Nonoperative management of pancreato-duodenal injuries

Following injuries to the pancreas and duodenum (PDI) patients often present in extremis and undergo immediate laparotomy for hemodynamic instability and peritoneal signs. Nonoperative management (NOM) may be offered in selected patients with lowgrade injuries. Precise mapping of the injury, most commonly by computed tomography, is a prerequisite for NOM because clinical symptomatology can be variable and misleading. Additionally, delaying the treatment of PDI that should be corrected surgically may lead to significant complications. Therefore, NOM of PDI presents unique challenges, and the decision-making is not as straightforward as it is with NOM of other solid abdominal organs. Essentially, only duodenal hematomas without fullthickness wall perforation (Grade I and selected II) and pancreatic trauma without major duct involvement (Grade I and selected II) could be offered NOM. In these cases, the reported success rates vary from 74 to 95%. There are also a few severe pancreatic injuries that can be managed by stents with adequate reconstitution of the major pancreatic duct integrity and resolution of symptoms and without the need for operative management. Intensive monitoring and follow-up by clinical examination and repeat CT imaging is essential in these patients, as the risk of complications, and particularly a pseudocyst is high.