F.G.
      • Hambley J.E.
      • Yon J.R.
      • et al.
      Management of adult pancreatic injuries: a practice management guideline from the Eastern Association for the Surgery of Trauma.
      Early operative management in patients with pancreatic injury is usually indicated in patients with pancreatic gland injury with severe ductal transection, in those with associated multiple other injuries or vessel injuries and in patients with deranged physiology on admission. In patients with blunt trauma, it is usually the complexity of the pancreatic injury and the subsequent complications that determine the morbidity and length of stay, whereas the presence of concomitant vascular injuries usually determines mortality.
      • Bozdag Z.
      • Kapan M.
      • Ulger B.V.
      • Turkoglu A.
      • Uslukaya O.
      • Oguz A.
      • et al.
      Factors affecting morbidity and mortality in pancreatic injuries.
      In a small, select subgroup of patients, damage control surgery is warranted as a life-saving procedure for these injured patients.
      • Krige J.E.
      • Navsaria P.H.
      • Nicol A.J.
      Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries.
      • Menahem B.
      • Lim C.
      • Lahat E.
      • Salloum C.
      • Osseis M.
      • Lacaze L.
      • et al.
      Conservative and surgical management of pancreatic trauma in adult patients.
      • Krige J.E.J.
      • Kotze U.K.
      • Setshedi M.
      • Nicol A.J.
      • Navsaria P.H.
      Management of pancreatic injuries during damage control surgery: an observational outcomes analysis of 79 patients treated at an academic level 1 trauma centre.
      A ‘trauma Whipple’ is rarely indicated, and only 47 cases were identified when reviewing the NTDB for the years 2008-2010.
      • van der Wilden G.M.
      • Yeh D.
      • Hwabejire J.O.
      • Klein E.N.
      • Fagenholz P.J.
      • King D.R.
      • et al.
      Trauma whipple: do or don't after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB).
      Indeed, in the two largest series to date, only 15 Whipple procedures were done for pancreatic trauma in Seattle, Washington over a 15-year period
      • Thompson C.M.
      • Shalhub S.
      • DeBoard Z.M.
      • Maier R.V.
      Revisiting the pancreaticoduodenectomy for trauma: a single institution's experience.
      and 19 in Cape Town, South Africa over a 22-year period.
      • Thompson C.M.
      • Shalhub S.
      • DeBoard Z.M.
      • Maier R.V.
      Revisiting the pancreaticoduodenectomy for trauma: a single institution's experience.
      Pancreatoduodenectomy for trauma remains a rare procedure outside very high-volume centres,
      • Krige J.E.J.
      • Kotze U.K.
      • Setshedi M.
      • Nicol A.J.
      • Navsaria P.H.
      Management of pancreatic injuries during damage control surgery: an observational outcomes analysis of 79 patients treated at an academic level 1 trauma centre.
      • Thompson C.M.
      • Shalhub S.
      • DeBoard Z.M.
      • Maier R.V.
      Revisiting the pancreaticoduodenectomy for trauma: a single institution's experience.
      • Krige J.E.
      • Nicol A.J.
      • Navsaria P.H.
      Emergency pancreatoduodenectomy for complex injuries of the pancreas and duodenum.
      with most other documentation in the literature being occasional case reports. Penetrating mechanisms account for 70–80% of such injuries requiring resection; immediate resection is typical for injuries to the body and tail, while pancreatic head injuries can be managed either as a staged procedure as part of damage control surgery or following the surgical placement of drains. The associated mortality is high.
      • van der Wilden G.M.
      • Yeh D.
      • Hwabejire J.O.
      • Klein E.N.
      • Fagenholz P.J.
      • King D.R.
      • et al.
      Trauma whipple: do or don't after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB).
      • Krige J.E.J.
      • Kotze U.K.
      • Setshedi M.
      • Nicol A.J.
      • Navsaria P.H.
      Management of pancreatic injuries during damage control surgery: an observational outcomes analysis of 79 patients treated at an academic level 1 trauma centre.
      • Thompson C.M.
      • Shalhub S.
      • DeBoard Z.M.
      • Maier R.V.
      Revisiting the pancreaticoduodenectomy for trauma: a single institution's experience.
      For most hospitals encountering a type of injury that would necessitate a pancreatoduodenectomy, other injuries should take precedence and initial surgical drainage of the pancreatic bed is appropriate until the patient is well enough to undergo final definitive surgery or referral to an appropriate centre with trauma and pancreatic surgery expertise to deal with the injury. Penetrating trauma to the ‘surgical soul’ involving major vessels such as the portal vein, inferior vena cava or mesenteric arteries is highly lethal and control of haemorrhage takes precedence over any pancreatic resection or reconstructive attempts.

      Management of pancreatic injury in children

      Pancreatic injuries in children are somewhat different from those occurring in adults. In children, pancreatic injury occurs in approximately 0.3% of all injuries and 0.6% of all abdominal injuries, making pancreatic trauma a relatively rare event overall.
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.
      One fifth of the pancreatic injuries are isolated and occur after relatively minor incidents,
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.
      such as ‘handle bar injuries’ from falling on a bike,
      • Dai L.N.
      • Chen C.D.
      • Lin X.K.
      • Wang Y.B.
      • Xia L.G.
      • Liu P.
      • et al.
      Abdominal injuries involving bicycle handlebars in 219 children: results of 8-year follow-up.
      sport activities, or other similar mechanisms.
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.
      • Moore T.
      Organ crushing tackle: pancreatic, bowel and splenic artery injury from blunt abdominal trauma playing rugby union.
      Thus, children may not initially present following the same injury mechanism as adults, and may present late or with so-called ‘occult injury’, with a dull, non-specific, diffuse abdominal pain after an apparently minor insult (Fig. 3). As children may be less likely to undergo CT for what are perceived minor injuries, one should recognize the low sensitivity of ultrasonography and have a high degree of suspicion and a corresponding low threshold for CT or MRI if symptoms do not settle, or if blood results or vital signs indicate changes that need further investigation.
      Two recent systematic reviews of children with pancreatic injury
      • Koh E.Y.
      • van Poll D.
      • Goslings J.C.
      • Busch O.R.
      • Rauws E.A.
      • Oomen M.W.
      • et al.
      Operative versus nonoperative management of blunt pancreatic trauma in children: a systematic review.
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.
      included some 20 studies each for a total of almost 1000 patients. Pancreatic injury is the fourth most frequent abdominal organ injury in children and mostly occurs in the age-group between 5 and 18 years.
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.
      Handlebar injury to the abdomen is reported as the trauma mechanism in about a quarter of all children.
      • Koh E.Y.
      • van Poll D.
      • Goslings J.C.
      • Busch O.R.
      • Rauws E.A.
      • Oomen M.W.
      • et al.
      Operative versus nonoperative management of blunt pancreatic trauma in children: a systematic review.
      Most children with grade I-II injuries can be managed non-operatively (Figure 1, Figure 3), while about 50% of grade III-V injuries can be managed non-operatively.
      • Koh E.Y.
      • van Poll D.
      • Goslings J.C.
      • Busch O.R.
      • Rauws E.A.
      • Oomen M.W.
      • et al.
      Operative versus nonoperative management of blunt pancreatic trauma in children: a systematic review.
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.
      The most frequent complication associated with non-operative management is development of a pseudocyst which occurs in almost 15–20% of patients, but about half to two-thirds of these can be handled non-operatively and recover without further operative management.
      • Koh E.Y.
      • van Poll D.
      • Goslings J.C.
      • Busch O.R.
      • Rauws E.A.
      • Oomen M.W.
      • et al.
      Operative versus nonoperative management of blunt pancreatic trauma in children: a systematic review.
      • Naik-Mathuria B.J.
      • Rosenfeld E.H.
      • Gosain A.
      • Burd R.
      • Falcone Jr., R.A.
      • Thakkar R.
      • et al.
      Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.
      • Mora M.C.
      • Wong K.E.
      • Friderici J.
      • Bittner K.
      • Moriarty K.P.
      • Patterson L.A.
      • et al.
      Operative vs nonoperative management of pediatric blunt pancreatic trauma: evaluation of the national trauma data bank.
      Notably, it is recognized that there is high variability between surgeons in terms of choice of management of pancreas injury in children, particularly for high-grade injuries,
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      Practice variability exists in the management of high-grade pediatric pancreatic trauma.
      • Westgarth-Taylor C.
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      Paediatric pancreatic trauma: a review of the literature and results of a multicentre survey on patient management.
      and there is considerable heterogeneity in the case series reported.
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      Practice variability exists in the management of high-grade pediatric pancreatic trauma.
      This is largely reflected in variation in outcomes such as time to enteral nutrition and length of hospital or intensive care stay, but not in mortality.
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      • et al.
      Operative vs nonoperative management of pediatric blunt pancreatic trauma: evaluation of the national trauma data bank.
      Generally, non-operative management in children is successful and surgery is most often undertaken for injuries to the tail (Fig. 2) with ductal disruption.
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      • Gulack B.C.
      • Rice H.E.
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      Management of blunt pancreatic trauma in children: review of the National Trauma Data Bank.
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      • Patterson L.A.
      • et al.
      Operative vs nonoperative management of pediatric blunt pancreatic trauma: evaluation of the national trauma data bank.
      Morbidity from the injury remains high. Mortality from pancreatic injury is rare in children and is usually attributed to associated injuries, such as severe head trauma.
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      • Goslings J.C.
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      Operative versus nonoperative management of blunt pancreatic trauma in children: a systematic review.
      • Antonsen I.
      • Berle V.
      • Søreide K.
      Blunt pancreatic injury in children.

      Outcomes after pancreatic injury

      Short-term outcome

      Mortality depends on a number of associated factors and is rarely caused by the pancreatic injury itself. In children, the mortality is reported to be very low,
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      • Wong K.E.
      • Friderici J.
      • Bittner K.
      • Moriarty K.P.
      • Patterson L.A.
      • et al.
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      • Dai L.N.
      • Chen C.D.
      • Lin X.K.
      • Wang Y.B.
      • Xia L.G.
      • Liu P.
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      with most deaths attributed to other severe injuries of the head and chest.
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      Blunt pancreatic injury in children.
      The outcome after penetrating injuries differs between stab wounds and gunshot wounds, with stab wounds
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      • et al.
      Hepatobiliary factors influencing morbidity rates after pancreatic stab wounds.
      having a lower risk of overall mortality (<5%) compared to gunshot wounds (>20%),
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      • Krige J.E.
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      • Navsaria P.
      • Nicol A.
      Surgical management and outcome of civilian gunshot injuries to the pancreas.
      likely reflecting the higher velocity and energy involved with increased risk of additional vascular injures in the latter. While mortality after stab-wounds is relatively low, the morbidity is high, with pancreatic fistulas developing in over 10%.
      • Bookholane H.L.
      • Krige J.E.J.
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      An analysis of predictors of morbidity after stab wounds of the pancreas in 78 consecutive injuries.
      As noted previously, associated organ injuries, vascular involvement and physiological compromise (e.g. shock) are strong predictors of mortality in these patients.

      Long-term outcome

      Overall, long-term outcome is good as the majority of injuries are low-grade and self-limiting with supportive care. The most prevalent sequela across injury severity types appears to be the risk of pseudocyst development. Pseudocysts may be dealt with as for other aetiologies, for which conservative observation is the predominant initial approach. However, a more aggressive approach towards pancreatic duct stenting can be considered, given that the pseudocyst likely reflects disruption of ductal structures after trauma, rather than general inflammatory changes, as seen in acute pancreatitis. Drainage procedures for unresolved pseudocysts should be dictated by symptoms and anatomical location, with preference for minimally invasive internal drainage procedures such as an endoscopic cystgastrostomy over open surgery whenever possible.
      In the very long-term, exocrine and endocrine function appears to be related to overall age and time from injury rather than the surgical treatment per se.
      • Morita T.
      • Takasu O.
      • Sakamoto T.
      • Mori S.
      • Nakamura A.
      • Nabeta M.
      • et al.
      Long-term outcomes of pancreatic function following pancreatic trauma.
      To date, no long-term assessment in a large series of all patients following pancreatic injury has been undertaken, so extrapolation from patients with pancreatitis-sequelae or who have undergone distal or pancreas head resections for other benign conditions may be used for assessing the long-term outcome in terms of both endocrine and exocrine function.

      Conclusions

      Pancreatic injuries are rare and usually of a severity that can be managed non-operatively with a high degree of success. Serum amylase as a screening test is unreliable for diagnosis. CT is less reliable as an imaging tool, and MRCP is the preferred choice for cross sectional imaging. ERCP may be useful for confirmation if a ductal leak is suspected, both to diagnose and to treat with a stent as an initial management (Fig. 3). Ductal disruption can be handled by early stenting with or without drainage in many cases, but distal resection may be an alternative. Severe disruption and associated parenchymal tissue loss is more frequent in severe penetrating injuries and may require urgent surgery. Non-operative management has a high degree of success, particularly in children. A pseudocyst may develop in one-fifth of all patients, with most managed conservatively. Long-term exocrine and endocrine function is generally good and usually related to patients' age and time from injury. The evidence-base for decision-making remains scant and largely based on registry data and retrospective multicentre observational studies.

      Conflicts of interest

      None declared.

      Appendix A. Supplementary data

      The following is the supplementary data related to this article:

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