0:06

Behind the Knife, the surgery

0:08

podcast, relevant and engaging content

0:10

designed to help you dominate

0:12

the day. Hey,

0:22

everyone, welcome to another episode of Behind

0:24

the Knife's Technical Challenge series. I'm

0:26

the director of the Miami Trauma Team, back

0:29

with another episode from Jackson Memorial Hospital's Rider

0:31

Trauma Center. Well, I'm sure most of

0:33

you have heard of the three rules of surgical training.

0:35

Eat when you can, sleep when you can, and don't

0:37

mess with a pancreas. Well, today, we're

0:39

going to talk about what happens when you have to break

0:41

that third rule. As always, we'd like

0:43

to start with some introductions. I'm

0:46

Mike Cobbler-Lichter, EGY3 in

0:48

general surgery, and my first of two

0:50

years of dedicated research with our trauma

0:52

faculty here in Miami. I'm

0:54

Eugenia Kwon, trauma and surgical critical care

0:56

fellow at the Rider Trauma Center. And

0:59

my name is Jonathan Meisoso. I'm an attending

1:01

trauma surgeon at the Rider Trauma Center and

1:04

an assistant professor of surgery at the University of Miami.

1:07

Today, as Mike mentioned, we're going to

1:09

be talking about something that can strike

1:11

fear into a lot of surgeons and

1:13

surgical trainees. We're going to be discussing

1:15

the management of traumatic pancreatic injuries using

1:17

the Western Trauma Association's clinical decision algorithm

1:19

as a guide, which will be included

1:22

in the show notes. There's a

1:24

lot to talk about here, so why don't we get right into it?

1:27

Before we get into our cases, though, maybe

1:29

we should do a quick review of the

1:31

double AST grading of pancreatic trauma. Yeah,

1:33

that's a great idea. So like

1:35

all of the double AST solid organ

1:37

grading scales, we go from grade one

1:39

to grade five with grade one being

1:41

the least severe and grade five

1:43

being the most severe. For me,

1:46

it's easiest to remember what the most extreme

1:48

grades are first, and then we're back from

1:50

there. So a

1:52

grade one injury is either a

1:54

contusion or a superficial laceration without

1:57

topical involvement. And then a grade

1:59

five injury is... massive disruption of the pancreatic

2:01

head. Then, if

2:03

I remember grade 1 is a contusion or

2:05

superficial laceration without duct injury, it's easy for

2:07

me to remember that a grade 2 injury

2:09

is slightly more severe than this, now

2:12

either involving multiple locations or laceration

2:14

with disruption of less than 50%

2:17

of the pancreatic rank of up. It's also

2:20

important to remember that grade 1 and 2 injury

2:22

is doing not involve the ducts, whereas

2:24

grade 3 and 4 injuries both involve

2:26

ductile disruption. The only difference between

2:29

grade 3 and 4 is where the ductile

2:31

injury occurs. Again, if we think

2:33

about this grade, there's going from less severe to

2:35

more severe. Grade 3 means there's

2:37

a distal ductile injury because that's generally

2:39

easier to manage. And grade

2:41

4 means there's a proximal duct injury since

2:43

those are more difficult to manage. That's

2:46

a great review. Now let's get into our cases.

2:49

So your first case is a

2:51

35-year-old female involved in a

2:53

head-on motor vehicle collision. You

2:56

do your primary survey as always, which

2:58

is intact. The patient is

3:00

hemodynamically stable, but on secondary

3:02

survey, you notice the patient's complaining of

3:05

epigastric and back pain and

3:07

has a prominent abdominal seat belt sign.

3:10

What kinds of injuries jump to the front of your

3:12

mind with this presentation? Well, anytime

3:14

I see a seat belt sign across

3:16

the belly, I think about anything that

3:18

could be compressed between that seat belt

3:20

and the spine and even the spine

3:22

itself. So obviously that includes

3:24

the viscera between the spine and abdominal wall,

3:27

which depends on the location and fit of the seat belt,

3:29

but it's usually small by all as well as a pancreas.

3:33

Great. And the point about location

3:36

and fit of the seat belt is important. Depending

3:38

on where you see the seat belt sign, whether

3:40

it's across the abdomen, the chest, or the neck,

3:43

you may have a higher index of suspicion

3:45

for certain injury patterns. But

3:47

this episode is about the pancreas, so

3:49

we have our hemodynamically stable patient with

3:51

a seat belt sign, abdominal

3:53

pain, and back pain. What's next? I

3:56

think at most places, the presence of a seat belt sign

3:58

is a part of the pancreas. pretty convincing critical

4:01

finding to head on over to the

4:03

truth machine and get that trauma scan.

4:05

But that's not the only way to

4:07

diagnose a pancreas injury. How else might

4:09

you diagnose a pancreatic injury Mike? Well

4:12

in the trauma setting you're probably either going

4:14

to diagnose it most of the time on

4:17

CT scan or on laparotomy in the case

4:19

of an unstable patient. If for

4:21

some reason the patient doesn't get scanned and

4:23

does get admitted, any kind

4:25

of worsening abdominal pain,

4:28

lipocytosis, unexplained metabolic acidosis,

4:30

fever, or elevation in amylase

4:32

or lipase may be signs of an assault

4:35

or a missed injury as well. But obviously

4:37

none of these are terribly sensitive but

4:39

they do all hit some underlying process

4:41

where they are in the abdomen whether

4:43

it's a missed helibiscus injury or an

4:45

injury to the pancreas. Good. Now what

4:47

can we expect to see on CT

4:49

that suggests a pancreatic injury? This

4:52

obviously will depend on the grade of

4:54

injury as it's much easier to see

4:56

a massive disruption of the pancreatic head

4:58

than it is a minor laceration at

5:00

the tail. But in general for these

5:03

lower grade injuries you may see the

5:05

laceration or contusion itself if it's large

5:07

enough or you may see edema, hematoma,

5:09

the princoma, or more non-specific signs such

5:11

as fat stranding or peripancuratic blood.

5:14

Similar to a small bowel injury these findings

5:16

may be subtle as imaged very close

5:18

to the time of injury. Are there

5:20

any other associated injuries you can see

5:22

on a CT scan that make you

5:24

more concerned for pancreatic injury? I think

5:27

I remember this from back in med school

5:29

so if you see a chance fracture of

5:31

the spine you should have a higher index

5:33

suspicion of a pancreatic injury. And what

5:35

exactly is a chance fracture Eugenia?

5:38

So this is essentially when the seat

5:40

belt acts as a fulcrum and the point of

5:43

motion is the spine itself. So

5:45

think about the spinal column bending around

5:47

the thick seat belt. This leads to

5:49

a horizontal fracture where the anterior and

5:51

middle columns are put into compression and

5:53

the posterior column is put into extension.

5:56

Okay great so let's get

5:58

back to our patient. She comes back from

6:00

CT, let's say she has

6:02

a 1 centimeter distal laceration to the

6:04

pancreas. What should your next question be?

6:07

I want to know if it involves a duct. Exactly.

6:10

Ductile involvement is what pushes you from

6:12

that low grade, grade one or two

6:14

injury into the higher

6:16

grade, grade three and above injury

6:18

territory. So what if you

6:20

can't rule out a distal duct injury based

6:23

on the CT scan? Does she need an

6:25

operation? Maybe but I would

6:27

probably want to get an MRCP before

6:29

deciding assuming they're stable. While new multi-detector

6:31

CTs have a pretty high sensitivity, we

6:33

really don't want to miss a high

6:35

grade injury with a duct disruption. Dr.

6:38

Mizzoso, what are your thoughts on when

6:40

to pursue MRCP for these distal injuries

6:42

with questionable duct involvement in a stable

6:44

patient? I know they're often difficult to

6:46

get done quickly, especially in the middle of the night. That's

6:50

a great question. In general, CT

6:52

is still not a great modality

6:54

for diagnosing pancreas injuries, which we've

6:56

already mentioned, and particularly for

6:58

identifying an injury to the pancreatic

7:00

duct, especially if you image the

7:03

patient's early after injury. Even

7:05

with a 64 slice CT, the sensitivity for

7:08

detecting a pancreatic injury greater than 50% of

7:10

the parenchyma is only about 50%,

7:12

so about a flip of a coin.

7:15

So you can imagine if we're talking about

7:17

greater than 50% laceration of the

7:19

parenchyma, the sensitivity for a ductile injury

7:21

is much lower. That being said,

7:24

my practice is to get an MRCP

7:27

if I'm suspicious enough that there may

7:29

be a ductile injury and the CT

7:31

findings cannot definitively rule it out. So

7:34

back to our case, let's say we

7:36

get an MRCP and there's no evidence

7:39

of a ductile injury. Do we

7:41

still think she needs to go to the operating room? At

7:44

this point, with a low grade injury

7:46

not involving the duct, our first line

7:48

would be expected non-operative management. Great.

7:51

Let's say we do that. How long would you

7:53

typically observe her for? If the

7:56

patient remains stable, her pain is

7:58

controlled, she's ambulated. and tolerating PO,

8:01

I think a period of a few

8:03

days is reasonable, assuming there are no

8:05

other injuries. But these are often

8:07

high energy mechanisms and patients often do have

8:09

other injuries that will keep them in the

8:11

hospital anyway. Okay, good. Yeah,

8:13

I think that's a good summary. In

8:16

general, if they only have an isolated

8:18

injury, they may be in the hospital

8:20

three or four days, but most of these patients are

8:22

a little bit on the sicker side and

8:24

multiply injured, so they'll be in the hospital for

8:27

a while. What do we need

8:29

to be on the lookout for in

8:31

the post-injury period if this patient doesn't

8:33

get discharged because of other injuries or

8:35

when they see us back in the clinic? What do

8:37

we have to be looking out for? Even

8:41

those low grade injuries have a

8:43

risk of persistent pancreatic fistula or

8:45

pseudosysformation, which may need

8:47

to be treated with drainage,

8:50

ERCP, stenting, or cystoenterostomy, but

8:52

that type of chronic management is a bit outside

8:54

the scope of this episode. Great.

8:57

Mike, what if this patient

8:59

had their injury discovered at the

9:01

time of laparotomy and not on

9:03

a CT scan? Well,

9:06

if it still looks like a low

9:08

grade injury, the vast majority can be

9:10

treated with hemostasis and wide drainage. In

9:13

fact, many low grade injuries can drain

9:15

for several days, so the recommendation is

9:17

really to use drainage liberally. Why

9:20

not just repair it if you're already there? Well,

9:22

most of these injuries are self-limited. The minor

9:24

fistula will close on their own and the

9:26

drainage is easily managed with a drain or

9:29

two. We don't want to risk

9:31

any of the possible complications of pancreas

9:33

surgery, such as pseudosysformation that could land

9:35

our patient in the hospital for months.

9:38

And these patients are often not

9:40

your chronically sick patients who get your whippable

9:43

of that hard pancreas. Is there soft pancreas

9:45

difficult to sew to? Great.

9:47

Now let's change it up a bit. What

9:50

if the MRCP had come back positive and

9:53

you had seen a distal pancreatic

9:55

transection? What now, Eugenia?

9:57

OR? So, that's one off.

10:00

option, and in smaller centers

10:02

or on your boards, that is probably

10:04

the best option for distal main duct

10:06

grade 3 injury. However, depending on your

10:08

local resource availability, endoscopic

10:10

management with ERCP and transpapillary pancreatic

10:12

duct stenting may be an option.

10:15

It is worth mentioning that there

10:17

is some evidence to suggest lower

10:19

rates of complication after operative compared

10:21

to endoscopic management, specifically

10:23

in regards to main duct structures. But

10:26

as with the entirety of this algorithm,

10:28

there is a positive class 1 data

10:30

involving RCTs in this topic. That's

10:32

exactly right. I would say that in

10:34

general, you need to be at a

10:36

high volume center with significant

10:39

experience in managing these types

10:41

of injuries with ERCP for

10:43

pancreatic duct stenting to even

10:45

consider doing some kind of

10:47

a non-operative management. I

10:49

would say I'm a surgeon. I like

10:51

to operate. This is an operative injury if

10:53

you have a distal ductal

10:56

injury. So in the absence

10:58

of significant experience with an

11:00

ERCP or surgeon judgment that

11:02

operation is the way to go, I

11:05

think it's probably safer to manage

11:08

these patients operatively. So let's say

11:10

for whatever reason you can't get

11:12

the ERCP, what's your plan, Mike?

11:15

So in this patient with a grade 3

11:17

pancreatic injury, I would plan on going to

11:19

the OR for an exploratory laparotomy. Okay,

11:22

good. That's probably what I would do too. Eugenia,

11:24

what would you plan on doing

11:26

in the case? So we

11:29

said this is a distal injury. The

11:31

location of the injury matters a lot

11:33

when treating pancreatic injuries. In this

11:35

case, I would plan on doing a

11:37

distal pancreatectomy with or without splenectomy.

11:40

Okay. We keep talking about

11:42

distal or proximal. What determines

11:44

if the injury is distal

11:46

or proximal for a pancreatic duct

11:48

injury? What's the cutoff? So

11:50

the SMB is a common landmark

11:52

to denote a left-sided pancreatic injury

11:54

from a right-sided pancreatic injury. That's

11:57

exactly right. So, Mike, why is it a matter of...

12:00

Important to make this distinction. So

12:02

as we mentioned before the management

12:04

changes I'm sure a lot of

12:06

our listeners have heard the crawfish analogy But for any

12:08

of you who haven't pancreatic injury

12:10

treatment is a lot like eating a crawfish You

12:13

suck the head and eat the tail So

12:15

things that are to the left of the SMB

12:17

we tend to resex and things to the right

12:19

of the SMB We tend to drain wisely That's

12:22

exactly right. And you mentioned that the

12:25

distal pancreatectomy can be done with

12:27

or without a splenectomy What

12:29

would make you decide one way or the other? So

12:32

there's a couple things to consider here as

12:35

we mentioned that these are often high

12:37

energy mechanisms with other component injuries if

12:40

we're in the OR for Hemodynamic instability

12:42

if the patient's sick if there's a

12:45

clear spleen injury this plane is going

12:47

to the bucket But

12:50

if the patient is hemodynamically normal as

12:53

few or minor other injuries or as younger

12:55

especially kids We can try and make more

12:57

of an effort to preserve the spleen while doing our distal

12:59

pancreatectomy Those are all

13:01

great points Eugenia However, I will

13:03

say that the vast majority

13:05

of these injuries end up getting both

13:07

the distal pancreatectomy and the splenectomy Atlantic

13:11

preservation should definitely be a

13:13

consideration whenever you're doing this especially when you're doing

13:15

it in a delayed fashion But

13:17

oftentimes it's gonna prove to be more difficult than

13:20

it looks in the textbooks. This

13:22

is particularly true in adults There's

13:24

usually a lot more visceral fat

13:26

that obscures the pancreatic vessel branches

13:28

to the splenic vessels and children

13:30

I think due to the immunologic

13:32

advantages of keeping the spleen Splenic

13:34

preservation is more common and more

13:36

doable again because of their

13:39

anatomy, but kind of

13:41

overall I think distal pancreatectomy

13:43

with splenectomy is generally the

13:45

operation that's done Definitely

13:47

if you're in your first operation

13:50

and the trauma has kind of done

13:52

the the majority of the operation already

13:54

and as You know essentially done the

13:56

distal pancreatectomy you generally just want to

13:59

finish it off and do the splenectomy

14:01

at the same time because those patients may

14:03

not be super stable. So back to our

14:05

patient, she had a grade

14:08

3 pancreas injury that was treated

14:10

with a distal pancreatectomy and splenectomy.

14:12

She recovers well, starts to tolerate

14:16

oral intake, but on the

14:18

first day after starting oral intake, we

14:21

noticed her drain output increases and

14:23

changes color. What do we

14:25

need to be on the lookout for

14:27

in the post-op period in this patient,

14:29

Mike? So this is definitely concerning for

14:31

a post-operative pancreatic fistula. And

14:33

how would you confirm your diagnosis? Well

14:36

with this increased drain output, I would start

14:38

by sending a drain amylase. If

14:40

this was higher than three times the upper limit

14:42

of normal in the serum, that

14:45

would be indicative of a post-op pancreatic

14:47

fistula. This is true, but

14:49

with one important caveat. To be strictly

14:51

defined as a post-operative pancreatic fistula, the

14:54

condition needs to be clinically relevant. What

14:56

we used to call a grade A

14:59

pancreatic fistula is now no longer actually

15:01

considered a true pancreatic fistula or even

15:03

an actual complication as described by the

15:05

International Study Group of Pancreatic Fistula's

15:08

2016 update. If the patient remains

15:10

clinically well and there's no true clinical

15:13

impact, this is considered to

15:15

be with normal post-operative pathway and

15:17

is described now as a biochemical

15:19

fistula. Okay, so what do

15:21

we consider a true post-operative pancreatic fistula?

15:24

So that's basically a pancreatic leak

15:26

in association with a clinically relevant

15:29

condition. So this would be

15:31

a grade B fistula and anything that leads to

15:33

organ failure, clinical instability, or

15:35

the need to go back to the

15:37

OR would be considered a grade C

15:39

fistula. And the severity of the fistula

15:41

determines the treatment and treatment can be

15:44

from supplementing with short medium

15:46

chain fatty acids and making FBO

15:48

to medical therapy with somatostatin and all

15:51

the way up until spontaneous endoscopic or

15:53

even surgical drainage as necessary. So this

15:55

is getting a little bit outside of

15:58

the scope of this episode. Great,

16:01

I agree. Let's go back and why don't

16:03

we change the scenario again. Let's

16:05

say we still have a ductile injury,

16:08

but this time it was to the right of the

16:10

SMV. Does this change management? Yeah,

16:13

it definitely does. So remember our

16:15

crawfish metaphor. In this case, we

16:17

have a grade four injury and

16:19

so it's recommended to train widely.

16:22

All right, that's excellent. I agree. Most

16:24

of the time it's best to do the least

16:26

amount possible in these cases. Draining

16:29

and getting out of dodge is usually the

16:31

best technique. However, I think for completion, it's

16:33

important to note that in some

16:35

cases that's not possible or reasonable

16:38

and at least according to the textbook, there

16:40

are some options to consider for a grade

16:43

four injury other than wide drainage.

16:45

So I'm just going to talk about that

16:47

for like a couple seconds. So

16:49

for example, depending on the injury,

16:52

a subtotal pancreatectomy of 70

16:54

to 90% of the pancreas

16:56

with a splenectomy may be indicated

16:59

and other injuries may even require

17:01

that trauma whipple that we all

17:03

talk about. But again, I think

17:05

in most cases, simple drainage, wide

17:07

drainage will suffice. That's what

17:09

I usually do and what's recommended in

17:11

the Western trauma algorithm. Now

17:13

let's say another patient comes in

17:15

with a similar mechanism, but

17:17

in the trauma bay, he's hypotensive and

17:20

has a positive fast. You

17:22

take him to the OR laparotomy. What

17:24

are some intraoperative clues that you may be

17:26

dealing with a pancreas injury? Yeah,

17:29

it's really critical to thoroughly

17:31

explore both the pancreas and duodenum

17:33

if there's concern for injury to this area.

17:36

Things that make you into this are

17:39

retroperitoneal hematoma, bile staining,

17:41

fat necrosis, or edema

17:43

in the supramisocolic region. If

17:47

you have any of these or even

17:49

a suspicious phi energy mechanism with associated

17:51

injuries like a chance fracture, you really

17:53

should be dividing the gastricolic ligament to

17:55

get into lesser size. This will let

17:57

you inspect the pancreatic body and tail.

18:00

And aside though, like always, it's

18:02

really important to approach trauma in

18:04

a systematic fashion the

18:06

same way every time. We mentioned this

18:08

patient has a positive fast. I

18:10

just wanted to point out that you won't see

18:12

a positive fast with retroperitoneal injuries. So it's

18:14

important to identify all injuries. Don't

18:17

get tunnel vision on the pancreas just because this is

18:19

the pancreas episode. Those are

18:21

great points. Got to remember the ABCs. Speak

18:24

of the pancreas though. Will you be able to

18:26

access the entirety of the pancreas

18:29

from the retro gastric approach by

18:31

opening the gastricolic ligament? No,

18:33

definitely not. If there is concern

18:35

for pancreatic head or duodenal injury,

18:38

we should be cochorizing the patient

18:40

in order to get better access to the duodenal

18:42

sleep as well as the head and unscented process

18:44

of the pancreas. Good.

18:46

Again, because this is the pancreas episode, there's

18:48

a lot of talk about if

18:51

there's concern for pancreatic injury to

18:53

X location. But most of

18:55

the time, you don't really know this at the

18:57

time of a trauma laparotomy that you're doing for

18:59

hemorrhage control. So I think

19:02

the safest technique and one that gives

19:04

you as trainees practice for when it's

19:06

like really go time and you really

19:08

do have an injury is to

19:10

get into the habit of routinely opening the lesser

19:12

sac, performing a cochlear maneuver

19:14

to fully assess the retroperitoneum. I

19:17

think that's really best practice for

19:19

a true exploratory laparotomy. Because part of

19:21

the name of the operation is

19:24

an exploratory laparotomy. If you're doing that,

19:26

then I think you should do all

19:29

of the maneuvers to really ensure that you don't

19:31

have an injury in an area that you suspect

19:33

you have an injury. So let's

19:36

say you do that and you find a clear

19:38

grade five injury where the pancreatic

19:40

head is just blown apart. Eugenia,

19:42

is this the time for the

19:44

trauma whipple? Fortunately

19:46

or unfortunately, depending on how you look at

19:49

it, no, it's not. A

19:51

grade five injury should really be treated

19:53

like it's damage control operation, control bleeding,

19:55

control sepsis with wide drainage and

19:57

live to fight another day. So

20:00

I was wondering is what if your patient

20:02

had been hemodynamically stable and you're discovering this

20:05

injury in the OR, is there ever a

20:07

role for a primary trauma wiggle or should

20:09

we basically always be planning on coming back

20:11

later? In general, I

20:14

would say the safest thing is to come

20:16

back. These patients are not in good shape

20:18

in the OR usually. If you

20:20

have a grade 5 pancreatic injury, that

20:22

usually comes with a duodenal injury, maybe

20:25

a liver injury or another

20:27

hollow viscous injury. Don't

20:29

poke the bear. We don't like leaving

20:31

abdomens open these days and have really

20:33

decreased the number of open abdomens significantly

20:36

even since I started my training, but

20:38

this is one time where it's very

20:40

appropriate to do so. So again,

20:42

don't poke the bear. Do the least possible in

20:44

the first case. Any

20:46

other things to consider with these challenging cases

20:49

that we haven't talked about? Well,

20:51

one thing to consider is that the vast

20:53

majority of these grade 5 injuries are going

20:55

to have associated duodenal trauma as I mentioned.

20:58

So you're going to have to know how to manage

21:00

this as well and maybe that's another future episode

21:03

for BTK. One very

21:05

important thing though is to think about

21:07

feeding access for these high

21:09

grade injury patients, especially those with

21:12

combined duodenal trauma. That's

21:14

preferably in the form of a feeding

21:16

jejunostomy, but you can also do that

21:18

with a nasojejunal tube. Additionally,

21:20

patients may benefit from

21:23

elemental formulas with lower fat and

21:25

higher pH to minimize the amount

21:27

of pancreatic stimulation. I

21:29

think it's also important in the

21:32

future once these patients recover from

21:34

their initial insult to talk

21:36

to your patients and let them know how

21:38

the operation that you did will affect

21:40

them in the future. For example, particularly

21:42

if you had to do an extended

21:45

distal pancreatectomy where you're removing a

21:47

significant proportion of their exocrine and

21:49

their islet cell function, patients need

21:52

to know that things like alcoholism

21:54

and obesity will affect their recovery and that

21:57

they may become diabetic and are going to

21:59

need to. to check their glucoses

22:01

to make sure that

22:03

they're not progressing into diabetes depending

22:06

on the residual endocrine function that they

22:08

have left. Okay,

22:11

great. So to summarize, pancreas

22:13

injuries and the associated grade are

22:15

most often diagnosed on either CT

22:17

or laparotomy. To rule out ductile

22:19

injury, patients may benefit from MRCP

22:21

if there are equivocal CT findings,

22:23

which are notoriously not as accurate

22:25

as we would like with pancreas

22:28

injuries. Low-grade injuries without ductile

22:30

involvement, so grade one or two, can

22:32

generally be managed non-operatively. But

22:35

higher-grade injuries with ductile involvement require

22:37

intervention of some kind, either ERCP

22:39

or laparotomy, but most of the

22:42

time, in most settings, this

22:44

should probably be laparotomy. Our

22:46

procedure of choice once in the belly depends on

22:48

location and grade of injury. Low-grade

22:50

injuries, again, grade one or two, with low

22:52

risk of ductile involvement, can be treated with

22:54

closed suction drainage. When we start getting

22:57

into grade three and four, the location matters a whole

22:59

lot more. Here's where you remember the crawfish.

23:01

Suck the head and eat the tail. If

23:03

it's to the right of the SMV, closed suction drainage

23:05

is your best option. But if

23:07

it's to the left, dysoprenchial catectomy, usually

23:09

with splenectomy is your best option. And

23:12

finally, if we're dealing with a destructive injury to

23:14

the pancreatic head, we're really talking about

23:16

a damage control situation. Control

23:19

bleeding, control sepsis, live to fight another day.

23:22

Then widely, stabilize the patient and come back

23:24

later for your reconstruction. There

23:26

are really very few indications for a trauma whipple

23:28

off the bat nowadays. Yeah,

23:30

that's right. And remember, the

23:32

trauma whipple is one of those

23:35

scenarios where no single trauma surgeon

23:37

has a very large series of

23:39

experience. I can't stress enough

23:42

how important it is to approach

23:44

these injuries with help. Don't be

23:46

the hero. Get advice from a senior

23:48

partner, but that's another trauma surgeon who's managed

23:50

a few of these great. If

23:53

it's someone outside your own division

23:55

who routinely does pancreatic surgery, that's

23:57

fine too. And if there's no one at

23:59

your institution, that's fine. who can help consider

24:01

transferring the patient somewhere else for

24:03

definitive management after you've done

24:05

the damage control. The good

24:08

thing is that with good drainage you

24:10

can usually temporize most of these injuries.

24:13

If you're getting help from a

24:15

non-trauma surgeon though remember they're used

24:17

to doing elective surgery so it's

24:19

your job as the trauma surgeon

24:21

to understand the physiology of the

24:23

patient and to stop them

24:25

from doing more than is necessary in

24:27

the acute setting and make sure to

24:29

advocate for doing you know the least

24:32

possible that the patient will pollinate to

24:34

address the injury and come

24:36

back for a more complicated reconstruction

24:38

when they've really been optimized as

24:40

much as possible. Alright

24:43

great work everyone hopefully people are feeling a

24:45

little less scared of the pancreas after that

24:47

review. I think it's time to

24:49

summarize these points with a few quick hits. Number

24:52

one pancreas injuries do not all require a

24:54

trip to the operating room. No

24:56

great injuries should be managed at a trial

24:58

of non-operative management if there are no other

25:00

operative indications. Number

25:02

two CT is the best initial imaging

25:05

modality although it has low sensitivity. If

25:07

there's high concern for pancreas injury based

25:09

on mechanism or associated injuries or other

25:11

investigations required. Number three pancreas

25:14

injuries are like crawfish suck the head and eat

25:16

the tail. Number four

25:19

injuries to the left of the SMV

25:21

can generally be treated with physical pain

25:23

protectomy and spleenectomy whereas injuries to

25:25

the right of the SMV are usually drained. Number

25:28

five it's important to identify and address

25:30

any concomitant injuries with duodenal injuries being

25:32

the most common and high grade injury.

25:36

Number six in the case of the dreaded

25:38

grade five injury the safe answer is to

25:40

come back and do your reconstruction at a

25:42

later time. Okay

25:44

thanks for listening everyone and until next

25:46

time dominate the day. Be

25:49

sure to check out our website at www.behindtheknife.org for

25:51

more great content. You can also follow us on

25:53

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25:55

the Knife podcast. If you like what you hear

25:58

please take a minute to leave a comment. this

26:00

review. Content produced by Behind the Knife

26:02

is intended for health professionals and is

26:04

for educational purposes only. We do not

26:06

diagnose, treat, or offer patient specific advice.

26:08

Thank you for listening. Until

26:11

next time, dominate the day.