Clinical Challenges in Trauma Surgery: Approach to Pancreatic Injury

Mar 28, 2024

What do crawfish and pancreatic injuries have in common? Listen in as experts dissect the AAST grading system for these delicate injuries. They reveal that not all pancreas injuries scream for surgery; some can be managed conservatively. Imaging challenges are discussed, particularly the limitations of CT scans. The hosts also debate operative strategies for various grades of injury and emphasize the need for careful management of complications like pancreatic fistulas. Discover why respecting the pancreas is crucial for surgical success!

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INSIGHT

AAST Grading Simplifies Pancreatic Injuries

AAST pancreatic grades range from 1 (superficial, no duct) to 5 (massive head disruption).
Grades 3–4 involve duct injury; 3 is distal, 4 is proximal and harder to manage.

ADVICE

Use MRCP When CT Leaves Duct Unclear

Use CT as the initial test but know its sensitivity for duct injury is low, especially early after trauma.
If CT cannot rule out duct injury in a stable patient, obtain MRCP for further evaluation.

ADVICE

Observe Stable Low-Grade Injuries

Manage low-grade (AAST 1–2) pancreatic injuries non-operatively if the patient is stable and has no other indications for surgery.
Observe clinically for a few days while monitoring pain, oral intake, and ambulation.

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Eat when you can, sleep when you can, and don’t F with the pancreas! What happens when that third rule goes wrong, and why do people say pancreas injuries are like eating crawfish? Whether you love the pancreas or just the mention of the P-word strikes fear in your heart, or if you just want the answer to the aforementioned questions, join Drs. Cobler-Lichter, Kwon, and Meizoso, as they guide you through all this and more!

Hosts:
- Michael Cobler-Lichter, MD, PGY3, University of Miami/Jackson Memorial Hospital/Ryder Trauma Center, @mdcobler (twitter)
- Eugenia Kwon, MD, Trauma/Surgical Critical Care Fellow, University of Miami/Jackson Memorial Hospital/Ryder Trauma Center
-Jonathan Meizoso, MD, MSPH Assistant Professor of Surgery, 4 years in practice, University of Miami/Jackson Memorial Hospital/Ryder Trauma Center, @jpmeizoso (twitter)

Learning Objectives:
- Describe the AAST grading system for pancreatic injuries
- Come up with a treatment plan for each grade of pancreatic injury
- Identify commonly associated injuries with pancreatic trauma
- List potential complications of pancreatic trauma and/or surgery

Quick Hits:
1. Pancreas injuries do not all require a trip to the operating room. Low grade injuries should be managed with a trial of nonoperative management if there are no other operative indications
2. CT is the best initial imaging modality, although it has low sensitivity. If there is high concern for a pancreas injury based on mechanism or associated injuries, further investigation is required.
3. Pancreas injuries are like crawfish: suck the head and eat the tail.
4. Injuries to the left of the SMV can generally be treated with distal pancreatectomy and splenectomy, whereas injuries to the right of the SMV are usually drained.
5. Its important to identify and address any concomitant injuries, with duodenal injuries being the most common in higher grade injuries.
6. In the case of the dreaded grade 5 injury, the safe answer is to come back and do your reconstruction at a later time.

References
1. https://www.westerntrauma.org/western-trauma-association-algorithms/management-of-pancreatic-injuries/
2. Bassi, Claudio et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery, Volume 161, Issue 3, 584 – 591
https://pubmed.ncbi.nlm.nih.gov/28040257/

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