|
1
|
Alizai Q, Anand T, Bhogadi SK, Nelson A, Hosseinpour H, Stewart C, Spencer AL, Colosimo C, Ditillo M, Joseph B. From surveillance to surgery: The delayed implications of non-operative and operative management of pancreatic injuries. Am J Surg 2023; 226:682-687. [PMID: 37543483 DOI: 10.1016/j.amjsurg.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries. METHODS We analyzed the 2017 Nationwide Readmissions Database on adult (≥18 years) trauma patients with pancreatic injuries. Patients who died on index admission were excluded. Patients were stratified into operative (OP) and non-operative (NOP) groups and compared for outcomes within 90 days of discharge. Multivariable regression analyses were performed. RESULTS We identified 1553 patients (NOP = 1092; OP = 461). The Mean (SD) age was 39 (17.0) years, 31% of patients were female, and 77% had blunt injuries. Median ISS was 17 [9-25] and 74% had concomitant non-pancreatic intraabdominal injuries. On multivariable analysis, operative management was independently associated with increased odds of 90-day readmissions (aOR = 1.47; p = 0.03), intraabdominal abscesses (aOR = 2.7; p < 0.01), pancreatic pseudocyst (aOR = 2.4; p = 0.04), and need for percutaneous or endoscopic management (aOR = 5.8; p < 0.001). CONCLUSION Operative management of pancreatic injuries is associated with higher rates of delayed complications compared to non-operative management. Surgically treated pancreatic trauma patients may need close surveillance even after discharge.
Collapse
Affiliation(s)
- Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Collin Stewart
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| |
Collapse
|
|
2
|
Rajput MZ, Mellnick VM. The Role of Magnetic Resonance in Evaluating Abdominopelvic Trauma - Part 1: Pancreatic and Hepatobiliary Injuries. Can Assoc Radiol J 2022; 73:680-688. [PMID: 35282708 DOI: 10.1177/08465371221077650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Trauma is an important cause of mortality, particularly in the young. While computed tomography (CT) is the mainstay of body imaging in the setting of trauma, magnetic resonance (MR) imaging can be useful in stable patients. Although more commonly used in spinal and musculoskeletal trauma, MR also has a role in abdominopelvic trauma. Broadly, its uses include clarification of equivocal cases, monitoring complications of trauma, particularly with solid organ injury, or as a primary imaging modality for patients with low suspicion for injury for whom avoiding ionizing radiation is a priority-namely, in pediatric and pregnant patients. In this two-part review article, we will review clinical scenarios where this may be encountered, utilizing case examples. This first installment will focus on pancreatic and hepatobiliary injuries. Pancreatic trauma may be difficult to diagnose on CT, and MR may aid in demonstrating pancreatic duct disruption, allowing for accurate grading according to American Association for the Surgery of Trauma (AAST) criteria. It may also be a useful modality for monitoring evolution of pancreatic injuries and/or pseudocyst development, guiding potential stenting, and/or drainage. Biliary injuries are also optimally evaluated with MR, particularly when aided by the use of hepatobiliary contrast material. This can allow for accurate delineation of biliary ductal anatomy and aid in planning percutaneous or endoscopic treatment of bile leaks.
Collapse
Affiliation(s)
- Mohamed Z Rajput
- Mallinckrodt Institute of Radiology, 116142Washington University School of Medicine, St Louis, MO, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, 116142Washington University School of Medicine, St Louis, MO, USA
| |
Collapse
|
|
3
|
Al-Thani H, Ramzee AF, Al-Hassani A, Strandvik G, El-Menyar A. Traumatic Pancreatic Injury Presentation, Management, and Outcome: An Observational Retrospective Study From a Level 1 Trauma Center. Front Surg 2022; 8:771121. [PMID: 35155546 PMCID: PMC8831377 DOI: 10.3389/fsurg.2021.771121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/20/2021] [Indexed: 12/26/2022] Open
Abstract
BackgroundWe aimed to study the presentation, management, and outcomes of patients with a pancreatic traumatic injury.MethodsWe retrospectively analyzed data for all patients who were admitted with pancreatic injuries between 2011 and 2017 at the only level 1 trauma center in the country.ResultsThere were 71 patients admitted with pancreatic trauma (0.6% of trauma admissions and 3.4% of abdominal injury admissions) with a mean age of 31 years. Sixty-two patients had pancreatic injury grade I–II and nine had injury grade III–IV. Thirty-eight percent had Glasgow Coma Scale (GCS) <9 and 73% had injury Severity Score (ISS) >16. The level of pancreatic enzymes was significantly proportional to the grade of injury. Over half of patients required laparotomy, of them 12 patients had an intervention on the pancreas. Eight patients developed complications related to pancreatic injuries ranging from pancreatitis to pancreatico-cutaneous fistula while 35% developed hemorrhagic shock. Mortality was 31% and regardless of the grade of injury, the mortality was associated with high ISS, low GCS, and presence of hemorrhagic shock.ConclusionPancreatic injuries following blunt trauma are rare, and the injured subjects are usually young men. However, most injuries are of low-grade severity. This study shows that regardless of the pancreatic injury grade on-admission shock, higher ISS and lower GCS are associated with worse in-hospital outcomes. Non-operative management (NOM) may suffice in patients with lower grade injuries, which may not be the case in patients with higher grade injuries unless carefully selected.
Collapse
Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ahmed Faidh Ramzee
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Gustav Strandvik
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- *Correspondence: Ayman El-Menyar
| |
Collapse
|
|
4
|
Lee MA, Lee SH, Choi KK, Park Y, Lee GJ, Yu B. Management of Traumatic Pancreatic Injuries: Evaluation of 7 Years of Experience at a Single Regional Trauma Center. JOURNAL OF TRAUMA AND INJURY 2021. [DOI: 10.20408/jti.2021.0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose Traumatic pancreatic injuries are rare, but their diagnosis and management are challenging. The aim of this study was to evaluate and report our experiences with the management of pancreatic injuries. Methods We identified all adult patients (age >15) with pancreatic injuries from our trauma registry over a 7-year period. Data related to patients’ demographics, diagnoses, operative information, complications, and hospital course were abstracted from the registry and medical records. Results A total of 45 patients were evaluated. Most patients had blunt trauma (89%) and 21 patients (47%) had pancreatic injuries of grade 3 or higher. Twenty-eight patients (62%) underwent laparotomy and 17 (38%) received nonoperative management (NOM). The overall in-hospital mortality rate was 24% (n=11), and only one patient died after NOM (due to a severe traumatic brain injury). Twenty-two patients (79%) underwent emergency laparotomy and six (21%) underwent delayed laparotomy. A drainage procedure was performed in 12 patients (43%), and pancreatectomy was performed in 16 patients (57%) (distal pancreatectomy [DP], n=8; DP with spleen preservation, n=5; pancreaticoduodenectomy, n=2; total pancreatectomy, n=1). Fourteen (31%) pancreas-specific complications occurred, and all complications were successfully managed without surgery. Solid organ injuries (n=14) were the most common type of associated abdominal injury (Abbreviated Injury Scale ≥3). Conclusions For traumatic pancreatic injuries, an appropriate treatment method should be considered after evaluation of the accompanying injury and the patient’s hemodynamic status. NOM can be performed without mortality in appropriately selected cases.
Collapse
|
|
5
|
Gupta V, Singh Sodha V, Kumar N, Gupta V, Pate R, Chandra A. Missed pancreatic injury in patients undergoing conservative management of blunt abdominal trauma: Causes, sequelae and management. Turk J Surg 2021; 37:286-293. [PMID: 35112064 PMCID: PMC8776419 DOI: 10.47717/turkjsurg.2021.5425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/16/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Pancreas is a less commonly injured organ in blunt abdominal trauma. This study aimed to analyze the management and outcomes of patients in whom the pancreatic injury was missed during the initial evaluation of blunt abdominal trauma. MATERIAL AND METHODS We retrospectively (2009-2019) analyzed the details and outcome of patients who underwent conservative management of blunt abdominal trauma, where the diagnosis of pancreatic injury was missed for at least 72 hours following trauma. RESULTS A total of 31 patients with missed pancreatic injury were identified. All patients were hemodynamically stable following trauma and most (21) were initially assessed only by an ultrasound. A delayed diagnosis of pancreatic injury was made at a mean of 28 (4 to 60) days after trauma when patients developed abdominal pain (31), distension (18), fever (10) or vomiting (8). On repeat imaging, 18 (58.1%) patients had high grade pancreatic injuries including complete transection or pancreatic duct injury. Seven (22.5%) patients were managed conservatively, seventeen (54.8%) underwent percutaneous drainage of intra-abdominal collections, seven (22.5%) underwent endoscopic or surgical drainage procedure for symptomatic pseudocyst. Eleven (35.4%) patients needed readmissions to manage recurrent pancreatitis, intra-abdominal abscess and pancreatic fistula. Three patients required pancreatic duct stenting for pancreatic fistula. There was no mortality. CONCLUSION Pancreatic injury may be missed in patients who remain hemodynamically stable with minimal clinical symptoms after abdominal trauma, especially if screened only by an ultrasound. In our series, there was significant morbidity of missed pancreatic injury.
Collapse
Affiliation(s)
- Vivek Gupta
- Division of Surgical Gastroenterology, King George’s Medical University, Lucknow, India
| | - Vikram Singh Sodha
- Division of Surgical Gastroenterology, King George’s Medical University, Lucknow, India
| | - Nitin Kumar
- Division of Surgical Gastroenterology, King George’s Medical University, Lucknow, India
| | - Vishal Gupta
- Division of Surgical Gastroenterology, King George’s Medical University, Lucknow, India
| | - Ravi Pate
- Division of Surgical Gastroenterology, King George’s Medical University, Lucknow, India
| | - Abhijit Chandra
- Division of Surgical Gastroenterology, King George’s Medical University, Lucknow, India
| |
Collapse
|
|
6
|
Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
|
7
|
Wiik-Larsen J, Thorsen K, Sandve KO, Søreide K. Incidence and characteristics of pancreatic injuries among trauma patients admitted to a Norwegian trauma centre: a population-based cohort study. Scand J Gastroenterol 2020; 55:1347-1353. [PMID: 33027601 DOI: 10.1080/00365521.2020.1829032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic injuries are rare. Reports are lacking from defined European populations covering all ages and genders and in areas with a low prevalence of penetrating trauma. We aimed to review pancreatic injuries identified within a defined population. METHODS Observational cohort study from a prospectively maintained trauma registry and all patients coded for a pancreatic injury between January 1, 2004 and December 31, 2018. RESULTS A total of 14 patients with pancreatic injury were identified over a 15-year time period. Pancreatic injuries represented 0,19% (14/7207) of all trauma patients and 3,1% (14/454) of patients with documented abdominal injuries. Nine patients 64% (9/14) were children, representing 1% (9/869) of all injured children in the registry and 11,4% (9/79) of children with documented abdominal injuries. Median age was 10,5 years (range 3-58). Ten were male (71%) and 86% (12/14) suffered blunt trauma. Median AAST-OIS was 2 (1-4). Single organ injury occurred in 43% (6/14). Concomitant liver injury was the most frequent associated intra-abdominal injury found in 29% (4/14). Four patients (29%) had associated injuries in other body regions, all thoracic injuries. Median ISS was 9,5 (4-41).Operative management was needed for four of the pancreatic injuries, one spleen-preserving distal pancreatectomy, one spleen-sacrificing distal pancreatectomy and two peripancreatic drainages. One patient died within 30-days, but the death was unrelated to the pancreatic injury. CONCLUSIONS Incidence of pancreatic injuries is low, even among trauma patients with documented abdominal injuries. Most pancreatic injuries occurred in children. Injuries requiring surgery was rare.
Collapse
Affiliation(s)
- Johannes Wiik-Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Knut Olav Sandve
- Department of Radiology, Stavanger University Hospital, Stavanger, Norway.,Stavanger Medical Image Laboratory, Stavanger University Hospital, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
|
8
|
|
|
9
|
Paulino J, Vigia E, Cunha M, Amorim E. Two-stage pancreatic head resection after previous damage control surgery in trauma: two rare case reports. BMC Surg 2020; 20:98. [PMID: 32397989 PMCID: PMC7216496 DOI: 10.1186/s12893-020-00763-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background This study describes the successful treatment of two clinical settings of grade V pancreaticoduodenal blunt trauma only possible due to the prompt collaboration of a peripheral trauma hospital and a central hepatobiliary and pancreatic unit. Case presentation We reviewed the clinical records of two male patients aged 17 and 47 years old who underwent a two-stage pancreaticoduodenectomy after a previous Damage-Control Surgery (DCS). Both patients were transferred to our Hepatobiliopancreatic Unit 2 days after immediate DCS with haemostasis, debridement, duodenostomy, gastroenterostomy, external drainage and laparostomy. One day after, they both underwent a two-stage Whipple’s procedure with external cannulation of the main bile duct and the main pancreatic duct with seized calibre silicone drains through the skin. The reconstructive phase was performed two weeks later. The first patient had an uneventful post-operative course and was discharged on post-operative day 8. The second patient developed a high debt biliary fistula on post-operative day 5 being submitted to a relaparotomy with extensive peritoneal lavage. After conservative measures the fistula underwent a progressive closure in 15 days, and the patient was discharged at post-operative day 50 without any limitations. Conclusions Pancreaticoduodenectomy is a life-saving operation in selected grade V pancreaticoduodenal trauma lesions. DCS is a salvage approach, often performed in peripheral hospitals, making an early referral to an hepatobiliopancreatic centre mandatory to achieve survival in these severely injured patients. A two-staged Whipple’s operation for severe duodenal / pancreatic trauma can be performed safely and may represent a life-saving option under these very unusual circumstances.
Collapse
Affiliation(s)
- Jorge Paulino
- Centro Hepatobiliopancreático e de Transplantação, Centro Hospitalar Universitário de Lisboa Central, Hospital Curry Cabral, Universidade Nova de Lisboa, Lisboa, Portugal.
| | - Emanuel Vigia
- Centro Hepatobiliopancreático e de Transplantação, Centro Hospitalar Universitário de Lisboa Central, Hospital Curry Cabral, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Miguel Cunha
- Department of Surgery, Centro Hospitalar Universitário do Algarve - Unidade de Portimão, Portimão, Portugal
| | - Edgar Amorim
- Department of Surgery, Centro Hospitalar Universitário do Algarve - Unidade de Portimão, Portimão, Portugal
| |
Collapse
|
|
10
|
Biyyam DR, Hwang S, Patel MC, Bardo DME, Bailey SS, Youssfi M. CT Findings of Pediatric Handlebar Injuries. Radiographics 2020; 40:815-826. [PMID: 32364888 DOI: 10.1148/rg.2020190126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Direct bicycle handlebar injuries are a significant cause of chest and abdominal trauma and morbidity in the pediatric population. However, these injuries have been underemphasized. While blunt abdominal trauma has been described well, the literature is limited in reviewing trauma imaging specifically related to direct handlebar injuries in the pediatric population. Major chest injuries include lung contusions, pneumatoceles, and pneumothorax. In the abdomen, injuries to the pancreas, small bowel, mesentery, liver, and spleen are the more common abdominal injuries attributed to direct handlebar trauma. Traumatic abdominal wall hernias and groin injuries, which may be associated with vascular injuries, are other known injuries. The challenge is in both clinical and radiographic diagnosis. The physical findings are often underwhelming, and laboratory values in many studies are shown to be not very sensitive or specific. As a result, there is a risk of delay in imaging, diagnosis, and treatment of significant and sometimes life-threatening injuries. CT is considered the standard examination to delineate intra-abdominal trauma, with a reported sensitivity of 60%-88% and a specificity of 97%-99%. Moreover, CT helps in grading some types of injury and helps guide the surgical treatment course. It is important for radiologists who perform imaging in adults and children to be aware of the significance of direct handlebar injuries and their imaging findings. ©RSNA, 2020.
Collapse
Affiliation(s)
- Deepa Reddy Biyyam
- From the Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016
| | - Steven Hwang
- From the Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016
| | - Mittun C Patel
- From the Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016
| | - Dianna M E Bardo
- From the Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016
| | - Smita S Bailey
- From the Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016
| | - Mostafa Youssfi
- From the Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016
| |
Collapse
|
|
11
|
Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y, Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:56. [PMID: 31867050 PMCID: PMC6907251 DOI: 10.1186/s13017-019-0278-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.
Collapse
Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA USA
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Imitiaz Wani
- Department of Surgery, DHS Hospitals, Srinagar, Kashmir India
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Gustavo Pereira Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Carlos Ordonez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Emmanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Grazia Sibilla
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Hospital, Chiba, Japan
| | - Peter T. Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mazyr, Belarus
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics and Gynecology, University of Buea, Buea, Cameroon
| | - Rao Ivatury
- General and Trauma Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Francesco Favi
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Fernando Machado
- General and Emergency Surgery Department, Montevideo Hospital, Montevideo, Uruguay
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes, UGA-Université Grenoble Alpes, Grenoble, France
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
| |
Collapse
|
|
12
|
Soon DSC, Leang YJ, Pilgrim CHC. Operative versus non-operative management of blunt pancreatic trauma: A systematic review. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618788111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Motor vehicle crashes are common causes of blunt abdominal trauma in the 21st century. While splenic trauma occurs very frequently and thus there is a well-established treatment paradigm, traumatic pancreatic injuries are relatively infrequent, occurring in only 3–5% of traumas. This low incidence means physicians have reduced experience with this condition and there is still ongoing debate with regards to the best practice in managing pancreatic trauma. During severe trauma, the pancreas can be injured as a consequence of blunt and penetrating injury. This has an estimated mortality rate ranging from 9 to 34%. Methods A systematic review was performed using three scientific databases: Embase, Medline and Cochrane and in-line with the PRISMA statement. We included only articles published in English, available as full text and describing only adults. Keywords included: pancrea*, trauma, blunt, operative management and non-operative management. Results Three studies were found that directly compared operative versus non-operative management in blunt pancreatic trauma. Length of stay, mortality and rate of re-intervention were lower in the non-operative group compared to the operative group. However, the average grade of pancreatic injury was lower in the non-operative group compared to the operative group. Discussion Our results revealed that patients who undergo non-operative management tend to have lower grade of injuries and patients with higher grade of injury tend to be managed in an operative fashion. This could be likely due to the fact that higher grade of pancreatic injuries is often accompanied by other injuries such as hollow viscus injury and therefore require operative intervention. Conclusion Non-operative management is a safe approach for low-grade blunt pancreatic trauma without ductal injuries. However, more evidence is required to improve our understanding and treatment plans. We suggest a large international multicentre study combining data from multiple international trauma centres to collect adequate data.
Collapse
Affiliation(s)
- David SC Soon
- Department of Surgery, Peninsula Health, Frankston, Australia
| | - Yit J Leang
- Department of Surgery, Peninsula Health, Frankston, Australia
| | | |
Collapse
|
|
13
|
Leppäniemi A. Nonoperative management of solid abdominal organ injuries: From past to present. Scand J Surg 2019; 108:95-100. [PMID: 30832550 DOI: 10.1177/1457496919833220] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Today, a significant proportion of solid abdominal organ injuries, whether caused by penetrating or blunt trauma, are managed nonoperatively. However, the controversy over operative versus nonoperative management started more than a hundred years ago. The aim of this review is to highlight some of the key past observations and summarize the current knowledge and guidelines in the management of solid abdominal organ injuries. MATERIALS AND METHODS A non-systematic search through historical articles and references on the management practices of abdominal injuries was conducted utilizing early printed volumes of major surgical and medical journals from the late 19th century onwards. RESULTS Until the late 19th century, the standard treatment of penetrating abdominal injuries was nonoperative. The first article advocating formal laparotomy for abdominal gunshot wounds was published in 1881 by Sims. After World War I, the policy of mandatory laparotomy became standard practice for penetrating abdominal trauma. During the latter half of the 20th century, the concept of selective nonoperative management, initially for anterior abdominal stab wounds and later also gunshot wounds, was adopted by major trauma centers in South Africa, the United States, and little later in Europe. In blunt solid abdominal organ injuries, the evolution from surgery to nonoperative management in hemodynamically stable patients aided by the development of modern imaging techniques was rapid from 1980s onwards. CONCLUSION With the help of modern imaging techniques and adjunctive radiological and endoscopic interventions, a major shift from mandatory to selective surgical approach to solid abdominal organ injuries has occurred during the last 30-50 years.
Collapse
Affiliation(s)
- A Leppäniemi
- Abdominal Center, Meilahti Hospital, University of Helsinki, Helsinki, Finland
| |
Collapse
|
|
14
|
Distal pancreatectomy for blunt pancreatic transection. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
|
15
|
Abstract
BACKGROUND Blunt pancreatic trauma is rare, and the reported mortality is high. The true outcomes in isolated pancreas trauma are not known, and the optimal management according to injury severity is controversial. The present study evaluated the incidence, outcomes, and optimal management of isolated blunt pancreatic injuries. METHODS National Trauma Data Bank study, including patients with blunt pancreatic trauma. Patients with major associated injuries or other severe intra-abdominal injuries were excluded. Patients' demographics, vital signs on admission, Abbreviated Injury Scale for each body area, Injury Severity Score (ISS), and therapeutic modality were extracted. Mortality and hospital length of stay were stratified according to the severity of pancreatic injury and therapeutic modality. RESULTS There were 388,137 patients with blunt abdominal trauma. Overall, 12,112 patients (3.1%) sustained pancreatic injury. Isolated pancreatic injury occurred in 2,528 (0.7%) of all abdominal injuries or 20.9% of pancreatic injuries. Most injuries were low-grade Organ Injury Scale ((OIS) score of 2, 82.7%) with only a small percentage of higher-grade injuries (OIS score of 3, 7.9%; OIS score of 4, 3.9%; and OIS score of 5, 5.5%). Overall, most patients (74.1%) were managed nonoperatively. Nonoperative management was selected in 80.5% of pancreas OIS score of 2, 48.5% of OIS score of 3, and 40.9% of OIS scores of 4 to 5. The overall mortality rate was 2.4%, while in severe pancreatic trauma it was 3.0%. In minor pancreatic trauma, nonoperative management was associated with lower mortality and shorter hospital length of stay than operative management. However, in the group of patients with severe pancreatic trauma (OIS scores, 4-5) nonoperative management was associated with higher mortality and longer hospital stay than definitive operative management of the pancreas. CONCLUSIONS The mortality in isolated pancreatic trauma is low, even in severe injuries. Nonoperative management of minor pancreatic injuries is associated with lower mortality and shorter hospital stay than operative management. However, in severe trauma, nonoperative management is associated with higher mortality and longer hospital stay than operative management. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.
Collapse
|
|
16
|
Affiliation(s)
- A N Smolyar
- Department of acute liver and pancreatic surgical diseases, Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - K T Agakhanova
- Department of acute liver and pancreatic surgical diseases, Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| |
Collapse
|
|
17
|
Kim SH, Kim KH. Conservative treatment using an endoscopic pancreatic stent in a patient with delayed diagnosis of pancreatic injury after blunt trauma: A case report. Trauma Case Rep 2017; 7:15-18. [PMID: 30014027 PMCID: PMC6024156 DOI: 10.1016/j.tcr.2017.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2017] [Indexed: 02/07/2023] Open
Abstract
The diagnostic evaluation of pancreatic injuries has improved dramatically in recent years. However, it is sometimes difficult to diagnose pancreatic injuries. Surgical treatment after delayed diagnosis is associated with increased risks of mortality and morbidity. A 47-year-old man was referred to our emergency department after experiencing blunt abdominal trauma 5 d earlier. The patient was diagnosed with a grade-III pancreatic injury. His hemodynamic status remained stable. He was managed successfully using endoscopic pancreatic stenting and percutaneous drainage catheter insertion.
Collapse
Affiliation(s)
- Se Hun Kim
- Department of Anesthesiology and Pain Medicine, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Ki Hoon Kim
- Department of Surgery, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| |
Collapse
|
|
18
|
Magnitude, Severity, and Outcome of Traumatic Pancreatic Injury at a Level I Trauma Center in India. Indian J Surg 2016; 79:515-520. [PMID: 29217902 DOI: 10.1007/s12262-016-1515-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 06/17/2016] [Indexed: 12/26/2022] Open
Abstract
Pancreatic injury is an uncommon and frequently missed injury in abdominal trauma patients. However, missed pancreatic injury is associated with significant morbidity and mortality. This study was conducted to know the burden of pancreatic injury and its outcome in our setup. A retrospective analysis of 53 patients with pancreatic injury from January 2008 through March 2012 at the Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi. Pancreatic injuries were present in 1.18 % of all trauma admissions. Blunt trauma to the abdomen (n = 49, 92.45 %) due to road traffic injury (n = 38, 71.70 %) was the most common mechanism of injury. Isolated pancreatic injury was present in eight (15.09 %) patients. Grade III pancreatic injury (n = 25, 47 %) was the most common. Of these patients, 18.86 % were managed nonoperatively and 81.13 % were managed operatively. Among the operatively managed patients (n = 43), 74.4 % were operated due to pancreatic injury and 25.5 % were operated due to associated injuries. Distal pancreatectomy with or without spleen preservation (n = 25) was the most common operative procedure done. Three out of five patients of Whipple operation for pancreatic injury died. Pancreatic injury was associated with complications in 43.40 % and death in 20 % (n = 11). Pancreatic injury is rare, but delay in diagnosis of pancreatic injury has been associated with higher morbidity and mortality. Low-grade pancreatic injury with intact main pancreatic duct (MPD) could be successfully managed nonoperatively, whereas in high-grade pancreatic injury, an operative intervention is invariably necessary. Distal pancreatectomy with spleen preservation is a desirable goal whenever possible for distal transaction of the pancreas. Whipple resection should be reserved only for hemodynamically stable patients with complex pancreaticoduodenal injury and is associated with high mortality.
Collapse
|
|
19
|
Kumar A, Panda A, Gamanagatti S. Blunt pancreatic trauma: A persistent diagnostic conundrum? World J Radiol 2016; 8:159-173. [PMID: 26981225 PMCID: PMC4770178 DOI: 10.4329/wjr.v8.i2.159] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 12/15/2015] [Indexed: 02/06/2023] Open
Abstract
Blunt pancreatic trauma is an uncommon injury but has high morbidity and mortality. In modern era of trauma care, pancreatic trauma remains a persistent challenge to radiologists and surgeons alike. Early detection of pancreatic trauma is essential to prevent subsequent complications. However early pancreatic injury is often subtle on computed tomography (CT) and can be missed unless specifically looked for. Signs of pancreatic injury on CT include laceration, transection, bulky pancreas, heterogeneous enhancement, peripancreatic fluid and signs of pancreatitis. Pan-creatic ductal injury is a vital decision-making parameter as ductal injury is an indication for laparotomy. While lacerations involving more than half of pancreatic parenchyma are suggestive of ductal injury on CT, ductal injuries can be directly assessed on magnetic resonance imaging (MRI) or encoscopic retrograde cholangio-pancreatography. Pancreatic trauma also shows temporal evolution with increase in extent of injury with time. Hence early CT scans may underestimate the extent of injures and sequential imaging with CT or MRI is important in pancreatic trauma. Sequential imaging is also needed for successful non-operative management of pancreatic injury. Accurate early detection on initial CT and adopting a multimodality and sequential imaging strategy can improve outcome in pancreatic trauma.
Collapse
|
|
20
|
Management of blunt pancreatic trauma: what's new? Eur J Trauma Emerg Surg 2015; 41:239-50. [PMID: 26038029 DOI: 10.1007/s00068-015-0510-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/03/2015] [Indexed: 12/17/2022]
Abstract
Pancreatic injuries are relatively uncommon but present a major challenge to the surgeon in terms of both diagnosis and management. Pancreatic injuries are associated with significant mortality, primarily due to associated injuries, and pancreas-specific morbidity, especially in cases of delayed diagnosis. Early diagnosis of pancreatic trauma is a key for optimal management, but remains a challenge even with more advanced imaging modalities. For both penetrating and blunt pancreatic injuries, the presence of main pancreatic ductal injury is the major determinant of morbidity and the major factor guiding management decisions. For main pancreatic ductal injury, surgery remains the preferred approach with distal pancreatectomy for most injuries and more conservative surgical management for proximal ductal injuries involving the head of the pancreas. More recently, nonoperative management has been utilized, especially in the pediatric population, with the potential for increased rates of pseudocyst and pancreatic fistulae and the potential for the need for further intervention and increased hospital stay. This review presents recent data focusing on the diagnosis, management, and outcomes of blunt pancreatic injury.
Collapse
|
|
21
|
O’Reilly DA, Bouamra O, Kausar A, Dickson EJ, Lecky F. The epidemiology of and outcome from pancreatoduodenal trauma in the UK, 1989-2013. Ann R Coll Surg Engl 2015; 97:125-30. [PMID: 25723689 PMCID: PMC4473389 DOI: 10.1308/003588414x14055925060712] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2014] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989-2013. METHODS The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both. RESULTS Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14-35) for blunt trauma and 14 (IQR: 9-18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation. CONCLUSIONS Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets.
Collapse
Affiliation(s)
- DA O’Reilly
- Department of HPB Surgery, North Manchester General Hospital, Manchester, UK
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - O Bouamra
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- EMRiS, Health Service Research, School of Health and Related Research, University of Sheffield
| | - A Kausar
- Department of HPB Surgery, North Manchester General Hospital, Manchester, UK
| | - EJ Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, UK
| | - F Lecky
- Trauma Audit & Research Network (TARN), The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- EMRiS, Health Service Research, School of Health and Related Research, University of Sheffield
| |
Collapse
|
|
22
|
van der Wilden GM, Yeh DD, Hwabejire JO, Klein EN, Fagenholz PJ, King DR, de Moya MA, Chang Y, Velmahos GC. Trauma Whipple: do or don’t after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB). World J Surg 2014; 38:335-40. [PMID: 24121363 DOI: 10.1007/s00268-013-2257-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy for trauma (PDT) is a rare procedure, reserved for severe pancreaticoduodenal injuries. Using the National Trauma Data Bank (NTDB), our aim was to compare outcomes of PDT patients to similarly injured patients who did not undergo a PDT. METHODS Patients with pancreatic or duodenal injuries treated with PDT (ICD-9-CM 52.7) were identified in the NTDB 2008–2010 Research Data Sets. We excluded those who underwent delayed PDT (>4 days). The PDT group (n = 39) was compared to patients with severe combined pancreaticoduodenal injuries (grade 4 or 5) who did not undergo PDT (non-PDT group, n = 38). Patients who died in the emergency department or did not undergo a laparotomy were excluded. Our primary outcome was death. Secondary outcomes were intensive care unit length of stay (LOS), hospital LOS, and total ventilator days. A multivariate model was used to determine predictors of in-hospital mortality within each group and in the overall cohort. RESULTS The non-PDT group had a significantly lower systolic blood pressure and Glasgow Coma Scale values at baseline and more severe duodenal, pancreatic, and liver injuries. There were no significant differences in outcomes between the two groups. The Injury Severity Score was the only independent predictor of mortality among PDT patients [odds ratio (OR) 1.12, 95 % confidence interval (CI) 1.01–1.24] and in the entire cohort (OR 1.06, 95 % CI 1.01–1.12). The operative technique did not influence any of the outcomes. CONCLUSIONS Compared to non-PDT, PDT did not result in improved outcomes despite a lower physiologic burden among PDT patients. More conservative procedures for high-grade injuries of the pancreaticoduodenal complex may be appropriate.
Collapse
|
|
23
|
Endoscopic management for pancreatic injuries due to blunt abdominal trauma decreases failure of nonoperative management and incidence of pancreatic-related complications. Injury 2014; 45:134-40. [PMID: 23948236 DOI: 10.1016/j.injury.2013.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 07/21/2013] [Accepted: 07/25/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The actual benefit of endoscopic techniques in the non-operative management (NOM) of pancreatic injury is still unclear, with its role and effectiveness in the NOM of pancreatic injury remains defined and doubted. The purpose of this study was to evaluate the feasibility and long-term results of endoscopic techniques in the NOM of blunt pancreatic injury, and to determine whether NOM can be performed safely for selective patients with pancreatic injury. PATIENTS AND METHODS The records and follow-up data of all patients with blunt pancreatic injuries over 16-year period from October 1, 1996, to September 30, 2012 at our department were retrospectively reviewed. Failure of NOM (FNOM) occurred if laparotomy was required after attempted NOM. RESULTS 132 patients (32% of all patients with blunt pancreatic injury) underwent NOM, including 58 who underwent endoscopic management (EM) and 74 who were observed without EM (NO-EM). FNOM of overall NOM was 20%, including 30% of NO-EM and 9% of EM. There was no significant difference in FNOM for NO-EM versus EM for grade I, however, a significant decrease in FNOM was noted with the addition of EM for grade II and III. EM was a statistically significant independent risk factor. Regular follow-up of 1 year showed that, for patients from grade I to III, 53 patients (42%) from operative management (OM) and 34 patients (46%) of the NO-EM developed various pancreatic-related complications, while only 15 patients (26%) of the EM developed such complications, and the difference was significant. CONCLUSION Application of strictly defined selection criteria for NOM and EM in patients with blunt pancreatic injury resulted in one of the lowest FNOM rates (9%) and pancreatic-related complications incidence (25%). Selective application of EM for hemodynamically stable patients with blunt pancreatic injury will extend the indications for, and improve success of NOM.
Collapse
|
|
24
|
Debi U, Kaur R, Prasad KK, Sinha SK, Sinha A, Singh K. Pancreatic trauma: A concise review. World J Gastroenterol 2013; 19:9003-9011. [PMID: 24379625 PMCID: PMC3870553 DOI: 10.3748/wjg.v19.i47.9003] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023] Open
Abstract
Traumatic injury to the pancreas is rare and difficult to diagnose. In contrast, traumatic injuries to the liver, spleen and kidney are common and are usually identified with ease by imaging modalities. Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities, and these injuries are often overlooked in cases with extensive multiorgan trauma. The most evident findings of pancreatic injury are post-traumatic pancreatitis with blood, edema, and soft tissue infiltration of the anterior pararenal space. The alterations of post-traumatic pancreatitis may not be visualized within several hours following trauma as they are time dependent. Delayed diagnoses of traumatic pancreatic injuries are associated with high morbidity and mortality. Imaging plays an important role in diagnosis of pancreatic injuries because early recognition of the disruption of the main pancreatic duct is important. We reviewed our experience with the use of various imaging modalities for diagnosis of blunt pancreatic trauma.
Collapse
|
|
25
|
Abu-Zidan FM, Hefny AF, Mousa H, Torab FC, Hassan I. Camel-related pancreatico-duodenal injuries: a report of three cases and review of literature. Afr Health Sci 2013; 13:762-767. [PMID: 24250319 PMCID: PMC3824447 DOI: 10.4314/ahs.v13i3.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Human pancreatico-duodenal injuries caused by camels are extremely rare. OBJECTIVE We report three patients who sustained camel-related pancreatico-duodenal injuries and review the literature on this topic. RESULTS A 32-year camel caregiver was kicked by a camel which then stepped on his abdomen trying to kill him. The patient's abdomen was soft and lax. CT scan of the abdomen showed free retroperitoneal air. Laparotomy revealed a complete tear of the anterior wall of the second part of duodenum which was primarily repaired. A 40-year camel caregiver was directly kicked into his abdomen by a camel. He developed traumatic pancreatitis which was treated conservatively. A 31-year-old male fell down on his abdomen while riding a camel. Abdominal examination revealed tenderness and guarding. Abdominal CT Scan showed complete transection of the neck of the pancreas which was confirmed by laparotomy. The patient had distal pancreatectomy with preservation of the spleen. All patients were discharged home in good condition. CONCLUSION These cases demonstrate the misleading presentation of the camel-related pancreatico-duodenal injuries and their unique mechanism of injury.
Collapse
Affiliation(s)
- F M Abu-Zidan
- Trauma Group, Faculty of Medicine and Health Sciences, UAE University, UAE ; Department of Surgery, Al-Ain Hospital, Al-Ain, UAE
| | | | | | | | | |
Collapse
|
|
26
|
Lee PH, Lee SK, Kim GU, Hong SK, Kim JH, Hyun YS, Park DH, Lee SS, Seo DW, Kim MH. Outcomes of hemodynamically stable patients with pancreatic injury after blunt abdominal trauma. Pancreatology 2012; 12:487-92. [PMID: 23217286 DOI: 10.1016/j.pan.2012.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 07/17/2012] [Accepted: 09/21/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND To date there is no systematical report about blunt pancreatic injury focused on hemodynamically stable patients. This study reports on our experience in this rare subgroup at a tertiary referral hospital. METHODS A total of 58 adult patients were identified during a 10-year period and their clinical data were analyzed. Injury to the main pancreatic duct (MPD) was basically confirmed by pancreatography or surgical findings. RESULTS MPD disruption was confirmed in 36 patients (62%) and was more frequent in the pancreatic neck and body. The median time from trauma to confirmation was 14 days [interquartile range (IQR) 3-23 days] including time from admission to confirmation of 10.5 days [IQR 3-20 days]. Patients with MPD injury showed higher injury severity score, more frequent pancreas-specific complications and longer hospital stays. The sensitivity and specificity of initial computed tomography (CT) for MPD injury were 63.9% (23/36) and 81.8% (18/22), respectively. The mortality rate was 7%, and all deaths were directly attributed to pancreatic injury. Complications occurred in 22 patients (37%) and 17 developed during hospitalization. Time from trauma to confirmation of MPD disruption (odds ratio 1.132; 95% confidence interval 1.021-1.255, P=0.019) was the only independent factor associated with unfavorable events among patients with high-grade injury. CONCLUSIONS MPD injury was not infrequent in hemodynamically stable patients. Physicians were more responsible for the delay in diagnosis of MPD disruption, which was primarily associated with adverse outcomes. A rapid, multidisciplinary approach may lead to better outcomes in hemodynamically stable patients with blunt pancreatic injury.
Collapse
Affiliation(s)
- Pil Hyung Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
27
|
Lee WJ, Foo NP, Lin HJ, Huang YC, Chen KT. The efficacy of four-slice helical CT in evaluating pancreatic trauma: a single institution experience. J Trauma Manag Outcomes 2011; 5:1. [PMID: 21214900 PMCID: PMC3022694 DOI: 10.1186/1752-2897-5-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 01/07/2011] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE To assess the efficacy of computed tomography (CT) in evaluating patients with pancreatic trauma. METHODS We undertook a retrospective review of all blunt trauma patients admitted to the Chi-Mei Medical Center from January 2004 to June 2006. Every patients underwent abdominal CT scan in emergency department and the CT scans were obtained with a four-slice helical CT. Diagnosis of a pancreatic injury in these patients was by surgical observation or by CT findings. Radiographic pancreatic injuries were classified as deep or superficial lesions. Deep lesions were defined as the hematomas or lacerations >50% thickness of the pancreas. Superficial lesions were described as the hematomas or lacerations <50% thickness of the pancreas; pancreatic edema; and focal fluid accumulation around the pancreas RESULTS Nineteen patients with pancreatic trauma, fourteen males and five females, average age 40.6 ± 21.4 years, were included. Most patients (73.7%) with pancreatic trauma had associated organ injuries. CT was performed in all patients and laparotomy in 14 patients. CT was 78.9% sensitive in detecting pancreatic trauma. All deep pancreatic lesions revealed on CT required surgical treatment, and complication was discovered in two patients undergoing delayed surgery. Superficial lesions were managed conservatively. CONCLUSION Four-slice helical CT can detect most pancreatic trauma and provide practical therapeutic guidance. Delayed operation might result in complications and is associated with prolonged hospital stays.
Collapse
Affiliation(s)
- Wei-Jing Lee
- Emergency Department, Chi-Mei Medical Center, 901 Chung-Hwa Road, Yung Kang, Tainan 710, Taiwan ROC
| | - Ning-Ping Foo
- Emergency Department, Chi-Mei Medical Center, 901 Chung-Hwa Road, Yung Kang, Tainan 710, Taiwan ROC
| | - Hung-Jung Lin
- Emergency Department, Chi-Mei Medical Center, 901 Chung-Hwa Road, Yung Kang, Tainan 710, Taiwan ROC
| | - Yen-Chang Huang
- Emergency Department, Chi-Mei Medical Center, 901 Chung-Hwa Road, Yung Kang, Tainan 710, Taiwan ROC
| | - Kuo-Tai Chen
- Emergency Department, Chi-Mei Medical Center, 901 Chung-Hwa Road, Yung Kang, Tainan 710, Taiwan ROC
| |
Collapse
|
|
28
|
Abstract
Left pancreatic traumas (LPTs) are rare but serious lesions occurring in 1 to 6 per cent of abdominal trauma patients and mainly resulting from blunt traumas. LPT severity is primarily dependent on the associated injuries and secondarily related to main pancreatic duct injury responsible for complications: acute pancreatitis, pseudocysts, pancreatic fistulas, or abscesses. The guidelines for blunt LPT management can be presented as follows. In case of emergency laparotomy, pancreas exploration is mandatory to detect pancreatic duct lesions. In the absence of main pancreatic duct lesions, simple drainage is advocated. In case of distal injury to the main pancreatic duct, a left pancreatectomy is mandatory. In the absence of initial laparotomy, the diagnosis is more and more based on CT and magnetic resonance cholangiopancreatography, which tend to replace endoscopic retrograde cholangiopancreatography (ERCP) as a first-intent diagnostic modality. In case of distal injury to the main pancreatic duct, spleen-preserving distal pancreatectomy is recommended. In the absence of main pancreatic duct lesions, nonoperative treatment is advocated. When LPTs are discovered at the time of complications, pancreatic fistulas and/or pseudocysts are associated with main pancreatic lesions, which can be treated by pancreatic duct stenting at ERCP and/or internal endoscopic cystogastrostomy. However, in such cases, spleen-preserving distal pancreatectomy remains the treatment of choice. Pancreatic ductal lesions resulting from LPT have to be diagnosed early to avoid late complications. Distal pancreatectomy remains the treatment of choice in case of severe pancreatic ductal lesions because the role of ERCP stenting and endoscopic techniques needs further evaluation.
Collapse
Affiliation(s)
- Brice Malgras
- Visceral Surgery Unit, Val de Grace University Military Hospital, Paris, France
| | - Richard Douard
- Digestive and Endocrinian Surgery Unit, Cochin AP-HP University Hospital, Paris, France
- Paris-Descartes Faculty of Medicine, Paris V University, Paris, France
| | - Nathalie Siauve
- Paris-Descartes Faculty of Medicine, Paris V University, Paris, France
- Radiology Unit, Georges Pompidou AP-HP University Hospital, Paris, France
| | - Philippe Wind
- General and Digestive Surgery Unit, Avicenne AP-HP University Hospital, Bobigny, France
- Faculté de Médecine de Bobigny, Université Paris XIII, Bobigny, France
| |
Collapse
|
|
29
|
Rekhi S, Anderson SW, Rhea JT, Soto JA. Imaging of blunt pancreatic trauma. Emerg Radiol 2009; 17:13-9. [PMID: 19396480 DOI: 10.1007/s10140-009-0811-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 03/30/2009] [Indexed: 12/26/2022]
Abstract
Blunt pancreatic trauma is an exceedingly rare but life-threatening injury with significant mortality. Computed tomography (CT) is commonly employed as the initial imaging modality in blunt trauma patients and affords a timely diagnosis of pancreatic trauma. The CT findings of pancreatic trauma can be broadly categorized as direct signs, such as a pancreatic laceration, which tend to be specific but lack sensitivity and indirect signs, such as peripancreatic fluid, which tend to be sensitive but lack specificity. In patients with equivocal CT findings or ongoing clinical suspicion of pancreatic trauma, magnetic resonance cholangiopancreatography (MRCP) may be employed for further evaluation. The integrity of the main pancreatic duct is of crucial importance, and though injury of the duct may be strongly suggested upon initial CT, MRCP provides clear delineation of the duct and any potential injuries. This article aims to review and illustrate the CT and magnetic resonance imaging findings of blunt pancreatic trauma and delineate the integration of these modalities into the appropriate imaging triage of severely injured blunt trauma patients.
Collapse
Affiliation(s)
- Satinder Rekhi
- Department of Radiology, Boston University Medical Center, Boston, MA, USA
| | | | | | | |
Collapse
|