DIAGNOSIS AND INITIAL MANAGEMENT OF BLUNT PANCREATIC TRAUMA - GUIDELINES FROM A MULTIINSTITUTIONAL REVIEW

Objective The authors' objective was to resolve the current controvers ies sies surrounding the diagnosis and management of blunt pancreatic trauma (BPT). Summary Background Data The diagnosis of BPT is notoriou sly difficult serum amylase has been claimed to be neither sensitive n or specific, and recent anecdotal reports have suggested a role for co mputed tomography. The therapy of BPT has been controversial, with som e suggesting selective observation and others advocating immediate exp loration to prevent a delay-induced escalation in morbidity and death. Methods The authors conducted a retrospective chart review of documen ted BPT from six institutions, using a standardized binary data form c omposed of 187 items and 237 data fields. Results A significant correl ation between pancreas-specific: morbidity and injury to the main panc reatic duct (MPD) was noted. Patients requiring delayed surgical inter vention after an unsuccessful period of observation demonstrated notab ly higher pancreas-specific mortality and morbidity rates, principally because of the incidence of unrecognized injuries to the MPD. Althoug h detection of MPD injuries by computed tomography was no better than flipping a coin, endoscopic pancreatography was accurate in each of th e five cases in which it was used. Conclusions The principal cause of pancreas-specific morbidity after BPT is injury to the MPD. Parenchyma l pancreatic injuries not involving the ductal system rarely result in pancreas-specific morbidity or death. Delay in recognizing MPD injury leads to increased mortality and morbidity rates. CT is unreliable in diagnosing MPD injury and should not be used to guide therapy. Initia l selection of patients with isolated BPT for observation or surgery c an be based on the determination of MPD integrity.