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Zhang Y, Cui YF. Severe acute pancreatitis complicated with intra-abdominal infection secondary to trauma: A case report. World J Clin Cases 2024; 12:5821-5831. [DOI: 10.12998/wjcc.v12.i25.5821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/12/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Pancreatic trauma (PT) is rare among traumatic injuries and has a low incidence, but it can still lead to severe infectious complications, resulting in a high mortality rate. Acute pancreatitis (AP) is a common complication after PT, and when combined with organ dysfunction and sepsis, it will result in a poorer prognosis.
CASE SUMMARY We report a 25-year-old patient with multiple organ injuries, including the pancreas, due to abdominal trauma, who developed necrotising pancreatitis secondary to emergency caesarean section, combined with intra-abdominal infection (IAI). The patient underwent performed percutaneous drainage, pancreatic necrotic tissue debridement, and abdominal infection foci debridement on the patient.
CONCLUSION We report a case of severe AP and IAI secondary to trauma. This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery, and a better outcome was obtained.
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Affiliation(s)
- Yu Zhang
- Department of Surgery, Tianjin Nankai Hospital, Tianjin Medical University, Tianjin 300070, China
| | - Yun-Feng Cui
- Department of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin 300100, China
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Li Y, Song Y, Jiang C, Li Y, Tang C, Liu S. Tube-in-tube for pancreatic fistula after pediatric pancreatic surgery: a case report. Gastroenterol Rep (Oxf) 2024; 12:goae063. [PMID: 38962064 PMCID: PMC11220174 DOI: 10.1093/gastro/goae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/29/2024] [Accepted: 05/26/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
- Yufeng Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People’s Hospital, Changsha, Hunan, P. R. China
| | - Yinghui Song
- Central Laboratory of Hunan Provincial People’s Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, P. R. China
| | - Chenlin Jiang
- Hunan Provincial Key Laboratory of Biliary Disease Prevention and Treatment, Changsha, Hunan, P. R. China
| | - Yuhang Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People’s Hospital, Changsha, Hunan, P. R. China
| | - Chenji Tang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People’s Hospital, Changsha, Hunan, P. R. China
| | - Sulai Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Hunan Provincial People’s Hospital, Changsha, Hunan, P. R. China
- Central Laboratory of Hunan Provincial People’s Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, P. R. China
- Hunan Provincial Key Laboratory of Biliary Disease Prevention and Treatment, Changsha, Hunan, P. R. China
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Lu X, Gao H, Jiang K, Miao Y, Wei J. Management and Outcome of Blunt Pancreatic Trauma: A Retrospective Cohort Study. World J Surg 2023; 47:2135-2144. [PMID: 37227485 DOI: 10.1007/s00268-023-07026-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Pancreatic injury is rare, but it has a high mortality rate and its optimal treatment remains controversial. This study aimed to evaluate the clinical characteristics, management strategies, and outcomes of patients with blunt pancreatic injury. METHODS This retrospective cohort study was performed on patients with a confirmed blunt pancreatic injury who were admitted to our hospital from March 2008 to December 2020. The clinical characteristics and outcomes of patients receiving different management strategies were compared. The risk factors for in-hospital mortality were evaluated by performing a multivariate regression analysis. RESULTS A total of 98 patients diagnosed with blunt pancreatic injury were identified, with 40 patients having undergone nonoperative treatment (NOT) and 58 patients having undergone surgical treatment (ST). The overall in-hospital deaths were 6 (6.1%), including 2 (5.0%) and 4 (6.9%) in the NOT and ST groups, respectively. Pancreatic pseudocysts occurred in 15 (37.5%) and 3 (5.2%) of the NOT and ST groups, respectively, showing a significant difference between the two groups (P < 0.001). In the multivariate regression analysis, concomitant duodenal injury (OR = 14.42, 95% CI 1.27-163.52; P = 0.031) and sepsis (OR = 43.47, 95% CI, 4.15-455.75; P = 0.002) were independently associated with in-hospital mortality. CONCLUSIONS Except for the higher incidence of pancreatic pseudocysts in the NOT group than in the ST group, there were no significant differences in the other clinical outcomes between the two groups. Concomitant duodenal injury and sepsis were the risk factors for in-hospital mortality.
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Affiliation(s)
- Xiaozhi Lu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Hao Gao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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Chui JN, Kotecha K, Gall TMH, Mittal A, Samra JS. Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit. World J Gastrointest Surg 2023; 15:834-846. [PMID: 37342855 PMCID: PMC10277947 DOI: 10.4240/wjgs.v15.i5.834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/22/2023] [Accepted: 03/16/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND The management of high-grade pancreatic trauma is controversial.
AIM To review our single-institution experience on the surgical management of blunt and penetrating pancreatic injuries.
METHODS A retrospective review of records was performed on all patients undergoing surgical intervention for high-grade pancreatic injuries [American Association for the Surgery of Trauma (AAST) Grade III or greater] at the Royal North Shore Hospital in Sydney between January 2001 and December 2022. Morbidity and mortality outcomes were reviewed, and major diagnostic and operative challenges were identified.
RESULTS Over a twenty-year period, 14 patients underwent pancreatic resection for high-grade injuries. Seven patients sustained AAST Grade III injuries and 7 were classified as Grades IV or V. Nine underwent distal pancreatectomy and 5 underwent pancreaticoduodenectomy (PD). Overall, there was a predominance of blunt aetiologies (11/14). Concomitant intra-abdominal injuries were observed in 11 patients and traumatic haemorrhage in 6 patients. Three patients developed clinically relevant pancreatic fistulas and there was one in-hospital mortality secondary to multi-organ failure. Among stable presentations, pancreatic ductal injuries were missed in two-thirds of cases (7/12) on initial computed tomography imaging and subsequently diagnosed on repeat imaging or endoscopic retrograde cholangiopancreatography. All patients who sustained complex pancreaticoduodenal trauma underwent PD without mortality. The management of pancreatic trauma is evolving. Our experience provides valuable and locally relevant insights into future management strategies.
CONCLUSION We advocate that high-grade pancreatic trauma should be managed in high-volume hepato-pancreato-biliary specialty surgical units. Pancreatic resections including PD may be indicated and safely performed with appropriate specialist surgical, gastroenterology, and interventional radiology support in tertiary centres.
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Affiliation(s)
- Juanita Noeline Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, NSW, Australia
| | - Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
| | - Tamara MH Gall
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, NSW, Australia
- Department of Surgery, University of Notre Dame, Sydney 2006, NSW, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, NSW, Australia
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Zhirong Z, Li H, Yiqun H, Chunyang H, Lichen Z, Zhen T, Tao W, Ruiwu D. Enhancing or inhibiting apoptosis? The effects of ucMSC-Ex in the treatment of different degrees of traumatic pancreatitis. Apoptosis 2022; 27:521-530. [PMID: 35612769 DOI: 10.1007/s10495-022-01732-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 11/28/2022]
Abstract
The animal models of traumatic pancreatitis (TP) were established to evaluate the specific mechanisms by which umbilical cord mesenchymal stem cell-derived exosomes (ucMSC-Ex) exert therapeutic effects. Sixty four rats were randomly divided into eight groups, including TP groups with three different degrees and relevant groups with ucMSC-Ex treated. The degrees of pancreatic tissue injury were evaluated by Histological Examination. Furthermore, enzyme-linked immunosorbent assay were applied to evaluate the activity of pancreatic enzymes and levels of inflammatory factors in serum. Finally, the apoptotic effects of each group were evaluated by TUNEL, western blot (WB), and real time fluorescence quantitative polymerase chain reaction (RT-qPCR). The pancreatic histopathological score and serum amylase and lipase levels gradually increased in various degrees of TP and the levels in the treatment group were all significantly decreased. The apoptosis index gradually increased in each TP group and significantly decreased in the treatment group in TUNEL results. WB and RT-qPCR showed the same trend, that bax and caspase-3 gradually increased and bcl-2 gradually decreased in TP groups. Compared with TP groups, the expression of bax and caspase-3 were lower while bcl-2 expression was higher in the treatment group. ucMSC-Ex suppressed the inflammatory response and inhibited pancreatic acinar cell apoptosis to promote repair of injured pancreatic tissue.
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Affiliation(s)
- Zhao Zhirong
- College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Han Li
- General Surgery Center, General Hospital of Western Theater Command, No. 270, Rongdu Rd, Jinniu District, Chengdu, 610083, Sichuan, China.,College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - He Yiqun
- The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - He Chunyang
- Hyperbaric Oxygen Department, General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Zhou Lichen
- General Surgery Center, General Hospital of Western Theater Command, No. 270, Rongdu Rd, Jinniu District, Chengdu, 610083, Sichuan, China.,College of Clinical Medicine, Southwest Medical University, Luzhou, Sichuan, China
| | - Tan Zhen
- General Surgery Center, General Hospital of Western Theater Command, No. 270, Rongdu Rd, Jinniu District, Chengdu, 610083, Sichuan, China
| | - Wang Tao
- General Surgery Center, General Hospital of Western Theater Command, No. 270, Rongdu Rd, Jinniu District, Chengdu, 610083, Sichuan, China
| | - Dai Ruiwu
- General Surgery Center, General Hospital of Western Theater Command, No. 270, Rongdu Rd, Jinniu District, Chengdu, 610083, Sichuan, China. .,College of Medicine, Southwest Jiaotong University, Chengdu, China. .,College of Clinical Medicine, Southwest Medical University, Luzhou, Sichuan, China.
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Somasekar R, Krishna PS, Kesavan B, Siva Sankar A. A Pragmatic Approach to Pancreatic Trauma: A Single-Center Experience From a Tertiary Care Center. Cureus 2022; 14:e24793. [PMID: 35677008 PMCID: PMC9168422 DOI: 10.7759/cureus.24793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction Pancreatic trauma is rare and is usually associated with adjacent organ and vascular injuries, which adds to the high morbidity and mortality. In the American Association for the Surgery of Trauma (AAST) pancreatic trauma (PT) grading system, the higher grades are a composite of less and more severe extents of injuries. We hereby present an observational study of PT with management based on an indigenous algorithmic approach. Our protocol incorporating both the extent of disruption of the main pancreatic duct (MPD) and its amenability to interventions (endoscopic, radiological, or surgical) is pragmatic. Methods Ours is a retrospective observational study of 28 consecutive cases of PT, done over a three-year period in an academic institution, by an expert Surgical Gastroenterology unit. All patients diagnosed with PT on a contrast abdominal CT scan were included. After stabilization, they were stratified and managed according to an indigenous protocol. The primary outcome measure was treatment success in terms of recovery. The secondary outcome measure was morbidity of any form. Results One patient with Grade 1 PT was operated on for associated hollow viscus injury. Two patients with AAST Grade 2 and two patients with AAST Grade 3 injury were managed successfully without surgery. Twelve of 21 patients with Grade 3 PT underwent Kimura’s splenic vessel preserving distal pancreatectomy. Distal pancreatectomy with splenectomy and central pancreatectomy with Roux-en-Y pancreaticojejunostomy (PJ) was done for 7/21 and 2/21 patients, respectively, with Grade 3 PT. Two with Grade 5 injury underwent trauma Whipple. The overall mortality and morbidity rates in our series were 15.7% and 64%, respectively. Conclusion The pathogenesis in PT is a dynamic process and shows temporal evolution. These patients require serial and periodical clinical and radiological monitoring, especially in those managed conservatively initially. PT can be low or high grade. Patients with isolated low-grade PT can be managed according to the standard step-up approach for acute pancreatitis. A carefully selected subgroup of patients with partial MPD disruption either in the head or body of the pancreas can be managed by endotherapy. Complete distal parenchymal transections require early surgery tailored to individual patients in the form of either splenic vessel preserving distal pancreatectomy (SPDP) or distal pancreatectomy with splenectomy (DP+S). Damage control surgery is the dictum in unstable patients with Grades 4 and 5 injuries not responding to resuscitative measures. A trauma Whipple can be done in a carefully selected subgroup of stable patients with proximal massive disruptions in an experienced hepato-pancreatico-biliary (HPB) unit.
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Affiliation(s)
- Rdr Somasekar
- Surgical Gastroenterology, Government Mohan Kumaramangalam Medical College Hospital, Salem, IND
| | - Pothugunta S Krishna
- Surgical Gastroenterology, Government Mohan Kumaramangalam Medical College Hospital, Salem, IND
| | - B Kesavan
- Surgical Gastroenterology, Government Mohan Kumaramangalam Medical College Hospital, Salem, IND
| | - A Siva Sankar
- Surgical Gastroenterology, Government Mohan Kumaramangalam Medical College Hospital, Salem, IND
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7
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Khalayleh H, Imam A, Cohen-Arazi O, Yoav P, Helou B, Miklosh B, Pikarsky AJ, Khalaileh A. An analysis of 77 cases of pancreatic injuries at a level one trauma center: Outcomes of conservative and surgical treatments. Ann Hepatobiliary Pancreat Surg 2022; 26:190-198. [PMID: 35393375 PMCID: PMC9136422 DOI: 10.14701/ahbps.21-144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/29/2021] [Accepted: 12/29/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Traumatic pancreatic injury (TPI) is rare as an isolated injury. There is a trend to perform conservative treatment even in patients with complete duct dissection and successful treatment. This study reviewed our 20 years of experience in the management of TPI and assessed patient outcomes according to age group and treatment strategy. Methods A retrospective analysis of patients diagnosed and treated with TPI at a level-I trauma center from 2000-2019. Patients were divided into two groups: adults and pediatrics. Conservative treatment cases were subjected to subgroup analysis. Level of evidence: IV. Results Of a total of 77 patients, the mean age was 24.89 ± 15.88 years. Fifty-six (72.7%) patients had blunt trauma with motor vehicle accident. Blunt trauma was the predominant mechanism in 42 (54.5%) patients. Overall, 38 (49.4%) cases had grade I or II injury, 24 (31.2%) had grade III injury, and 15 (19.5%) had grade IV injury. A total of 30 cases had non-operative management (NOM). Successful NOM was observed in 16 (20.8%) cases, including eight (32.0%) pediatric cases and eight (15.4%) adult cases. Higher American association for the surgery of trauma (AAST) grade of injury was associated with NOM failure (16.7% for grade I/II, 100% for grade III, and 66.7% for grade IV injury; p = 0.001). An independent factor for NOM failure was female sex (69.2% in females vs. 29.4% in males; p = 0.03). Conclusions High AAST grade TPI is associated with a high rate of NOM failure in both pediatric and adults.
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Affiliation(s)
- Harbi Khalayleh
- Department of Surgery, Kaplan Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ashraf Imam
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oded Cohen-Arazi
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Pikkel Yoav
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Brigitte Helou
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Bala Miklosh
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alon J Pikarsky
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Abed Khalaileh
- Department of Surgery, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Aoki Y, Sasanuma H, Kimura Y, Saito A, Morishima K, Kaneda Y, Endo K, Yoshida A, Kihara A, Sakuma Y, Horie H, Hosoya Y, Lefor AK, Sata N. Pancreas-preserving double pancreaticogastrostomy after traumatic injury to the head of the pancreas: a case report. J Int Med Res 2021; 48:300060520962967. [PMID: 33059503 PMCID: PMC7580157 DOI: 10.1177/0300060520962967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Traumatic injury to the main pancreatic duct requires surgical treatment, but optimal management strategies have not been established. In patients with isolated pancreatic injury, the pancreatic parenchyma must be preserved to maintain long-term quality of life. We herein report a case of traumatic pancreatic injury with main pancreatic duct injury in the head of the pancreas. Two years later, the patient underwent a side-to-side anastomosis between the distal pancreatic duct and the jejunum. Eleven years later, he presented with abdominal pain and severe gastrointestinal bleeding from the Roux limb. Emergency surgery was performed with resection of the Roux limb along with central pancreatectomy. We attempted to preserve both portions of the remaining pancreas, including the injured pancreas head. We considered the pancreatic fluid outflow tract from the distal pancreatic head and performed primary reconstruction with a double pancreaticogastrostomy to avoid recurrent gastrointestinal bleeding. The double pancreaticogastrostomy allowed preservation of the injured pancreatic head considering the distal pancreatic fluid outflow from the pancreatic head and required no anastomoses to the small intestine.
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Affiliation(s)
- Yuichi Aoki
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Hideki Sasanuma
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Yuki Kimura
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Akira Saito
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Kazue Morishima
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Yuji Kaneda
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Kazuhiro Endo
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Atsushi Yoshida
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Atsushi Kihara
- Department of Pathology, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Yasunaru Sakuma
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Hisanaga Horie
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Yoshinori Hosoya
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Yakushiji Shimotsuke, Tochigi, Japan
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Joos E, de Jong N, Ball CG, Quigley S, Trottier V, Massé M, Engels PT, Rao J, Gillman LM, Visser R, Widder S, Hameed MS, Vogt KN. Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers. J Trauma Acute Care Surg 2021; 90:434-440. [PMID: 33617195 DOI: 10.1097/ta.0000000000003025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers. METHODS This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity. RESULTS Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury. CONCLUSION Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system. LEVEL OF EVIDENCE Therapeutic/care management, level V; Prognostic and epidemiological, level IV.
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Affiliation(s)
- Emilie Joos
- From the Division of General Surgery/Department of Surgery (E.J., M.S.H.), University of British Columbia, Vancouver; University of Groningen (N.d.J.), Faculty of Medicine; Department of Surgery (C.G.B., S.Q.), University of Calgary, Calgary; Department of Surgery (V.T., M.M.), Laval University, Québec City; Department of Surgery (P.T.E.), McMaster University, Hamilton; Department of Surgery (J.R.), University of Saskatchewan, Regina; Department of Surgery (L.M.G., R.V.), University of Manitoba, Winnipeg; Department of Surgery (S.W.), University of Alberta, Edmonton; and Department of Surgery (K.N.V.), Western University, London, Canada
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10
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Ando Y, Okano K, Yasumatsu H, Okada T, Mizunuma K, Takada M, Kobayashi S, Suzuki K, Kitamura N, Oshima M, Suto H, Nobuyuki M, Suzuki Y. Current status and management of pancreatic trauma with main pancreatic duct injury: A multicenter nationwide survey in Japan. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:183-191. [PMID: 33280257 PMCID: PMC7986433 DOI: 10.1002/jhbp.877] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/22/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
Background Pancreatic trauma is reportedly associated with high morbidity and mortality. Main pancreatic duct (MPD) injury is critical for treatment. Methods As a study project of the Japanese Society for Abdominal Emergency Medicine (JSAEM), we collected the data of 163 patients with pancreatic trauma who were diagnosed and treated at JSAEM board‐certified hospitals from 2006 to 2016. Clinical backgrounds, diagnostic approaches, management strategies, and outcomes were evaluated. Results Sixty‐four patients (39%) were diagnosed as having pancreatic trauma with MPD injury that resulted in 3% mortality. Blunt trauma and isolated pancreatic injury were independent factors predicting MPD injury. Nine of 11 patients with MPD injury who were initially treated nonoperatively had serious clinical sequelae and five (45%) required surgery as a secondary treatment. Among all cases, the detectability of MPD injury of endoscopic retrograde pancreatography (ERP) was superior to that of other imaging modalities (CT or MRI), with higher sensitivity and specificity (sensitivity = 0.96; specificity = 1.0). Conclusions Acceptable outcomes were observed in pancreatic trauma patients with MPD injury. Nonoperative management should be carefully selected for MPD injury. ERP is recommended to be performed in patients with suspected MPD injury and stable hemodynamics.
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Affiliation(s)
- Yasuhisa Ando
- Department of Gastroenterological Surgery, Kagawa University, Kita-gun, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University, Kita-gun, Japan
| | - Hiroshi Yasumatsu
- Shock and Trauma Center/Hokusoh HEMS, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Japan
| | - Toshimasa Okada
- Department of Digestive Surgery, Kawasaki Medical School, Kurashikishi-City, Japan
| | | | - Minoru Takada
- Department of Surgery, Teine Keijinkai Hospital, Sapporo-City, Japan
| | - Shinjiro Kobayashi
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kawasaki-City, Japan
| | - Keisuke Suzuki
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Bunkyo-ku, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu-City, Japan
| | - Minoru Oshima
- Department of Gastroenterological Surgery, Kagawa University, Kita-gun, Japan
| | - Hironobu Suto
- Department of Gastroenterological Surgery, Kagawa University, Kita-gun, Japan
| | | | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Kagawa University, Kita-gun, Japan
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Ordoñez CA, Parra MW, Millán M, Caicedo Y, Padilla N, Guzmán-Rodríguez M, Miñan-Arana F, García A, González-Hadad A, Pino LF, Rodríguez-Holguin F, Serna JJ, Salcedo A, Ferrada R, Ivatury R. Pancreatic damage control: the pancreas is simple don't complicate it. Colomb Med (Cali) 2020; 51:e4164361. [PMID: 33795904 PMCID: PMC7968433 DOI: 10.25100/cm.v51i4.4361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/14/2020] [Accepted: 10/10/2020] [Indexed: 12/29/2022] Open
Abstract
Pancreatic trauma is a rare but potentially lethal injury because often it is associated with other abdominal organ or vascular injuries. Usually, it has a late clinical presentation which in turn complicates the management and overall prognosis. Due to the overall low prevalence of pancreatic injuries, there has been a significant lack of consensus among trauma surgeons worldwide on how to appropriately and efficiently diagnose and manage them. The accurate diagnosis of these injuries is difficult due to its anatomical location and the fact that signs of pancreatic damage are usually of delayed presentation. The current surgical trend has been moving towards organ preservation in order to avoid complications secondary to exocrine and endocrine function loss and/or potential implicit post-operative complications including leaks and fistulas. The aim of this paper is to propose a management algorithm of patients with pancreatic injuries via an expert consensus. Most pancreatic injuries can be managed with a combination of hemostatic maneuvers, pancreatic packing, parenchymal wound suturing and closed surgical drainage. Distal pancreatectomies with the inevitable loss of significant amounts of healthy pancreatic tissue must be avoided. General principles of damage control surgery must be applied when necessary followed by definitive surgical management when and only when appropriate physiological stabilization has been achieved. It is our experience that viable un-injured pancreatic tissue should be left alone when possible in all types of pancreatic injuries accompanied by adequate closed surgical drainage with the aim of preserving primary organ function and decreasing short and long term morbidity.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Fernando Miñan-Arana
- Universidad Espiritu Santo, Department of Surgery, Guayaquil, Ecuador
- Hospital Dr. Abel Gilbert Ponton, Department of Surgery, Division of Trauma and Acute Care Surgery, Guayaquil, Ecuador
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Fernando Rodríguez-Holguin
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Ricardo Ferrada
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
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12
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Ayoob AR, Lee JT, Herr K, LeBedis CA, Jain A, Soto JA, Lim J, Joshi G, Graves J, Hoff C, Hanna TN. Pancreatic Trauma: Imaging Review and Management Update. Radiographics 2020; 41:58-74. [PMID: 33245670 DOI: 10.1148/rg.2021200077] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Traumatic injuries of the pancreas are uncommon and often difficult to diagnose owing to subtle imaging findings, confounding multiorgan injuries, and nonspecific clinical signs. Nonetheless, early diagnosis and treatment are critical, as delays increase morbidity and mortality. Imaging has a vital role in diagnosis and management. A high index of suspicion, as well as knowledge of the anatomy, mechanism of injury, injury grade, and role of available imaging modalities, is required for prompt accurate diagnosis. CT is the initial imaging modality of choice, although the severity of injury can be underestimated and assessment of the pancreatic duct is limited with this modality. The time from injury to definitive diagnosis and the treatment of potential pancreatic duct injury are the primary factors that determine outcome following pancreatic trauma. Disruption of the main pancreatic duct (MPD) is associated with higher rates of complications, such as abscess, fistula, and pseudoaneurysm, and is the primary cause of pancreatic injury-related mortality. Although CT findings can suggest pancreatic duct disruption according to the depth of parenchymal injury, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography facilitate direct assessment of the MPD. Management of traumatic pancreatic injury depends on multiple factors, including mechanism of injury, injury grade, presence (or absence) of vascular injury, hemodynamic status of the patient, and associated organ damage. ©RSNA, 2020 See discussion on this article by Patlas.
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Affiliation(s)
- Andres R Ayoob
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - James T Lee
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Keith Herr
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Christina A LeBedis
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Ashwin Jain
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Jorge A Soto
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Jihoon Lim
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Gayatri Joshi
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Joseph Graves
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Carrie Hoff
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Tarek N Hanna
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
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13
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Wen XD, Liu DQ, Zhang BY, Xiao L, Yan HT, Liu WH. The bridge stenting-based internal drainage in pancreatic trauma patients with main pancreatic duct injury. Updates Surg 2020; 72:717-726. [PMID: 32572695 DOI: 10.1007/s13304-020-00807-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 05/18/2020] [Indexed: 12/28/2022]
Abstract
Pancreatic trauma is associated with high mortality and morbidity, especially in main pancreatic duct (MPD) injuries. Here, we introduce a novel technique via the placement of bridge stenting-based internal drainage (BSID) along the injured MPD to restore pancreatic tissue integrity. Twelve patients with MPD injury underwent unobstructed BSID as physical support for healing. Six patients with peripheral organ injuries underwent operative end-to-end anastomosis of the MPD by using a polyurethane central venous catheter for the BSID, and the other six patients with isolated proximal MPD rupture received BSID via endoscopic pancreatic stent placement. The BSID technique was successfully performed in all pancreatic trauma patients without the need for a second open surgery. With this simplified BSID-based operation, a short procedure duration (242.7 ± 38.71 min in the surgical group and 100.2 ± 16.24 min in the endoscopic group) and a short hospital stay (13.0 ± 7.05 days) were achieved. However, a few complications (41.67%) still occurred, including pancreatitis, fistula, abscess, pseudocyst, cholangitis, and haemorrhage. Except for the deceased case, all postoperative courses were marked by decreases in the peripancreatic fluid collection, blood amylase recovery, and normal endocrine function. The BSID approach is a feasible surgical approach for the treatment of MPD injury and can be used endoscopically in isolated MPD injuries for its safety and convenience.
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Affiliation(s)
- Xu-Dong Wen
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, 610072, Sichuan Province, China
- Department of Gastroenterology and Hepatology, Chengdu First People's Hospital, Chengdu, 610016, Sichuan Province, China
| | - Dan-Qing Liu
- General Surgery Center, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan Province, China
| | - Bing-Yin Zhang
- General Surgery Center, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan Province, China
| | - Le Xiao
- General Surgery Center, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan Province, China
| | - Hong-Tao Yan
- General Surgery Center, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan Province, China.
| | - Wei-Hui Liu
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, 610072, Sichuan Province, China.
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14
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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: 0.5] [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.
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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
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Hosseininejad SM, Bozorgi F, Assadi T, Montazar SH, Jahanian F, Hoseini V, Shamsaee M, Tabarestani M. The predictive role of amylase and lipase levels on pancreas injury diagnosis in patients with blunt abdominal trauma. Horm Mol Biol Clin Investig 2020; 41:hmbci-2019-0066. [PMID: 32374282 DOI: 10.1515/hmbci-2019-0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 04/04/2020] [Indexed: 12/26/2022]
Abstract
Objectives Despite the low incidence of pancreatic injury in the abdominal blunt trauma (BTA), its early diagnosis is very important; since pancreatic injury is associated with high rates of morbidity and mortality. However, due to the high association of pancreatic injury with injury of other abdominal organs, its diagnosis may be delayed and complicated. The use of imaging modalities is also subject to limitations for reasons such as cost, unavailability, and harmfulness. Consequently, the present study aimed to investigate the predictive role of amylase and lipase enzyme levels in the final diagnosis of pancreatic injury in patients with BTA. Methods In a prospective diagnostic study, 384 patients with BTA referring to Imam Khomeini hospital of Sari (north of Iran) were enrolled according to the inclusion and exclusion criteria. Initial patient data including age and sex were recorded. Blood samples were analyzed in the laboratory to measure complete blood count (CBC), amylase and lipase enzyme levels. Patients were followed up during hospitalization and focal ultrasound for abdominal trauma (FAST), CT-Scan and laparotomy results were recorded. Finally, the data was analyzed using SPSS version 22. Results The level of amylase enzyme was significantly higher in males (p = 0.04), but the level of lipase enzyme was not significantly different between two genders (p > 0.05). The most common symptoms and signs in patients were pain, tenderness, and hematoma, respectively. The frequency of pancreatic injury in all patients with blunt abdominal trauma was 7.5% based of FAST, 7% based on CT-Scan and 12.4% based on laparotomy. Comparison of laboratory findings based on FAST, CT-Scan and laparotomy results showed that the level of amylase and lipase enzymes in patients with internal organ and pancreatic damage were higher than in patients without internal organ injury (p < 0.05). But based on FAST results; patients with pancreatic injury and injury of other organs had no significant difference (p > 0.05). However, comparison of laboratory findings based on CT-Scan and laparotomy results showed a significant increase in the level of amylase and lipase enzymes in patients with pancreatic trauma compared to patients with injury of other organs (p < 0.001). Conclusions The results of this study showed that pancreatic injury in blunt trauma is associated with a significant increase in levels of amylase and lipase enzymes. In addition, an increase in levels of amylase and lipase enzymes is associated with internal organ damage. Serum amylase and lipase levels can be used as useful biomarkers to decide whether to perform CT-Scan or laparotomy.
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Affiliation(s)
- Seyed Mohammad Hosseininejad
- Department of Emergency Medicine, Diabetes Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Farzad Bozorgi
- Department of Emergency Medicine, Gut And Liver Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Touraj Assadi
- Department of Emergency Medicine, Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Seyyed Hosein Montazar
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Fatemeh Jahanian
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Vahid Hoseini
- Department of Emergency Medicine, Gut And Liver Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Mahboobeh Shamsaee
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Mohammad Tabarestani
- Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
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16
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Odedra D, Mellnick VM, Patlas MN. Imaging of Blunt Pancreatic Trauma: A Systematic Review. Can Assoc Radiol J 2020; 71:344-351. [PMID: 32063010 DOI: 10.1177/0846537119888383] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Despite several published reports on the value of imaging in acute blunt pancreatic trauma, there remains a large variability in the reported performance of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). The purpose of this study is to present a systematic review on the utility of these imaging modalities in the acute assessment of blunt pancreatic trauma. In addition, a brief overview of the various signs of pancreatic trauma will be presented. METHODS Keyword search was performed in MEDLINE, EMBASE, and Web of Science databases for relevant studies in the last 20 years (1999 onward). Titles and abstracts were screened, followed by full-text screening. Inclusion criteria were defined as studies reporting on the effectiveness of imaging modality (US, CT, or MRI) in detecting blunt pancreatic trauma. RESULTS After initial search of 743 studies, a total of 37 studies were included in the final summary. Thirty-six studies were retrospective in nature. Pancreatic injury was the primary study objective in 21 studies. Relevant study population varied from 5 to 299. Seventeen studies compared the imaging findings against intraoperative findings. Seven studies performed separate analysis for pancreatic ductal injuries and 9 studies only investigated ductal injuries. The reported sensitivities for the detection of pancreatic injuries at CT ranged from 33% to 100% and specificity ranged from 62% to 100%. Sensitivity at US ranged from 27% to 96%. The sensitivity at MRI was only reported in 1 study and was 92%. CONCLUSION There remains a large heterogeneity among reported studies in the accuracy of initial imaging modalities for blunt pancreatic injury. Although technological advances in imaging equipment would be expected to improve accuracy, the current body of literature remains largely divided. There is a need for future studies utilizing the most advanced imaging equipment with appropriately defined gold standards and outcome measures.
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Affiliation(s)
- Devang Odedra
- Department of Radiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Vincent M Mellnick
- Abdominal Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Michael N Patlas
- Division of Emergency/Trauma Radiology, Department of Radiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
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17
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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: 59] [Impact Index Per Article: 11.8] [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.
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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
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18
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An Unlikely Cause of a Blunt Pancreatic Injury. Pediatr Emerg Care 2019; 35:e238-e240. [PMID: 29698344 DOI: 10.1097/pec.0000000000001478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report the case of a 17-year-old male football player with blunt abdominal trauma. Careful evaluation, including computed tomography and laboratory, revealed a pancreatic body laceration. Pancreatic injuries are relatively uncommon and associated with significant morbidity and mortality and require early diagnosis for optimal management and outcome.
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19
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Wiik Larsen J, Søreide K. The worldwide variation in epidemiology of pancreatic injuries. Injury 2019; 50:1787-1789. [PMID: 31421815 DOI: 10.1016/j.injury.2019.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/10/2019] [Indexed: 02/02/2023]
Affiliation(s)
- Johannes Wiik Larsen
- Department of Gastrointestinal Surgery, 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.
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20
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Sue T, Matcovici M, Paran S. A non-operative strategy for grade IV blunt pancreatic trauma. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.101287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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21
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Du B, Wang X, Wang X, Shah S, Ke N. A rare case of central pancreatectomy for isolated complete pancreatic neck transection trauma. BMC Surg 2019; 19:91. [PMID: 31299958 PMCID: PMC6626428 DOI: 10.1186/s12893-019-0557-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/03/2019] [Indexed: 02/05/2023] Open
Abstract
Background Pancreatic trauma accounts for only 0.2% of blunt trauma and 1–12% of penetrating injuries. Injuries to other organs, such as spleen, liver, or kidney, are associated with 50.5% of the cases. The isolated complete traumatic transection of the pancreatic neck is rare. In the past, pancreatoduodenectomy or distal pancreatectomy and splenectomy was the standard care for patients with traumatic transection of the pancreatic head, duodenum or distal pancreas, and pancreatic neck. However, limited cases have been reported on the central pancreatectomy for pancreatic neck injuries. We present a rare case of a 21-year-old male patient who received central pancreatectomy for isolated complete traumatic transection of the pancreatic neck. Case presentation A 21-year-old male patient with mild abdominal pain and showed no apparent abnormality in the initial abdominal computed tomography (CT) was brought to the local hospital’s emergency department due to a traffic accident. The patient’s abdominal pain became progressively worse during observation in the hospital that led to the patient being referred to our hospital. The patient’s vital signs were stable, and a physical examination revealed marked tenderness and rebound pain throughout the abdomen. The patient’s white blood cells were increased; The serum amylase and lipase levels were elevated. The abdominal computed tomography revealed pancreatic neck parenchymal discontinuity, peripancreatic effusion, and hemorrhage. The patient underwent exploratory laparotomy. Intraoperative examination identified the neck of the pancreas was completely ruptured, and no apparent abnormalities were observed in the other organs. The patient underwent central pancreatectomy and Roux -Y pancreaticojejunostomy. The patient was treated with antibiotics, acid inhibition and nutritional supports for 10 days after surgery. Symptoms of the patient were significantly relieved, and white blood cells, serum amylase, and lipase levels returned to normal. The patient underwent follow up examination for 6 months with no evidence of exocrine or endocrine insufficiency. Conclusions Central pancreatectomy is an effective pancreas parenchyma preserving procedure, may be a promising alternative to distal pancreatectomy and splenectomy for this complex pancreatic trauma in hemodynamically stable patients. Patient selection and surgeon experience are crucial in the technical aspects of this procedure.
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Affiliation(s)
- Bingqing Du
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Shashi Shah
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Nengwen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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22
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Kuza CM, Hirji SA, Englum BR, Ganapathi AM, Speicher PJ, Scarborough JE. Pancreatic Injuries in Abdominal Trauma in US Adults: Analysis of the National Trauma Data Bank on Management, Outcomes, and Predictors of Mortality. Scand J Surg 2019; 109:193-204. [PMID: 31142209 DOI: 10.1177/1457496919851608] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Traumatic pancreatic injury is associated with high morbidity and mortality rates, and the management strategies associated with the best clinical outcomes are unknown. Our aims were to identify the incidence of traumatic pancreatic injury in adult patients in the United States using the National Trauma Data Bank, evaluate management strategies and clinical outcomes, and identify predictors of in-hospital mortality. MATERIALS AND METHODS We retrospectively analyzed National Trauma Data Bank data from 2007 to 2011, and identified patients ⩾14 years old with pancreatic injuries either due to blunt or penetrating trauma. Patient characteristics, injury-associated factors, clinical outcomes, and in-hospital mortality rates were evaluated and compared between two groups stratified by injury type (blunt vs penetrating trauma). Statistical analyses used included Pearson's chi-square, Fisher's exact test, and analysis of variance. Factors independently associated with in-hospital mortality were identified using multivariable logistic regression. RESULTS We identified 8386 (0.3%) patients with pancreatic injuries. Of these, 3244 (38.7%) had penetrating injuries and 5142 (61.3%) had blunt injuries. Penetrating traumas were more likely to undergo surgical management compared with blunt traumas. The overall in-hospital mortality rate was 21.2% (n = 1776), with penetrating traumas more likely to be associated with mortality (26.5% penetrating vs 17.8% blunt, p < 0.001). Unadjusted mortality rates varied by management strategy, from 6.7% for those treated with a drainage procedure to >15% in those treated with pancreatic repair or resection. Adjusted analysis identified drainage procedure as an independent factor associated with decreased mortality. Independent predictors of mortality included age ⩾70 years, injury severity score ⩾15, Glasgow Coma Scale motor <6, gunshot wound, and associated injuries. CONCLUSIONS Traumatic pancreatic injuries are a rare but critical condition. The incidence of pancreatic injury was 0.3%. The overall morbidity and mortality rates were 53% and 21.2%, respectively. Patients undergoing less invasive procedures, such as drainage, were associated with improved outcomes.
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Affiliation(s)
- C M Kuza
- Department of Anesthesiology and Critical Care, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - S A Hirji
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.,Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - B R Englum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - A M Ganapathi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - P J Speicher
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - J E Scarborough
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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23
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Søreide K, Weiser TG, Parks RW. Clinical update on management of pancreatic trauma. HPB (Oxford) 2018; 20:1099-1108. [PMID: 30005994 DOI: 10.1016/j.hpb.2018.05.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma. METHODS Systematic literature review until May 2018. RESULTS Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries. CONCLUSION Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.
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Affiliation(s)
- Kjetil Søreide
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Clinical Medicine, University of Bergen, Norway; Department of Gastrointestinal Surgery, Stavanger University Hospital, Norway.
| | - Thomas G Weiser
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Stanford University Department of Surgery, Section of Trauma and Critical Care, Stanford, CA, USA
| | - Rowan W Parks
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK
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24
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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
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25
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An Interesting Case of Isolated Pancreatic Transection Following Blunt Abdominal Trauma in Emergency Department. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2018; 2:e48. [PMID: 31172111 PMCID: PMC6548144 DOI: 10.22114/ajem.v0i0.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Traumatic injury to the pancreas is not common, but if the diagnosis is delayed or misdiagnosed in the emergency department (ED), the condition is associated with high morbidity and mortality and raises a question about the quality of emergency care. Here, we describe a rare case of blunt abdominal trauma resulted in isolated pancreas injury. Case presentation: A 25-year-old young male came to our emergency room (ER) in a conscious, anxious state from a nearby town with a history of roadside trauma. Further investigations revealed an isolated pancreatic injury due to trauma with no other major injuries, which occurred due to a sudden high-speed impact of the steering wheel to the epigastrium of a driver while driving the car, severely compressing the pancreas between the backbone and steering wheel. The patient was admitted to the intensive care unit for close observation and monitoring. He was managed conservatively on intravenous fluids, antibiotics, analgesics, and vasopressors. He was discharged after five days in a hemodynamically stable and afebrile condition, on a normal diet. Conclusion: Isolated pancreatic injury following blunt abdominal trauma is rare, and the symptoms are difficult to analyze early due to its retroperitoneal anatomy. Early detection and early intervention are important in the ED, and if left unrecognized, could result in a poor outcome.
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26
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Mungazi SG, Mbanje C, Chihaka O, Madziva N. Combined pancreatic and duodenal transection injury: A case report. Int J Surg Case Rep 2017; 39:285-287. [PMID: 28886391 PMCID: PMC5591448 DOI: 10.1016/j.ijscr.2017.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 08/20/2017] [Accepted: 08/21/2017] [Indexed: 11/18/2022] Open
Abstract
Pancreatic-duodenal injuries are rare. They are associated with high morbidity and mortality. Damage control or less complex surgery improves outcome.
Introduction Combined pancreatic-duodenal injuries in blunt abdominal trauma are rare. These injuries are associated with high morbidity and mortality, and their emergent management is a challenge. Case presentation We report a case of combined complete pancreatic (through the neck) and duodenal (first part) transections in a 24-year-old male secondary to blunt abdominal trauma following a motor vehicle crash. The duodenal stumps were closed separately and a gastrojejunostomy performed for intestinal continuity. The transacted head of pancreas main duct was suture ligated and parenchyma was over sewn and buttressed with omentum. The edge of the body and tail pancreatic segment was freshened and an end to side pancreatico-jejunostomy was fashioned. A drain was left in situ. Post operatively the patient developed a pancreatic fistula which resolved with conservative management. After ten months of follow up the patient was well and showed no signs and symptoms of pancreatic insufficiency. Discussion Lengthy, complex procedures in pancreatic injuries have been associated with poor outcomes. Distal pancreatectomy or Whipple’s procedure for trauma are viable options for complete pancreatic transections. But when there is concern that the residual proximal pancreatic tissue is inadequate to provide endocrine or exocrine function, preservation of the pancreatic tissue distal to the injury becomes an option. Conclusion Combined pancreatic and duodenal injuries are rare and often fatal. Early identification, resuscitation and surgical intervention is warranted. Because of the large number of possible combinations of injuries to the pancreas and duodenum, no one form of therapy is appropriate for all patients.
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Affiliation(s)
- Simbarashe Gift Mungazi
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Box 167 Avondale Harare, Zimbabwe.
| | - Chenesa Mbanje
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Box 167 Avondale Harare, Zimbabwe
| | - Onesai Chihaka
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Box 167 Avondale Harare, Zimbabwe
| | - Noah Madziva
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Box 167 Avondale Harare, Zimbabwe
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Abstract
Pancreatic injuries are relatively uncommon, but considerable morbidity and mortality may result if associated vascular and duodenal injuries are present or if the extent of the injury is underestimated and appropriate intervention is delayed. Optimal management includes the need for early diagnosis and accurate definition of the site and extent of injury. Prognosis is influenced by the cause and complexity of the pancreatic injury, the amount of blood lost, duration of shock, the rapidity of resuscitation and the quality and appropriateness of surgical intervention. Early mortality results from uncontrolled or major bleeding due to associated injuries while late mortality is generally a consequence of infection or multiple organ failure. Initial management of pancreatic trauma is similar to that of any patient with a severe abdominal injury. Stable patients with a suspected pancreatic injury should have non-invasive imaging including a CT scan or MRI. Urgent laparotomy is required in patients with evidence of major intraperitoneal bleeding, associated visceral trauma, or peritonitis. Operative intervention is guided by the integrity of the main pancreatic duct. External drainage is adequate for parenchymal injuries with an intact duct, while duct injuries of the neck, body and tail require a distal pancreatectomy. Pancreatic head injuries are more complex. If the duodenum is reparable and the ampulla is intact, external drainage suffices. Rarely, complex injuries may require a pancreatoduodenectomy after damage control surgery if the patient has multiple injuries and is unstable. Postoperative pancreatic complications including fistula and pseudocysts are common but can usually be treated endoscopically.
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Affiliation(s)
- JEJ Krige
- Department of Surgery, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
- Surgical Gastroenterology, Groote Schuur Hospital, Cape Town, South Africa
| | - E Jonas
- Department of Surgery, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
- Surgical Gastroenterology, Groote Schuur Hospital, Cape Town, South Africa
| | - SR Thomson
- Department of Medicine, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
| | - SJ Beningfield
- Department of Radiology, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
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28
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Diagnostic and therapeutic role of endoscopic retrograde pancreatography in the management of traumatic pancreatic duct injury patients: Single center experience for 34 years. Int J Surg 2017; 42:152-157. [DOI: 10.1016/j.ijsu.2017.03.054] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/06/2017] [Accepted: 03/17/2017] [Indexed: 12/13/2022]
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Abstract
In the last decade, higher rates of nonoperative management of liver, spleen, and kidney injuries have been achieved. An algorithmic approach may improve success on a national level. Factors for success include management strategy based on physiologic status of the child, early attempt at resuscitation using blood products, and appropriate use of adjuncts. Shorter hospitalizations are appropriate for children who have not bled significantly, and discharge instructions facilitate the safety of early discharge. Although routine imaging is not required for liver or spleen injury, symptoms should prompt reevaluation. Reimaging of renal injuries remains in common use.
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30
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Nanashima A, Imamura N, Tsuchimochi Y, Hamada T, Yano K, Hiyoshi M, Fujii Y, Kawano F, MitsuruTamura. Horizontal traumatic laceration of the pancreas head: A rare case report. Int J Surg Case Rep 2017; 31:119-123. [PMID: 28135676 PMCID: PMC5279907 DOI: 10.1016/j.ijscr.2017.01.030] [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] [Received: 11/29/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This case report is intended to inform acute care surgeons about treating rare horizontal laceration of the pancreas head caused by blunt trauma. CASE PRESENTATION A 57-year-old woman who sustained blunt abdominal trauma during a car crash was transported to the emergency center of our hospital with unstable vital signs due to hemorrhagic shock. Computed tomography showed transection of the pancreas head and massive intra-abdominal hemorrhage. She was referred for emergency surgery because of a transient response. Laparotomy at five hours after the accident initially revealed consistent massive bleeding from branches of the superior mesenteric artery and vein, which we resolved by suturing the vessels without damaging the main trunks. A horizontal laceration and complete transection of the pancreatic head were then confirmed but the main pancreatic duct remained intact. The lower part of the pancreatic head including the uncus with the attached part of the duodenum was resected, and the pancreatic stump remaining after transection was fixed by suturing. The jejunal limb was attached to the remnant duodenum by side-to-side functional anastomosis. Although gastric emptying was delayed for one month after surgery, the postoperative course was good and the patient recovered at three months thereafter. The embryonic border of pancreas head accompanied with pancreatic divisum was considered for this laceration without disruption of the main pancreatic duct. DISCUSSION Blunt pancreatic trauma usually causes vertical transection and thus, horizontal transection is considered rare. The embryological anatomical border between the ventral and dorsal pancreas due to pancreatic divisum was supposed to be transected and therefore the main pancreatic duct was not damaged. CONCLUSION Hemorrhagic shock and rare pancreatic head trauma were treated by appropriate intraoperative management.
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Affiliation(s)
- Atsushi Nanashima
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan.
| | - Naoya Imamura
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Yuki Tsuchimochi
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Takeomi Hamada
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Kouichi Yano
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Masahide Hiyoshi
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Yoshiro Fujii
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - Fumiaki Kawano
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
| | - MitsuruTamura
- Division of Hepato-biliary-pancreas Surgery, Department of Surgery, Faculty of Medicine University of Miyazaki, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan
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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
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32
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Predictors of successful non-operative management of grade III & IV blunt pancreatic trauma. Ann Med Surg (Lond) 2016; 10:103-9. [PMID: 27594995 PMCID: PMC4995476 DOI: 10.1016/j.amsu.2016.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/08/2016] [Accepted: 08/08/2016] [Indexed: 12/15/2022] Open
Abstract
Introduction Although surgery is the preferred treatment for grade III&IV pancreatic trauma, there is a growing movement for non-operative management. in blunt pancreatic trauma. Very few studies compare operative versus non-operative management in adult patients. Methods Retrospective analysis of a prospectively maintained database was performed from 2004 to 2013 in the department of gastrointestinal surgery, NIMS, Hyderabad. Comparative analysis was performed between patients who failed versus those who were successfully managed with non-operative management. Results 34 patients had grade III/IV trauma out of which 8 were operated early with the remaining 26 initially under a NOM strategy, 10 of them could be successfully managed without any operation. Post-traumatic pancreatitis, Necrotizing pancreatitis, Ileus, contusion on CT, surrounding organ injuries are independently associated with failure of NOM on a univariate analysis. On multivariate logistic regression presence of necrosis& associated organ injury are factors that predict failure of NOM independently. Development of a pseudocyst is the only significant factor that is associated with a success of NOM. Conclusions Non-operative measures should be attempted in a select group of grade III&IV blunt pancreatic trauma. In hemodynamically stable patients with a controlled leak walled off as a pseudocyst without associated organ injuries and pancreatic necrosis, NOM has a higher success rate. Non-operative measures should be attempted in a select group of high grade (grade III/IV) pancreatic trauma. Controlled leak walled off as a pseudocyst, absent necrosis&organ injuries predict high success rate for NOM. Dedicated nutritional, gastrointestinal and interventional radiological support are the key components of care.
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33
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Magnetic resonance imaging of pancreaticobiliary diseases in children: from technique to practice. Pediatr Radiol 2016; 46:778-90. [PMID: 27229496 DOI: 10.1007/s00247-016-3608-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 02/09/2016] [Accepted: 03/11/2016] [Indexed: 02/06/2023]
Abstract
Magnetic resonance imaging is useful for evaluating pancreaticobiliary diseases in children after initial sonography, obviating the use of ionizing radiation or invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) or transhepatic biliary procedures. Advanced MRI applications have improved depiction of pediatric pancreaticobiliary anatomy and have greatly impacted management of biliary and pancreatic diseases in children. In this article, we review current MRI and magnetic resonance cholangiopancreatography (MRCP) techniques and discuss their role in the assessment of common pancreatic and biliary disorders in children.
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34
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Lim C, Lahat E, Azoulay D. Isolated injury to the pancreas: The importance of the baseline computed tomography scan. J Visc Surg 2016; 153:237. [PMID: 27032316 DOI: 10.1016/j.jviscsurg.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- C Lim
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri-Mondor Hospital, Assistance publique-Hôpitaux de Paris, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France; Université Paris-Est, 94000 Créteil, France
| | - E Lahat
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri-Mondor Hospital, Assistance publique-Hôpitaux de Paris, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - D Azoulay
- Department of Digestive, Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri-Mondor Hospital, Assistance publique-Hôpitaux de Paris, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France; Université Paris-Est, 94000 Créteil, France; Inserm, Unité 955, 94000 Créteil, France.
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35
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Peitzman AB. Focus on blunt abdominal trauma. Eur J Trauma Emerg Surg 2015; 41:217. [PMID: 26038049 DOI: 10.1007/s00068-015-0531-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 04/07/2015] [Indexed: 11/26/2022]
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