The pancreas is an organ located deep in the abdominal cavity, whose anatomical relationship with the digestive and vascular structures [1-4]explains the complexity and severity of pancreatic trauma which represents less than 5% of abdominal trauma [5,6]. Pancreatic trauma is rare compared to other solid organ injuries of the abdomen [7-9].

Incidence is difficult to properly calculate, but a Scottish population-based study found pancreatic injury to occur in 0.21% of over 52,000 trauma patients [2]. In the UK Trauma and Research Network (TARN) database there were 0.32% pancreatoduodenal injuries detected among over 356,000 injured patients [10]. A similar pancreatic injury incidence of 0.3% was noted in children in the United States National Trauma Data Bank [11].

While injuries to the liver, spleen, and kidneys are far more common, pancreatic injury occurs in less than 10% of all abdominal injuries, depending on the evaluation of the population at risk and the underlying etiology. Penetrating injuries are far more common in regions with a high prevalence of gunshot wounds, such as in North America and South Africa [12,13].

In most other regions, a blunt etiology following motor vehicle crashes or falls, or ‘insignificant’ trauma sustained during leisure activities is the prevailing mechanism leading to this rare injury.

Pancreatic trauma is potentially lethal when combined with duodenal perforation or closely related arterial bleeding. These injuries remain difficult to diagnose and undeniably pose a problem in therapeutic strategy. An abdominal computer tomography (CT) allows diagnosis and severity assessments of pancreatic trauma, presence of pancreatic duct injury, or associated bleeding [14-17].

These injuries are difficult to diagnose and pose a problem in treatment strategy. Penetrating injuries are more commonly associated with pancreatic trauma in countries such as the USA and South Africa whereas, in third world countries such as India, blunt trauma to the abdomen is the most common cause of pancreatic injury.

Pancreas injury is not solitary, especially in blunt trauma patients, where more than 80% of patients have at least one other abdominal organ injured.¹⁸

The mean age was 27.8±6.5 years. Baseline characteristics of the population were described in (Table 1).

Table 1: Population characteristics of study participants

Road traffic accident (RTA) (n=20) was the leading cause of pancreatic trauma in the study population followed by fall from height (n=7) and assault (n=3). No penetrating pancreatic trauma was observed in the present study.

The majority of the study population had Grade III pancreatic injury (n=12) followed by Grade IV (n=8), Grade II (n=7), and Grade I (n=3) injuries. No patients had Grade V injury.

Isolated pancreatic trauma was seen in 13 patients. Associated liver and spleen injury was seen in 15 patients. Renal trauma was seen in 2 patients. The extra-abdominal injury was seen to be associated with pancreatic injury in 7 patients.

Twenty-one were managed conservatively. Six patients were managed by non-surgical intervention, 5 patients required pigtail insertion under radiologic guidance for peripancreatic collection, and 1 patient required intercostal chest drain (ICD) drain for post-traumatic pancreatitis with pancreatopleural fistula 1 year after trauma.

3 patients required surgical intervention. One patient with grade II pancreatic injury underwent laparotomy and suturing of coexisting liver laceration for hemodynamic instability.

The main causes of pancreatic trauma in this series were motor vehicle accidents and stab wounds, unlike data from the United States where the main cause of pancreatic trauma is penetrating (firearms and knives) [27-30]. Non-operative management (NOM) is the most effective treatment strategy for grade 1 and 2 pancreatic injury.

Morbidity is less than 20% and mortality is relatively low. Our results are in accordance with this, as 4 out of 5 patients with grade 2 injury were managed conservatively and one patient required emergency laparotomy for grade 3 liver laceration. For grade 3 and grade 4 pancreatic injuries, distal pancreatectomy, or surgical drainage is usually indicated [31].

In our series, 12 patients had grade 3 injury, out of which only one patient underwent cystogastrostomy one month after trauma for pseudocyst of the pancreas. In grade 5 pancreatic injury, possibilities vary from NOM to Whipple's resection. Early ERCP and pancreatic duct stenting have a role in the management of ductal disruption in select cases of grade 3 and 4 injuries thereby avoiding laparotomy and resection [32].

However, in our series mean interval of presentation after injury for grade 3 and grade 4 injuries was 4.6 days ruling out the role of ERCP. Literature favors NOM, even in cases of duodenal and common bile duct injury [33].

There were reports describing pancreatoduodenectomy in trauma in two steps where reconstruction is done after 24-48 hrs. However, any case of grade 5 pancreatic injury was not encountered in the present study. No mortality is observed in the present study.

The mean length of hospital stay in our series was 12.7±4.4 days, length of hospital stay correlated with the grade of injury. This is in accordance with the published literature [34].

Pancreatic trauma can be managed conservatively irrespective of the grade of injury supported by radiological percutaneous drainage and pancreatic duct stenting in selective cases.

Few patients with higher grades of injury develop pseudocyst of the pancreas, which can be dealt with later on.