Surgery, Gastroenterology and Oncology

Introduction: Blunt or penetrating pancreatic trauma represents only 0.2-2% of all trauma cases and approximately 3-12% of all abdominal injuries. While treatment protocol debates of other intraabdominal and thoracic organ injuries seem to reach comforting conclusions, satisfying evidencebased recommendations regarding the pancreas have not been released yet. However, high grade trauma of the pancreas can lead to substantial morbidity and mortality. The question is, when and how to treat it conservatively or operatively.

Objectives/Methods: This study is a review of contemporary literature on children and adultpancreatic trauma management strategies and findings. The purpose is to evaluate current classifications and the efficacy of subsequent non-operative and operative treatments. We list theestablished grading systems starting from physical examination, imaging diagnosis, to indications forsurgery or conservative management, followed by post-treatment morbidity and mortality rates.

Conclusions: Current operative or non-operative management strategies are not based onrandomized - or even, in fact, on prospective - clinical trials. Most of the available publicationsdemonstrate small retrospective patient cohorts and expert opinions. To date, no convincing highlevel (at least Level III) evidence-based recommendations have been published in terms of treatmentof these injuries. There is a general agreement, that the injury of the main pancreatic duct is the thinred line, dividing conservative and operative strategies. Low grade pancreatic injury can be treatedconservatively not significantly different from protocols developed for mild pancreatitis of otherorigin. Pancreatic duct damage in adults requires either minimal invasive intervention or explorationand reconstruction/resection via laparotomy.
Treatment strategies of high grade paediatric pancreaticinjuries remain controversial. Associated organ injuries can mask the symptoms of pancreatic trauma.
Missed main pancreatic duct injuries pose a clinically challenging situation with serious complicationsand considerable mortality. Pancreatic injury in polytrauma poses the highest risk.
Presentperspectives for survival of pancreatic injury as mono trauma varies between 95-100%, while as apart of polytrauma, the mortality rate is as high as 30-35%. Multicentre prospective, randomizedclinical trials would be ideal to support optimal decision making. Heterogeneity of cases and relativerarity of the pathology makes the creation of such a database highly unlikely.

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