An overview of pancreatic trauma

Abstract

Pancreatic trauma remains a challenge to a trauma surgeon even with extensive advancement in medicine. The mortality and morbidity associated with this injury remain high. A high index of suspicion, mechanism of injury, and early identification hold key in the final outcome. The management of pancreatic injury should involve a multidisciplinary team comprising of trauma surgeons, radiologists, and gastroenterologists. This review highlights the burden of the pancreatic injury and its management.

Introduction

Trauma is a major public health problem worldwide. It is one of the leading causes of death and disability in both developed and developing countries. About 5.8 million people of all ages and socioeconomic groups die each year from both unintentional and violence-related injuries that is, every 5 seconds someone in the world dies as a result of an injury. This accounts for 10% of the world's deaths, 32% more than the number of fatalities that result from malaria, tuberculosis, and HIV/AIDS combined. For people between the ages of 5 and 44 years, injuries are 1 of the top 3 causes of death.^[1] The National Academy of Science in the United States has labeled injury as the ‘neglected disease of modern society.’^[2]

Major trauma is defined as an injury severity score (ISS) of 15 or above. Abdominal trauma is commonly seen amongst polytrauma patients with a reported incidence of 7% to 10%. 1 in 10 trauma-related deaths occurs due to blunt abdominal trauma.^[3] Hepatobiliary injury is a major cause of morbidity and mortality in patients with abdominal trauma.^[4] In patients with blunt abdominal trauma, injuries to solid organs predominate, with splenic and liver injury being commonest, while trauma to the pancreas is uncommon with a reported incidence of 0.4% to 12%. Owing to its retroperitoneal location, pancreatic injuries are often associated with other organ injuries, and cause significant morbidity and mortality.^[5] The delay in diagnosis and missed pancreatic injuries add to increased morbidity and mortality. Hence, it is important that surgeons are aware of the challenges and management principles of the pancreatic injury.

Incidence and mechanism of pancreatic trauma

Injuries to the pancreas occur in approximately 5% of patients with blunt abdominal trauma,^[6] 6% of patients with gunshot wounds to the abdomen,^[7] and 2% of patients with stab wounds to the abdomen.^[8] The reported incidence ranges from 0.4% to 12%. Akhrass et al^[9] had reported a 0.4% incidence of blunt pancreatic injury while Lin et al^[10] reported 5.4% incidence of blunt pancreatic trauma with 1.3% incidence of high-grade pancreatic injury. Duchesne et al^[11] reported 0.6% incidence of pancreatic injury, while we at our center reported an incidence of 1.2%.

Because of its retroperitoneal location and proximity to multiple important structures, isolated pancreatic injuries are rarely seen. Asensio et al^[12] reported on 18 patients with combined pancreaticoduodenal injuries with an average of 2.7 associated nonvascular injuries and 0.89 associated vascular injuries per patient. Bradley et al^[13] had reported 41.5% incidence of isolated pancreatic injuries.

Since pancreas is a retroperitoneal structure, it becomes difficult to screen the pancreas with ultrasonography (USG) or routine radiology. As such, it becomes important that a clinician is aware of the mechanisms of injuries which may lead to a pancreatic injury. Both blunt and penetrating trauma may cause pancreatic injury. After blunt abdominal trauma, injuries to the pancreas are most commonly associated with trauma to the duodenum, liver, and spleen. Conversely, victims of penetrating trauma most frequently have associated injuries to the stomach, major vascular structures, liver, colon, spleen, kidney, and duodenum.

Acceleration–deceleration injury and direct compression force in the epigastrium is responsible for pancreatic injury. Since spine is immobile and pancreatic tail is mobile, a shearing force between the 2 may lead to pancreatic injury at neck and body as is seen in high-velocity motor crashes. Moreover, the direct impact on epigastrium can also lead to pancreatic injury by compressing the pancreas against the spine. Motor vehicle crash is the most common cause of pancreatic injury, with steering wheel impact being a distinctive mechanism of injury. Lin et al reported steering wheel injury in 71% of the cases as the causative mechanism. Similarly, Duchesne et al^[11] reported steering wheel injury in 33 (94.2%) cases followed by fall and work-related crush injury in 1 (2.8%) case each. Another important mechanism is bicycle handlebar injury, especially in pediatric population, with Sutherland et al^[14] reporting it as the commonest cause in high-grade pancreatic injuries.

Grading system

To standardize the diagnosis and treatment of pancreatic injuries, the American Association for the Surgery of Trauma (AAST) published a pancreas Organ Injury Scale (OIS) in 1990 (Table 1).^[15] This organ injury system has been used widely over last many years in grading pancreatic trauma as it is useful in guiding the management and also helps to correlate with other organ injury scores. This scale has provided a common way of describing the injury and its severity. This scale involves 5 grades, which are determined by the ductal integrity and by the anatomic location of injury. These 2 factors are important as they guide the management, with operative management being limited to patients with ductal disruption only (Grades 3–5). However, it is important to understand that a major drawback of AAST grading system is that it does not incorporate physiological parameters and pre-existing comorbid conditions of a patient, which have a major impact on the final outcome.

Table 1: AAST organ injury scoring for pancreatic trauma.^[15]

Injury severity score

ISS is a validated score for anatomical grading of injuries in trauma patients. It involves grading of an injury from 1 to 6, based on which final score is derived which ranges from 1 to 75.^[16] Pancreatic trauma is usually associated with other injuries, which increase the overall ISS of the patient. Ilahi et al^[17] reported a mean ISS of 29 ± 13 in 40 patients with blunt pancreatic injuries. Vasquez et al^[8] described 62 patients with penetrating pancreatic trauma with a mean ISS of 28 ± 17. Similar results have been shown by other studies as well. A high range of ISS also suggests that it is associated with injuries to other body regions as well and not only abdominal injuries, signifying the high impact of injury a patient bears when he/she suffers pancreatic trauma.

Diagnosis

The signs and symptoms of pancreatic injury are vague and nonspecific. Therefore, it is important to keep a high index of suspicion for possible pancreatic injury in trauma patients based on the mechanism of injury, even in the absence of any clinical signs or symptoms of pancreatic injury. A seat belt sign over abdomen, steering wheel injury or a handlebar injury over epigastrium are notable distinct features and should arouse a high index of suspicion of pancreatic injury. Emphasis on knowing the mechanism of injury is important due to the fact that clinical signs may not be evident in early phases of injury and they may get masked due to other injuries. Early symptoms may be extremely subtle being limited to mild epigastric pain while in delayed cases it may present as peritonitis. Missed pancreatic injury can also present as acute fluid collection or pancreatic pseudocyst. As such, the diagnosis of pancreatic injury is aided by investigations like serum amylase, ultrasound of the abdomen, multislice contrast enhanced computed tomography (CECT) scan of the abdomen, endoscopic retrograde cholangiopancreaticography (ERCP), and magnetic retrograde cholangiopancreaticography (MRCP).

• (1) Serum amylase and lipase levels: Serum amylase and lipase levels have low sensitivity and specificity for the diagnosis of pancreatic injury. Bradley et al^[13] found that serum amylase levels were elevated among 82% of people with documented pancreatic injuries. Jones^[18] and Wisner et al^[19] reported that 1/3 of patients with injuries as severe as complete pancreatic transaction had serum amylase concentrations within the normal range. However, Takishima et al^[20] observed that the presence of hyperamylasemia after blunt pancreatic trauma is time-dependent; elevated serum amylase was present in all their cases when the samples were collected more than 3 hours following injury. They concluded that serum amylase levels, determined before this time period, were not diagnostic. Mahajan et al did a systematic review of pancreatic enzymes in blunt pancreatic trauma patients and found that elevation of these enzyme levels is time-dependent and non-diagnostic in the first 6 hours of injury. It has also been demonstrated that there is no relation between the degree of pancreatic trauma and the level of hyperamylasemia. We have also shown similar results in patients with blunt abdominal trauma.^[21] We studied 55 patients with pancreatic injury and found normal serum amylase levels in 33% of patients in the first 24 hours of injury. Further, they may be elevated in other abdominal injuries as well which was shown by our study on 55 patients with blunt trauma abdomen. We had excluded patients with pancreatic injury and found elevated amylase and lipase levels in solid organ as well as hollow viscus injuries.^[22] Having said that, it becomes important to understand that a raised pancreatic enzyme level should raise a suspicion of a pancreatic injury. However, normal enzyme levels should not be used to rule out pancreatic injury, especially in the first 6 hours of injury.
• (2) USG abdomen: Most patients with penetrating abdominal trauma associated with hypotension, peritonitis, or evisceration proceed to the operating room without much diagnostic workup. In the hemodynamically stable patient with blunt trauma in whom there is a suspicion of pancreatic trauma, additional diagnostic studies are warranted. USG abdomen has a limited role in identifying pancreatic injury because of the retroperitoneal location of pancreas. However, recently the Contrast-Enhanced Ultra Sonography (CEUS) is being studied extensively for identification of pancreatic injuries. This modality can be of utility in pediatric and pregnant populations as it avoids radiation and can be performed at bedside. Lv et al reviewed 22 cases with pancreatic injury and were able to identify pancreatic injury in 21 patients. They were able to identify 6 patients with ductal injury out of 7 patients.^[23] However, it was a retrospective study and there remains a possibility of bias. Further, the sample size was small and a greater number of studies with larger sample size are required to reach a definite recommendation. Also, this modality is operator dependent. Thus, as of now CEUS remains under research for pancreatic injury trauma and more studies are required.
• (3) CECT scan: A multi-slice CECT scan of the abdomen represents the best non-invasive diagnostic method for the detection of pancreatic injury (Fig. 1). However, the reported sensitivity of multidetector computed tomography (MDCT) ranges from 43% to 95%.^[17,24–26] Ilahi et al^[17] demonstrated an overall sensitivity of only 68% with a correct injury grade in less than 50% of the 40 patients in their series. Similarly, Udekwu et al^[26] found that the overall accuracy of the CECT scan for diagnosis of pancreatic trauma was lowest among all abdominal organs. Akhrass et al^[9] Jeffrey et al^[27], and Cook et al^[28] have independently found that the CECT to be “normal” in up to 40% of patients with an operatively proven pancreatic injury, while Teh et al^[29] reported a sensitivity and specificity of 91%. Similarly, at our center we achieved a sensitivity of 94.7% and a specificity of 100% of MDCT.^[30] This gross variation in the sensitivity is due to the advancements in CT technology over the years and also due to the fact that MDCT may miss pancreatic injury when done early, especially in the first 12 hours of injury. So, normal initial findings do not exclude appreciable pancreatic injury, and repeated CECT scan in the light of continuing symptoms may improve its diagnostic efficiency when clinical features of the patient demand.
• At our center, we divide the CT findings into hard (direct) signs and soft (indirect) signs.^[31] Hard signs are definite signs of pancreatic injury, while soft signs are indirect signs of pancreatic injury and would require further imaging to definitely diagnose a pancreatic injury (Table 2). A major drawback of CT imaging remains in delineation of ductal status, especially in borderline cases. Wong et al^[24] have suggested that when there is laceration of more than half of the parenchymal tissue as determined on abdominal CECT imaging, major duct injury should be suspected. Gordon et al^[32] evaluated 53 patients with pancreatic injury and reported simple peripancreatic fluid as most sensitive for ductal injury (100%) while active hemorrhage within pancreatic parenchyma was most specific for ductal injury (100%). Laceration >50% was found to have a specificity of 95.1%. However, the study population was small and the results were obtained on only 2 patients with active hemorrhage and 5 patients with laceration >50%. At our center, we evaluated 24 patients with pancreatic injury in whom CT could successfully identify 18/19 ductal injuries and ruled out successfully in 5/5 patients.^[30]
• However, even with these gratifying results, there are certain pitfalls of CT in pancreatic trauma. Cirillo et al^[33] reported that retroperitoneal fat can make small defects difficult to identify and other abdominal visceral injuries can mask pancreatic injury. Further, a pancreatic cleft may be mistaken for a pancreatic laceration. These can be differentiated by the presence of fluid and surrounding inflammation in pancreatic laceration, while cleft has a lining of fat with no features of adjacent inflammation.^[31] Also, pancreatic fragments may be in close apposition which may mask a laceration. Although CT has its inherent drawbacks, still CT remains the investigation of choice for identifying pancreatic injury in patients with blunt trauma abdomen. It also helps in identifying and ruling out other abdominal injuries.
• (4) Magnetic retrograde cholangiopancreaticography: MRCP can noninvasively delineate the pancreatic parenchyma and the morphology of the pancreatic duct. The modality is of value in cases in which findings of MDCT are equivocal about ductal integrity. In a study of 7 patients with confirmed pancreatic injury, Soto et al^[34] found that MRCP was able to delineate the site of pancreatic disruption and also the part of the duct located beyond the site of duct disruption.
• Although MRCP is a good non-invasive modality for demonstration of ductal system, there are some limitations to it. MRCP is a non-dynamic study where real-time visualization of ductal filling and extravasations are not seen; the pancreatic duct injury in a non-dilated duct may, therefore, be missed. Rosenfeld et al^[35] reviewed MRCP and MDCT in pediatric population and concluded that MRCP may be more useful in identifying the duct but has no added advantage over CT in determining ductal integrity. Thus, further studies are required to reach a definite conclusion about the usefulness and cost-effectiveness of MRCP in pancreatic trauma.
• (5) Endoscopic retrograde cholangiopancreaticography: ERCP is the most accurate method for detecting pancreatic duct trauma in the physiologically stable patient, by demonstrating extravasations of contrast medium from the pancreatic duct system.^[36]
• Patients with raised serum amylase level, persistent abdominal pain, and questionable abdominal CT findings, who are being considered for non-operative management (NOM), should have the integrity of the duct system demonstrated.^[37] It also has therapeutic role as pancreatic ductal stenting and transgastric cystoenterostomy can be performed, thus supplementing NOM.^[38] Takishima et al^[39] evaluated 40 patients with blunt pancreatic injury. They introduced a classification system using ERCP results (Table 3).
• Kim et al. studied patients with pancreatic trauma in whom CECT scan and ERCP was performed to predict main pancreatic duct (MPD) injury. ERCP predicted status of MPD in all case whereas CECT scan could predict MPD injury in only 6 out of 11 (55%) patients and missed in 3 patients and gave a false-positive result in 2 others.^[40] Keil et al^[41] also studied 25 pediatric patients of suspected pancreatic injury and concluded that ERCP is helpful in excluding ductal injury. However, ERCP is an invasive investigation and is associated with procedure-related complications like acute pancreatitis. Hence, in the present era of MRCP, it should not be used as a diagnostic tool.^[30] However, in cases who remain equivocal even after MDCT and MRCP, it may be done to establish ductal integrity.

FIGURE 1: CECT abdomen showing (A) Garde 3 pancreatic injury, (B) Grade 4 pancreatic injury (C) multiloculated collections in a missed pancreatic injury (D) solitary, large pseudocyst after pancreatic injury. CECT = contrast enhanced computed tomography.

Table 2: CT signs of pancreatic trauma.^[31]

Table 3: ERCP grading of pancreatic trauma by Takishima et al.^[39]

Treatment

The management of pancreatic injury depends on hemodynamic status, time to presentation, degree of pancreatic parenchymal injury, status of MPD and associated injuries. Bradley et al demonstrated a correlation between grades of pancreatic injury and outcome using the AAST-OIS system. They had also shown that ductal status is an important predictor of outcome in pancreatic trauma and is essential for establishing the basis for treatment decision.^[13]

Wisner et al^[19] and Leppäniemi et al^[42] have independently shown that a delay in the diagnosis of pancreatic injury increases pancreas-related morbidity and mortality. Bradley et al^[13] and Oláh et al^[43] have shown that pancreatic injury has high rates of morbidity and mortality, with overall complications rates up to 62%, reaching 80% when diagnosis is made >24 hours after injury. There is a wide range of modalities available for management of pancreatic injuries depending on the grade of injury. Western Trauma Association propsoed an algorithm in 2013 for management of pancreatic injuries.^[44]

• (1) Grades 1 and 2 pancreatic injury: Although many authors in the past had advocated drainage of low-grade pancreatic injury, the recent series of management of low-grade pancreatic injury have shown better outcome with NOM as in other solid organ injuries. Patton et al^[45] had shown that surgical intervention was always indicated for pancreatic blunt injury with the use of wide drainage of the pancreas for Grades 1 and 2 and complex surgical intervention for Grades 3, 4, and 5 injuries. However, Akhrass et al^[9] demonstrated that patients with low grade blunt pancreatic injury (LGBPI), confirmed by laparotomy, had higher morbidity with external drainage in comparison to exploration without drainage. Similarly, Duchesne et al reported that NOM of LGBPI diagnosed by CT scan was successful in the majority of hemodynamically stable patients, with low morbidity and mortality.^[11] These injuries are nowadays invariably managed non-operatively, with surgical exploration being limited to hemodynamic unstable patients due to intra-abdominal hemorrhage or exploration required for associated injuries. However, it is essential to rule out any ductal injury by imaging. Further, the components of NOM in a low-grade pancreatic injury have not been clearly defined just like ATOMAC guidelines for splenic and liver trauma in children.^[46] At our center, we follow hemodynamic monitoring, analgesics, stress ulcer prophylaxis and clinical evaluation of abdomen as a part of NOM. Early enteral feeding is recommended if there is no contraindication for it. These low-grade injuries, when found incidentally on exploratory laparotomy, can be managed with drain placement and/or suture repair. Eastern Association for the Surgery of Trauma analyzed 14 articles and studied 299 patients. They found that intra-abdominal abscess formation was higher in patients undergoing resection for low-grade pancreatic injuries and recommended non-resectional management when these injuries were found on exploratory laparotomy.^[47]
• (2) Grade 3 pancreatic injuries: Distal pancreatectomy (DP) has been recommended as a treatment of choice for these injuries.^[47] Other procedures that have been utilized include distal pancreatico-gastrostomy, roux-en-Y pancreatico-jejunostomy and stenting with repair of the duct and pancreas. However, there has been a recent trend of initial NOM of these injuries followed by management of its complications, especially in pediatric population. This concept has evolved in the light of the fact that morbidity is high when the injury is diagnosed late leading to delay in operative intervention. Kao et al^[48] showed that pancreatic complications and length of hospital stay were higher in patients with delayed diagnosis. Koh et al performed a systematic review of pediatric pancreatic trauma patients. They included 365 patients with high-grade pancreatic injury of whom 167 patients underwent NOM initially with a success rate of 89% (148/167).^[49] Further, NOM in pancreatic trauma has been supplemented by Endoscopic management. Kong et al^[50] managed 15 patients of Grade 3 pancreatic injury with endoscopy with procedures including naso-jejunal tube placement, transpapillary stent placement, and diagnostic ERCP. Kim et al^[51] also reviewed the role of endoscopy and found that in 15 out of 43 cases ERCP and stenting could be performed successfully, thus avoiding laparotomy. However, further studies are required to evaluate the role of NOM and ERCP in pediatric pancreatic trauma, and whether the same can be applied to adult population as well.
• Although at present, DP is the standard surgical approach in Grade 3 pancreatic injury, preservation of spleen during DP is controversial. But many recent series of DP has advocated spleen preservation whenever possible. Carrère et al^[52] found higher rate of complications in splenectomy group (13% vs 34%, P = .03). Goh et al^[53] had shown that splenectomy was associated with an increased risk of developing pancreatic fistula and nonpancreatic fistula related complications. Richardson and Scott-Conner^[54] and Aldridge and Williamson^[55] have advocated DP with spleen preservation a safe and feasible procedure. We have also shown that spleen preserving DP is a safe option.^[21] Lin et al^[56] reviewed 51 patients who underwent DP for pancreatic trauma, of whom 23 underwent spleen preserving DP and 28 underwent DP with splenectomy. They found that patients who underwent spleen preserving DP were younger and had a shorter median time interval from injury to DP. Thus, if possible, especially in pediatric population spleen preserving DP should be tried. Management of remnant pancreatic stump remains controversial with no clear recommendation at present. Diener et al^[57] conducted an Randomized controlled trial (RCT) (DISPACT Trial) comparing stapling vs suture closure after DP and found no significant reduction in pancreatic fistula rates after stapled closure. However, Byrge et al^[58] did a retrospective review and found stapled closure superior to suture repair. Regardless of the technique of closure of pancreatic stump, it is essential to close the stump and ligation of duct, if possible.
• (3) Grade 4 and 5 pancreatic injuries: These injuries are to the right of superior mesenteric vessels and management of these injuries remains controversial with very little literature available on these injuries. As a notion that has been followed for long, ductal injury would mandate a surgical exploration. DP which is very suitable for Grade 3 injuries may not serve the purpose in these injuries as the pancreatic remnant would be very small. As such a variety of procedures have been advocated like drainage alone, pancreatico-gastrostomy, pancreaticoduodenctomy, and midsegment pancreatectomy. The safest option is to manage them by external drainage if there is no devitalisation of the pancreatic head or duodenum and the ampulla is intact.^[59] Even with these options available, the superiority of one over others has never been proven. This discrepancy in management has led to evolution of NOM in these injuries, supplemented by Endoscopic management. Moheseni et al reviewed 274 patients with penetrating Grade 4 pancreatic injury of whom 104 patients underwent resection procedures and 170 were managed with non-resectional procedures. They found no statistically significant difference between the 2 groups. However, resectional procedures were associated with increased length of hospital stay.^[60] Other notable procedures include pancreatic parenchyma preserving procedures like distal pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) and resection procedure in the form of pancreaticoduodenectomy. PG has been advocated in isolated studies. However, it is associated with risks of anastomotic leaks. Pancreaticoduodenectomy is indicated when there is extensive trauma to the head of pancreas, a severe combined pancreaticoduodenal injury, or destruction of the ampulla of Vater. This operation has been used in approximately 10% to 11% of combined pancreaticoduodenal injuries and has a mortality rate of 30% to 40%.^[8,12] In a study of 18 patients with pancreatectomy for trauma, Asensio et al^[12] found that 28% of these patients were treated with 2-staged Whipple's procedure with 33% mortality rate. There are 2 main differences between performing a pancreaticoduodenectomy in the clinical setting of trauma and that of cancer. First, in trauma surgery it is not necessary to remove the uncinate process. Second, the gall bladder is not removed in a trauma case as it can be used for biliary-enteric reconstruction in the presence of a delicate common bile duct. However, a non-dilated system and a soft pancreas make reconstruction difficult. Further, associated injuries also increase reconstruction issues. Krige et al^[61] studied 14 patients who underwent pancreatoduodenectomy for pancreatic trauma, of which 6 patients underwent damage control surgery owing to associated vascular injuries. The choice of reconstruction by PG or PJ also remains debatable. Jin et al^[62] did a meta-analysis of the 2 techniques after pancreatoduodenectomy and concluded that there was no difference in pancreatic fistula rates with either of the techniques. Hence, either of them can be done based on surgeon's experience and expertise.

Complications and outcome

Complication rates after the operative treatment of pancreatic injuries range from 26% to 86%.^[7,9,42,49] Sepsis and multiple organ failure cause 30% of deaths after pancreatic trauma. Several studies have shown that pancreatic injury is associated with a mortality of up to 25% and a morbidity of up to 66%.^[63–66] We have reported 43% morbidity and 40% mortality in patients with pancreatic injuries.^[21] Pancreatic injury-related mortality was 20%. However, other associated organ injuries contribute to this high mortality. Philips et al showed that mortality rate decreased from 16.9% to 6.8% if severe head injury and early deaths were excluded.^[63] Similarly, Siboni et al^[67] reviewed 2528 patients with isolated blunt pancreatic injury and reported a mortality rate of 3%. The mortality and morbidity also increase with grade of injury.

• (1) Postoperative pancreatic fistula (POPF): a clinically relevant POPF is now redefined as a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the POPF.^[68] POPF is the most common complication following operative intervention, the reported incidence ranging from 5% to 37%.^[6–9,55] Most series report spontaneous closure within 4 months in 50% to 100% of patients. Fistulae secondary to major disruption of the pancreatic duct can generally be sealed by endoscopic stenting. If this fails, a DP is recommended for fistulae of the neck, body and tail, and a Roux-en-Y loop to the head of the pancreas for fistulae of the head. Somatostatin analogue administered subcutaneously has not been shown to shorten the healing time of a postoperative fistula, although it may decrease the daily output.
• (2) Intra-abdominal abscess: The incidence of abscess formation after pancreatic trauma ranges from 10% to 25%, depending on the number and type of associated injuries. In many series, the leading cause of morbidity in patients with injuries to the pancreas is an intra-abdominal abscess.^[6,8,10] Image-guided drainage usually suffices.
• (3) Vascular complications: Recinos et al^[69] 256 patients with pancreatic injury, of which 74 patients had an associated vascular injury with a mortality of 48 patients. Apart from associated vascular injuries, pancreatic surgeries also predispose a patient to vascular complications with a reported incidence of 2% to 15%. International Study Group of Pancreatic Surgery (ISGPS) had defined postpancreatectomy hemorrhage on the basis of time of onset, location, and severity.^[70] Early endovascular management is the cornerstone in management of such hemorrhages, especially in delayed cases.
• (4) Acute fluid collection and pseudocyst: This complication is very frequent after the NOM of pancreatic trauma. These are managed non-operatively as spontaneous resolution has been reported. However, these may get infected and may lead to sepsis or they may produce pressure symptoms and intestinal obstruction, which mandates intervention. Endoscopic internal drainage is the preferred procedure where expertise is available.^[11,37,40] External drainage is usually reserved for infected fluid collections.
• (5) Exocrine and endocrine insufficiency: The risks and incidence of this complication are debatable with incidence varying from 5% to 40%. Mansfield et al^[71] studied 80 cases of pancreatic surgery after trauma. They reported that only 2 patients required insulin at discharge, while 1 patient required oral hypoglycemic agents. Further, no patient required exocrine enzyme supplementation at the time of discharge. On the contrary, Kusakabe et al^[72] in a review of 1717 patients reported endocrine insufficiency rate of 20% and exocrine insufficiency in 36.2% of patients. However, their study was not limited to trauma population, with majority of cases done for malignancy. Further, they did not evaluate endocrine or exocrine insufficiency directly. Rather indirect markers in the form of escalation of medicines for endocrine and exocrine insufficiency were used. As such, further studies are required to reach a definite conclusion. It would be prudent to monitor patients for these complications.

To conclude, pancreatic trauma remains a challenge to a trauma surgeon with controversies persisting in the management. It is important to realize that early diagnosis is key for successful outcome of a patient. A high index of suspicion and early imaging depending on the mechanism of injury, and clinical features help in diagnosis. Different modalities of treatment are available but the superiority of 1 modality over other is not conclusively established. Also, a large number of controversies exist in management. NOM suffices in Grades 1 to 3 pancreatic injury while most patients with Grads 4 to 5 injury would require operative intervention.

Acknowledgments

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Funding

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Competing interests

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Conflicts of interest

The authors declare no conflicts of interest.