Management of blunt pancreatic trauma: what's new?

 

Pancreatic injuries, both blunt and traumatic, are relatively uncommon, occurring in 0.2–2 % of all trauma patients and 3–12 % of patients with an abdominal injury. Nevertheless, these injuries are associated with significant mortality, primarily due to concomitant or related injuries. In instances of pancreas-specific mortality, the most critical diagnostic question relates to injury to the main pancreatic duct, associated as it is with higher mortality and morbidity.
 
Following penetrating abdominal trauma, diagnosis of such injury is most often only made at the time of laparotomy. In patients without an indication for urgent laparotomy, diagnosis can therefore be a challenge. The retroperitoneal location of the pancreas additionally may cause the clinical signs of pancreatic injury to be subtle and become apparent only later in the post-injury course, as pancreatic secretions become activated and pancreatic and peri-pancreatic inflammation increases. Serum amylase determination is the most widely used laboratory test to aid in the diagnosis. It is, however, neither sensitive nor specific. Due to the aforementioned retroperitoneal location of the pancreas, both diagnostic peritoneal lavage (DPL) and ultrasonography have likewise proven relatively insensitive in detecting pancreatic injury.
 
In terms of imaging modalities, Computed tomography (CT) is a similarly imperfect diagnostic aid. Endoscopic Retrograde Cholangiopancreatography (ERCP) and more recently, Magnetic Resonance Cholangiopancreatography (MRCP), are both proving to be more efficient imaging tools in diagnosing these injuries.
 
Regarding management the status of the pancreatic duct, the location of injury (proximal versus distal), and the patient's overall status are the major determinants of the appropriate course of treatment.Recent literature has favoured simplified protocols utilizing external drainage and distal pancreatectomy rather than more complex procedures. In terms of innovations: Fibrin glue and other sealants have been reviewed with respect to their ability to decrease the incidence of pancreatic leak/fistula in elective cases. No clear benefit was established for
this approach.
 
Octreotide, an eight-amino-acid synthetic analogue of somatostatin, has however been shown to reduce morbidity and enhance closure of pancreatic fistulae after elective pancreatic resections for cancer and chronic pancreatitis. Surgery remains the elected treatment approach for main pancreatic ductal injury, with distal pancreatectomy preferred for most injuries and more conservative surgical management for proximal ductal injuries involving the head of the pancreas.

   

Summary reproduced with kind permission from MedSpec Publishing.

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References
Potoka DA, Gaines BA, Leppäniemi A, Peitzman AB. Management of blunt pancreatic trauma: what's new?. Eur J Trauma Emerg Surg. 2015;41(3):239-250. doi:10.1007/s00068-015-0510-3
Accessed June 2019. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26038029/
 

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