I hate the pancreas. It just doesn’t play by the rules. No matter how good your operation is, there are frequent complications caused by this organ. Thus, my management recommendations are based on simplicity. Easy stuff is good. No anastomoses are better than one or more.

So you’ve already figured out the location and presence or absence of ductal injury, meaning that you know the grade. Let’s look at what you can do by grade.

• Grade I – somebody rubbed the pancreas. Really, you only need to worry about a little “pancreas sweat”, secretions from roughed up surfaces on the gland. I recommend placing a nice drain in the vicinity to carry this fluid away. This is especially important if there are bowel injuries / anastomoses in nearby areas.
• Grade II – somebody punched the pancreas. This can also be caused by anatomic issues when removing the spleen. Once again, drainage of (non-ductal) secretions is key, so a nice big fat drain is in order.
• Grade III – distal duct injury. A simple, distal pancreatectomy is in order. I like to do this with a linear stapler, and I typically do not try to spare the spleen. It just takes too long, and you may push your badly injured trauma patient down the damage control route if you persist with saving the spleen for too long.
• Grade IV – injury to the proximal pancreas with duct. You can get fancy here and do resections and roux-en-y limbs and all kinds of stuff. But I try to keep it simple, and if the destruction is not too bad, I’ll just drain it. External drains are good, but in some more severe cases I will drain internally via a roux limb (shudder). On rare occasion, a proximal pancreatectomy with roux drainage of the distal portion may be considered. 
• Grade V – shattered head plus/minus duodenum. Oh crap! The only way out of this is with a pancreaticoduodenectomy, and it’s tough to find a good time with major trauma patients. If they are well-behaved during the initial operation, get started with it. If they are not, or start to have problems during, you can continue to the first damage control takeback. But, to ensure the best quality tissue for anastomoses, you must finish at the first takeback! And expect complications. They always get them.

Friday, I’ll talk about the (foolhardy) idea of trying to treat this injury nonoperatively in children.

Related posts:

• Pancreas I: Grading
• Pancreas II: Diagnosis
• Pancreas IV: Pediatric Management

The pancreas is a weird and mysterious organ. It’s considered a solid organ, but it doesn’t follow any of the usual rules. Today, I’ll review the grading system for injuries to this organ. Then over the next few days, I’ll review pancreatic injury management in adults and children.

The AAST has developed quite a few organ injury grading schemes over the years (32 to be exact). These are actually important to know, because they help us accomplish several things:

• Objectively describe the degree of injury
• Choose management strategies
• Develop research cohorts so meaningful studies can be constructed

There are 5 grades that follow the usual AAST schema (numbered I-V). Unfortunately, I have not been able to find any quality diagrams, so you’ll just have to use your imagination.

• Grade I: Minor contusion or laceration of the parenchyma without duct involvement
• Grade II: Major contusion or laceration of the parenchyma without duct involvement
• Grade III: Distal duct laceration or transection. Distal means to the left of the superior mesenteric vein
• Grade IV: Proximal transection or parenchymal injury not involving the ampulla (note that this was corrected after publication of the original scale in 1990, which omitted the word not)
• Grade V: Massive disruption of the pancreatic head

Tomorrow I’ll delve into diagnosis and management options in adults.

Related posts:

• Pancreas II: Diagnosis
• Pancreas III: Management
• Pancreas IV: Pediatric Management

Reference: Pancreatic organ injury scale. J Trauma 30:1427–1429, 1990.