Management of Pancreatic Injury in the Geriatric Patient
Surgeons always like to perform their magic on young adults who are in training in some athletic event for the upcoming Olympics. Unfortunately, our society continues to age so that more and more operations are performed in the elderly. The challenges of surgery in the geriatric population relate to the adverse events that aging has on both physical well-being and mental acumen. The extent of physical derangement is often referred to by the popular term “frailty” whereas the progressive mental deterioration often falls under the name of “Alzheimer’s disease.” Although aging, per se, is not the cause of fragility or reduced acumen, the trend is for both to become progressively worse each year. Clearly, the effect of fragility and decreased cognitive function impair successful surgical treatment. This is true not only for elective surgery but especially for emergency operations after injury.
Consequently, the treatment of pancreatic injury may differ in the frail elderly patient. Patients with grade I injury (small laceration) and grade II injury (larger laceration without major ductal injury) will more likely be treated by percutaneous drainage to avoid the insult of a major laparotomy. Patients with grade III injury (deep distal laceration with ductal injury) will more likely be treated with percutaneous drainage, deferring definitive treatment of a subsequent pseudocyst until the patient is more stable. Grade IV lacerations to the pancreatic head will likely be treated with exploration and wide extensive drainage without major organ resection. Patients with grade V injury (severe combined pancreatic head laceration with duodenal rupture) will more likely be treated with primary repair of the duodenal injury and wide extensive drainage of the associated pancreatic injury. Definitive treatment of complications of this ultra-conservative approach will be carried out when the patient is more stable.
- 1.Augustin T, Chalikonda S, Wey J, Burstein M, Merrig-Stiff G, Walsh N. Frailty predicts risk of life threatening complications and mortality after pancreatic resections. Surg 2016;160(4):987–996.Google Scholar
- 4.Cook AC, Bellal J, Kenji I, Nakonezny PA, Bruns BR, Kerby JD, Brasel KJ, Wolf SE, Cuschieri J, Paulk ME, Rhodes RL, Brakenridge SC, Phelan HA. Multicenter external validation of the Geriatric Trauma Outcome Score: A study by the Prognostic Assessment of Life and Limitations after Trauma in the Elderly (PALLIATE) consortium. J Trauma Acute Care Surg. 2016;80:204–9.CrossRefPubMedGoogle Scholar
- 5.Lucas CE. Injury severity scoring after gunshot wounds treated at an inner-city trauma center. (Submitted).Google Scholar
- 6.Lucas CE, Ledgerwood AM. Injuries to the stomach, duodenum, pancreas, small bowel, colon and rectum. In: Wilmore C, Harken H, Soper M, editors. ACS Surgery Principles and Practice 2003. New York, NY: webMD Inc; 2003. p. 420–31.Google Scholar
- 14.Bokhari F, Phelan H, Holevar M, Brautigam R, Collier B, Como JJ, Clancy K, Cumming JK, Cullinane D, Smith L. Diagnosis and management of pancreatic trauma. East Practice Management Guidelines. 2009. https://www.east.org/education/practice-management-guidelines/pancreatic-trauma-diagnosis-and-management-of.
- 19.Leppanimi AK, Haapiainen RK. Pancreatic trauma with proximal duct injury. Ann Chir Gynaecol. 1954;83:191–5.Google Scholar
- 22.Lucas CE, Ledgerwood AM. Ongoing unpublished personal data.Google Scholar