Management of pancreatic injuries during damage control surgery: an observational outcomes analysis of 79 patients treated at an academic Level 1 trauma centre. Eur J Trauma Emerg Surg. 2017;43:411-420. [PMID: 26972574 DOI: 10.1007/s00068-016-0657-6]

Delayed distal pancreatectomy for isolated complete pancreatic disruption secondary to "trivial" blunt abdominal injury: A case report and literature review

Pancreatic injury is a formidable diagnostic and therapeutic challenge owing to its relative rarity. Most injuries are from motor vehicle related injuries in blunt trauma patients. We present a 22-year-old male patient presented after sustaining a kick to the abdomen. He developed progressive abdominal pain with vomiting with delayed generalization of the pain and involuntary guarding. On initial exploratory laparotomy, suction drainage was inserted, and patient underwent delayed spleen sparing distal pancreatectomy on the 25th post-admission day. Patient had smooth postoperative course and was discharged on the 7th postoperative day.

Feasibility and safety of “bridging” pancreaticogastrostomy for pancreatic trauma in Landrace pigs

BACKGROUND

In recent years, we created and employed a new anastomosis method, “bridging” pancreaticogastrostomy, to treat patients with extremely severe pancreatic injury. This surgery has advantages such as short length of surgery, low secondary trauma, rapid construction of shunts for pancreatic fluid, preventing second surgeries, and achieving good treatment outcomes in clinical practice. However, due to the limited number of clinical cases, there is a lack of strong evidence to support the feasibility and safety of this surgical procedure. Therefore, we carried out animal experiments to examine this procedure, which is reported here.

AIM

To examine the feasibility and safety of a new rapid method of pancreaticogastrostomy, “bridging” pancreaticogastrostomy.

METHODS

Ten Landrace pigs were randomized into the experimental and control groups, with five pigs in each group. “Bridging” pancreaticogastrostomy was performed in the experimental group, while routine mucosa-to-mucosa pancreaticogastrostomy was performed in the control group. After surgery, the general condition, amylase levels in drainage fluid on Days 1, 3, 5, and 7, fasting and 2-h postprandial blood glucose 6 mo after surgery, fasting, 2-h postprandial peripheral blood insulin, and portal vein blood insulin 6 mo after surgery were assessed. Resurgery was carried out at 1 and 6 mo after the former one to examine the condition of the abdominal cavity and firmness and tightness of the pancreaticogastric anastomosis and pancreas.

RESULTS

After surgery, the general condition of the animals was good. One in the control group did not gain weight 6 mo after surgery, whereas significant weight gain was present in the others. There were significant differences on Days 1 and 3 after surgery between the two groups but no differences on Days 5 and 7. There were no differences in fasting and 2-h postprandial blood glucose and fasting and 2-h insulin values of postprandial peripheral blood and portal vein blood 6 mo after surgery between the two groups. One month after surgery, the sinus tract orifice/anastomosis was patent in the two groups. Six months after surgery, the sinus tract orifice/anastomosis was sealed, and pancreases in both groups presented with chronic pancreatitis.

CONCLUSION

“Bridging” pancreaticogastrostomy is a feasible and safe a means of damage control surgery during the early stage of pancreatic injury.

Pancreatic damage control: the pancreas is simple don't complicate it

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.

Two-stage pancreatic head resection after previous damage control surgery in trauma: two rare case reports

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.

Clinical update on management of pancreatic trauma

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.

Surgical outcomes of pancreaticoduodenal injuries in children

PURPOSE

To examine surgical outcomes of children with pancreaticoduodenal injuries at a Quaternary Level I pediatric trauma center.

METHODS

We queried a prospectively maintained trauma database of a level one pediatric trauma center for all cases of pancreatic and/or duodenal injury from 2002 to 2017. Analysis was conducted using JMP 13.1.0.

RESULTS

170 children presented with pancreatic and/or duodenal injury. 13 (7.7%) suffered a combined injury and this group forms the basis for this report with mean ISS of 22.8 (± 15.1), RTS2 of 6.4(± 2.1), and median age of 6.6 (1.3-13.5) years. Child abuse (31%) and bicycle injuries (23%) were the most common mechanisms. 8/13 (61.5%) required operative intervention. Higher AAST pancreatic and duodenal injury grade (2.9 vs. 1.2, p = 0.05 and 3.6 vs. 1.4, p = < 0.01), lower RTS2 (7.84 vs. 5.49, p < 0.01), and lower GCS (9.6 vs. 15, p = 0.03) predicted operative intervention. 6/8 (75%) undergoing surgery survived to discharge with only (2/6) survivors suffering postoperative complications. Both mortalities were secondary to severe traumatic brain injury.

CONCLUSION

Surgical management of complex pancreaticoduodenal injury is an uncommon traumatic event that is associated with high injury severity, but survival occurs in most scenarios.

Approach and Management of Traumatic Retroperitoneal Injuries

Traumatic retroperitoneal injuries constitute a challenge for trauma surgeons. They usually occur in the context of a trauma patient with multiple associated injuries, in whom invasive procedures have an important role in the diagnosis of these injuries. The retroperitoneum is the anatomical region with the highest mortality rates, therefore early diagnosis and treatment of these lesions acquire special relevance. The aim of this study is to present current published scientific evidence regarding incidence, mechanism of injury, diagnostic methods and treatment through a review of the international literature from the last 70 years. In conclusion, this systematic review showed an increasing trend towards non-surgical management of retroperitoneal injuries.