›Begin with clear liquids
›Low-fat diet during recovery phase
›Grade I–II incidental operative findings
›External drainage may be considered
›Avoid resection (resection carries pancreas-related complication rates equivalent to high-grade injuries)
›Avoid suture repair of lacerations (increases pseudocyst risk)
›Grade III distal duct injury
›Distal pancreatectomy with or without splenectomy for injuries distal to the SMV
›Procedure of choice per WSES-AAST guidelines
›Spleen-preserving distal pancreatectomy preferred when feasible
›Drainage alone may be a non-inferior alternative in selected cases
›Grade IV proximal duct injury
›Management is controversial
›Operative drainage or resection depending on extent
›ERCP with ductal stenting is an emerging option
›Drainage alone has higher pancreas-related complication rate (61%) vs. resection (32%)
›Grade V destructive head injury
›Pancreaticoduodenectomy (Whipple procedure) may be required
›Best performed as staged procedure after damage control surgery
›Requires experienced hepatobiliary surgeon
›Damage control: hemorrhage control and contamination control first
›Reconstruction deferred to 24–48 hours after physiologic restoration
›DCS indications
›Hemorrhagic shock with physiologic derangement
›pH < 7.2 or temperature < 35 degrees Celsius or INR > 1.5
›DCS stages
›Stage 1: Hemorrhage control, contamination control, abdominal packing
›Temporary abdominal closure
›Transfer to ICU for resuscitation
›Stage 2: ICU resuscitation and physiologic correction
›Correct coagulopathy, hypothermia, acidosis
›Target lactate normalization
›Stage 3: Definitive repair at 24–48 hours
›Planned reoperation for pancreatic reconstruction
Minimally invasive and endoscopic management
›ERCP with stenting
›Hemodynamically stable patients with ductal injury
›Early post-trauma application in appropriate patients
›Comparable outcomes to operative management in some series
›Indications: Grade III–IV with ductal disruption, post-operative fistula
›Percutaneous drainage
›Interventional radiology for pseudocyst or abscess drainage
›Symptomatic pseudocysts persisting more than 4 weeks
›Pseudocysts greater than 6 cm
›Pancreatic fistula: more than 60% of internal fistulae close without surgery
›Analgesics
›Fentanyl IV for acute pain control
›1–2 mcg/kg IV as initial dose
›Titrate to pain score
›Morphine IV alternative
›0.05–0.1 mg/kg IV every 4 hours as needed
›Avoid NSAIDs in setting of hemorrhage or renal compromise
›Antiemetics
›Ondansetron 4–8 mg IV every 6–8 hours as needed
›Metoclopramide 10 mg IV every 6–8 hours as alternative
›Antibiotics
›Broad-spectrum coverage if peritonitis, bowel injury, or infected necrosis suspected
›Piperacillin-tazobactam 3.375 g IV every 6 hours
›Alternative: cefepime 2 g IV every 8 hours plus metronidazole 500 mg IV every 8 hours
›Tetanus prophylaxis for penetrating injuries
›Octreotide
›Not routinely recommended post-operatively
›EAST guidelines conditionally recommend against routine octreotide prophylaxis
›May be considered for high-output pancreatic fistula in selected cases
›100–250 mcg subcutaneously three times daily if used
›NPO initially in all suspected pancreatic injuries
›Enteral nutrition
›Nasojejunal tube feeding preferred over TPN when feasible
›Resume after hemorrhage control and bowel function returns
›TPN may be required in 37–75% of patients with severe duodeno-pancreatic injuries
›Low-fat diet during recovery phase for NOM patients