Impact of a defined management algorithm on outcome after traumatic pancreatic injury

The optimal management of pancreatic injuries, specifically with respect to defining ductal integrity, remains controversial. Our previous experience suggested that decisions based on probability of ductal injury might improve outcome. Consequently, a management algorithm (ALG) was developed and implemented. The purpose of this study was to evaluate the impact of this ALG on outcomes.

Consecutive patients more than 13 years with pancreatic injuries subsequent to the development of the ALG were evaluated. Pancreatic injuries were defined as proximal or distal and ductal injuries classified as definite, high, low, or indeterminate (IND) probability. Pancreas-related morbidity (fistula, abscess, and pseudocyst) and mortality were recorded. Patients managed by the ALG were compared with the previous study (PS).

In all, 245 patients were identified; 35 died within 12 hours and were excluded. Demographics and severity of shock (24-hour transfusions) were similar between groups. Pancreas-related morbidity for proximal injuries was 13.8% in the ALG group and 13.5% in the PS (p = 0.948). Pancreas-related morbidity was significantly reduced in the ALG group for distal injuries requiring drainage alone (11% vs. 25%, p = 0.05) and for distal injuries requiring resection + drainage (26% vs. 58%, p = 0.003) when compared with the PS. There was no pancreas-related mortality in the ALG group (1.6% in the PS group, p = 0.065).

Adherence to a defined ALG simplified the management of traumatic pancreatic injuries and contributed to a reduction in both pancreas-related morbidity and mortality. The majority of all proximal pancreatic injuries can be treated with drainage alone. For distal injuries, a clinical decision based on defined parameters and suspicion of ductal injury dictates definitive management.