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Li KW, Chen WS, Wang K, Yang C, Deng YX, Wang XY, Hu YP, Liu YX, Li WQ, Ding WW. Open or Not Open the Retroperitoneum: A Pandora's Box for Blunt High-Grade Pancreatic Trauma? J Surg Res 2024; 293:79-88. [PMID: 37734295 DOI: 10.1016/j.jss.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/19/2023] [Accepted: 08/14/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION The optimal management strategy for pancreatic trauma remains unclear. We aimed to determine whether the initial nonoperative management (NOM) strategy based on percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement would improve outcomes for blunt high-grade pancreatic trauma. METHODS Patients with blunt abdominal trauma who were hemodynamically stable without signs of diffuse peritonitis were consecutively enrolled at a high-volume center. The primary outcome was the occurrence of severe complications (Clavien‒Dindo classification ≥ Ⅲb) for patients who underwent initial laparotomy (LAP) versus NOM. Modified Poisson regression was used to model the primary outcome. Propensity score matching and weighting models were included into a regression-based sensitivity analysis. RESULTS Of 119 patients with grade III/IV pancreatic trauma, 29 patients underwent initial NOM, and 90 underwent initial LAP. The incidence of severe complications in the LAP group was higher than that in the NOM group (65/90 [72.2%] versus 9/29 [31.0%], P < 0.001). In the multivariable modified Poisson regression model, the relative risk for severe complications was decreased in the NOM group (relative risk, 0.52; 95% confidence interval, 0.30-0.90; P = 0.020). The results of the sensitivity analysis were consistent with those of the multivariable analysis. The mean number of reinterventions per patient was 1.8 in the NOM group and 2.6 in the LAP group (P = 0.067). CONCLUSIONS For blunt high-grade pancreatic trauma patients with stable hemodynamics and no diffuse peritonitis, the NOM strategy was associated with a lower risk of severe complications (Clavien‒Dindo classification ≥ Ⅲb) and did not require more invasive reintervention procedures. In high-volume centers with sufficient expertise, percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement may serve as an initial reasonable option for selected patients.
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Affiliation(s)
- Kai-Wei Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Wen-Song Chen
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Kai Wang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Chao Yang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yun-Xuan Deng
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Xin-Yu Wang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yue-Peng Hu
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yu-Xiu Liu
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China; Division of Data and Statistics, Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
| | - Wei-Qin Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
| | - Wei-Wei Ding
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
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Brigode W, Roberts D, Capron G, Starr F, Bokhari F. Validating the American Association for the Surgery of Trauma Pancreas Injury Grade Using Trauma Quality Improvement Program Data. Am Surg 2023:31348231161768. [PMID: 36867713 DOI: 10.1177/00031348231161768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for the pancreas was created in 1990. Our aim was to validate the ability of the AAST-OIS pancreas grade to predict adjuncts to operative management, including endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous drain placement. We analyzed the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019, including all patients with a pancreas injury. Outcomes included the rates of mortality, laparotomy, ERCP, and peri-pancreatic or hepatobiliary percutaneous drain placement. Outcomes were analyzed by AAST-OIS, and odds ratios (ORs) and 95 confidence intervals (CIs) were calculated for each. 3571 patients were included in the analysis. The AAST grade was associated with increased rates of mortality and laparotomy at every level (P < .05). Endoscopic retrograde cholangiopancreatography rates increased from grade 2 to 3 (OR 4.685, 95% CI 3.254-6.745), were similar between grades 3 and 4 (P > .05), and decreased from grades 4 to 5 (OR .443, CI .250-.788). Likewise, rates of percutaneous drain placement increased from grade 2 to 3 (OR 1.999, CI 1.192-3.353), were similar between grades 3 and 4 (P > .05), and decreased from grades 4 to 5 (OR .266, .076-.934). Increasing pancreatic injury grade is associated with increased mortality and laparotomy rates at all levels. Endoscopic retrograde cholangiopancreatography and percutaneous drainage procedures are used most in mid-grade (3-4) pancreatic trauma. The decrease in nonsurgical procedures in grade 5 pancreatic trauma is likely secondary to increased rates of surgical management (resection and/or wide drainage). The AAST-OIS for pancreatic injury is associated with mortality and interventions.
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Affiliation(s)
- William Brigode
- 25430John H. Stroger Jr. Hospital of Cook County, Chicago, IL, 1969 West Ogden Ave, Chicago, IL 60612, USA
| | - Drew Roberts
- 25430John H. Stroger Jr. Hospital of Cook County, Chicago, IL, 1969 West Ogden Ave, Chicago, IL 60612, USA
| | - Gweniviere Capron
- 25430John H. Stroger Jr. Hospital of Cook County, Chicago, IL, 1969 West Ogden Ave, Chicago, IL 60612, USA
| | - Fred Starr
- 25430John H. Stroger Jr. Hospital of Cook County, Chicago, IL, 1969 West Ogden Ave, Chicago, IL 60612, USA
| | - Faran Bokhari
- 25430John H. Stroger Jr. Hospital of Cook County, Chicago, IL, 1969 West Ogden Ave, Chicago, IL 60612, USA
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Li H, Zhirong Z, Shibo Z, Lichen Z, Ming S, Hua J, Zheng T, Ruiwu D. The Effects of Umbilical Cord Mesenchymal Stem Cells on Traumatic Pancreatitis in Rats. Dig Dis Sci 2023; 68:147-154. [PMID: 35430701 DOI: 10.1007/s10620-022-07493-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/17/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE This study explored the therapeutic and protective effects of umbilical cord mesenchymal stem cells (ucMSCs) on traumatic pancreatitis (TP) to provide a theoretical basis for TP treatment with MCSs by establishing a TP rat model. METHODS We used 60 healthy adult male Sprague Dawley (SD) rats to create four experimental groups: sham, ucMSC control, TP, and ucMSC treatment. We observed ucMSC homing in the rats by fluorescence microscopy and assessed the degree of pancreatic tissue injury by hematoxylin and eosin (HE) staining on days 1, 3, and 7 after transplantation. Furthermore, we used an in vivo imaging system to evaluate the localization of cell membrane-stained ucMSCs in rats with TP. Finally, we measured the serum levels of amylase, lipase, pro-and anti-inflammatory factors, and oxidative stress factors by enzyme-linked immunosorbent assay (ELISA). RESULTS The pancreatic histopathological score and the serum amylase and lipase levels were lower in the ucMSC treatment group than in the TP group (P < 0.05). Interleukin (IL)-6, tumor necrosis factor-α (TNF-α), and oxidase malondialdehyde (MOD) levels were significantly higher in the ucMSC treatment group than in the TP group. However, IL-10, transforming growth factor-β, and superoxide dismutase (an antioxidant enzyme, SOD) levels were significantly higher in the ucMSC treatment group than in the TP group (P < 0.05). CONCLUSION ucMSCs can migrate and implant in injured areas of the pancreas in rats. Furthermore, they participate in pancreatic tissue repair and regulate immunity by inhibiting the systemic inflammatory response and oxidative stress.
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Affiliation(s)
- Han Li
- College of Medicine, Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China
| | - Zhao Zhirong
- College of Medicine, Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China.,General Surgery Center, General Hospital of Western Theater Command, Chengdu, 610083, China
| | - Zhou Shibo
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, 610083, China.,College of Clinical Medicine Southwest, Medical University, Luzhou, 646000, Sichuan Province, China
| | - Zhou Lichen
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, 610083, China.,College of Clinical Medicine Southwest, Medical University, Luzhou, 646000, Sichuan Province, China
| | - Shi Ming
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, 610083, China.,College of Clinical Medicine Southwest, Medical University, Luzhou, 646000, Sichuan Province, China
| | - Ji Hua
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, 610083, China.,College of Clinical Medicine Southwest, Medical University, Luzhou, 646000, Sichuan Province, China
| | - Tang Zheng
- General Surgery Center, General Hospital of Western Theater Command, Chengdu, 610083, China.,College of Clinical Medicine Southwest, Medical University, Luzhou, 646000, Sichuan Province, China
| | - Dai Ruiwu
- College of Medicine, Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China. .,General Surgery Center, General Hospital of Western Theater Command, Chengdu, 610083, China. .,College of Clinical Medicine Southwest, Medical University, Luzhou, 646000, Sichuan Province, China.
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Tamrat G, Kejela S. Delayed distal pancreatectomy for isolated complete pancreatic disruption secondary to “trivial” blunt abdominal injury: A case report and literature review. Clin Case Rep 2022; 10:e6295. [PMID: 36093448 PMCID: PMC9446079 DOI: 10.1002/ccr3.6295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 08/08/2022] [Accepted: 08/17/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Girmaye Tamrat
- Department of Surgery College of Health Sciences Addis Ababa University Addis Ababa Ethiopia
| | - Segni Kejela
- Department of Surgery College of Health Sciences Addis Ababa University Addis Ababa Ethiopia
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Reina R, Anand T, Bhogadi SK, Nelson A, Hosseinpour H, Ditillo M, El-Qawaqzeh K, Castanon L, Stewart C, Joseph B. Nonoperative management of blunt abdominal solid organ injury: Are we paying enough attention to patients on preinjury anticoagulation? Am J Surg 2022; 224:1308-1313. [DOI: 10.1016/j.amjsurg.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/06/2022] [Accepted: 06/23/2022] [Indexed: 11/01/2022]
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Al-Thani H, Ramzee AF, Al-Hassani A, Strandvik G, El-Menyar A. Traumatic Pancreatic Injury Presentation, Management, and Outcome: An Observational Retrospective Study From a Level 1 Trauma Center. Front Surg 2022; 8:771121. [PMID: 35155546 PMCID: PMC8831377 DOI: 10.3389/fsurg.2021.771121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/20/2021] [Indexed: 12/26/2022] Open
Abstract
BackgroundWe aimed to study the presentation, management, and outcomes of patients with a pancreatic traumatic injury.MethodsWe retrospectively analyzed data for all patients who were admitted with pancreatic injuries between 2011 and 2017 at the only level 1 trauma center in the country.ResultsThere were 71 patients admitted with pancreatic trauma (0.6% of trauma admissions and 3.4% of abdominal injury admissions) with a mean age of 31 years. Sixty-two patients had pancreatic injury grade I–II and nine had injury grade III–IV. Thirty-eight percent had Glasgow Coma Scale (GCS) <9 and 73% had injury Severity Score (ISS) >16. The level of pancreatic enzymes was significantly proportional to the grade of injury. Over half of patients required laparotomy, of them 12 patients had an intervention on the pancreas. Eight patients developed complications related to pancreatic injuries ranging from pancreatitis to pancreatico-cutaneous fistula while 35% developed hemorrhagic shock. Mortality was 31% and regardless of the grade of injury, the mortality was associated with high ISS, low GCS, and presence of hemorrhagic shock.ConclusionPancreatic injuries following blunt trauma are rare, and the injured subjects are usually young men. However, most injuries are of low-grade severity. This study shows that regardless of the pancreatic injury grade on-admission shock, higher ISS and lower GCS are associated with worse in-hospital outcomes. Non-operative management (NOM) may suffice in patients with lower grade injuries, which may not be the case in patients with higher grade injuries unless carefully selected.
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Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ahmed Faidh Ramzee
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Gustav Strandvik
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
- *Correspondence: Ayman El-Menyar
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Gupta V, Singh Sodha V, Kumar N, Gupta V, Pate R, Chandra A. Missed pancreatic injury in patients undergoing conservative management of blunt abdominal trauma: Causes, sequelae and management. Turk J Surg 2021; 37:286-293. [DOI: 10.47717/turkjsurg.2021.5425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/16/2021] [Indexed: 11/23/2022]
Abstract
Objective: Pancreas is a less commonly injured organ in blunt abdominal trauma. This study aimed to analyze the management and outcomes of patients in whom the pancreatic injury was missed during the initial evaluation of blunt abdominal trauma.
Material and Methods: We retrospectively (2009-2019) analyzed the details and outcome of patients who underwent conservative management of blunt abdominal trauma, where the diagnosis of pancreatic injury was missed for at least 72 hours following trauma.
Results: A total of 31 patients with missed pancreatic injury were identified. All patients were hemodynamically stable following trauma and most (21) were initially assessed only by an ultrasound. A delayed diagnosis of pancreatic injury was made at a mean of 28 (4 to 60) days after trauma when patients developed abdominal pain (31), distension (18), fever (10) or vomiting (8). On repeat imaging, 18 (58.1%) patients had high grade pancreatic injuries including complete transection or pancreatic duct injury. Seven (22.5%) patients were managed conservatively, seventeen (54.8%) underwent percutaneous drainage of intra-abdominal collections, seven (22.5%) underwent endoscopic or surgical drainage procedure for symptomatic pseudocyst. Eleven (35.4%) patients needed readmissions to manage recurrent pancreatitis, intra-abdominal abscess and pancreatic fistula. Three patients required pancreatic duct stenting for pancreatic fistula. There was no mortality.
Conclusion: Pancreatic injury may be missed in patients who remain hemodynamically stable with minimal clinical symptoms after abdominal trauma, especially if screened only by an ultrasound. In our series, there was significant morbidity of missed pancreatic injury.
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8
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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: 5] [Impact Index Per Article: 1.7] [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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Kanno H, Hirakawa Y, Yasunaga M, Midorikawa R, Taniwaki S, Uchino Y, Sasaki S, Kojima S, Nomura Y, Nakayama G, Goto Y, Sato T, Kawahara R, Sakai H, Ishikawa H, Hisaka T, Okuda K. Successful nonoperative management by endoscopic and percutaneous drainage for penetrating pancreatic duct injury: a case report. J Med Case Rep 2021; 15:33. [PMID: 33531082 PMCID: PMC7856793 DOI: 10.1186/s13256-020-02647-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 12/21/2020] [Indexed: 12/15/2022] Open
Abstract
Background Pancreatic trauma is a rare condition with a wide presentation, ranging from hematoma or laceration without main pancreatic duct involvement, to massive destruction of the pancreatic head. The optimal diagnosis of pancreatic trauma and its management approaches are still under debate. The East Association of Surgery for Trauma (EAST) guidelines recommend operative management for high-grade pancreatic trauma; however, several reports have reported successful outcomes with nonoperative management (NOM) for grade III/IV pancreatic injuries. Herein, we report a case of grade IV pancreatic injury that was nonoperatively managed through endoscopic and percutaneous drainage. Case presentation A 47-year-old Japanese man was stabbed in the back with a knife; upon blood examination, both serum amylase and lipase levels were within normal limits. Contrast-enhanced computed tomography (CT) showed extravasation of the contrast medium around the pancreatic head and a hematoma behind the pancreas. Abdominal arterial angiography revealed a pseudo aneurysm in the inferior pancreatoduodenal artery, as well as extravasation of the contrast medium in that artery; coil embolization was thus performed. On day 12, CT revealed a wedge-shaped, low-density area in the pancreatic head, as well as consecutive pseudocysts behind the pancreas; thereafter, percutaneous drainage was performed via the stab wound. On day 22, contrast radiography through the percutaneous drain revealed the proximal and distal parts of the main pancreatic duct. The injury was thus diagnosed as a grade IV pancreatic injury based on the American Association for the Surgery of Trauma guidelines. On day 26, an endoscopic nasopancreatic drainage tube was inserted across the disruption; on day 38, contrast-enhanced CT showed a marked reduction in the fluid collection. Finally, on day 61, the patient was discharged. Conclusions Although the EAST guidelines recommend operative treatment for high-grade pancreatic trauma, NOM with appropriate drainage by endoscopic and/or percutaneous approaches may be a promising treatment for grade III or IV trauma.
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Affiliation(s)
- Hiroki Kanno
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan.
| | - Yusuke Hirakawa
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Masafumi Yasunaga
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Ryuta Midorikawa
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Shinichi Taniwaki
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Yoshihiro Uchino
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Shin Sasaki
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Satoki Kojima
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Yoriko Nomura
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Goichi Nakayama
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Yuichi Goto
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Toshihiro Sato
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Ryuichi Kawahara
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Hisamune Sakai
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Hiroto Ishikawa
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Toru Hisaka
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
| | - Koji Okuda
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Japan
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Pancreatic Trauma: Proposal for Management Algorithm. Int Surg 2020. [DOI: 10.9738/intsurg-d-20-00015.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction
Pancreatic trauma is potentially lethal despite recent improvements in surgical techniques and conservative management. However, no guidelines for the management of pancreatic trauma have been established. In this report, we propose an algorithm for the management of pancreatic trauma based on our experience of 9 cases and 1 literature review.
Case presentation
This study included 9 patients with pancreatic trauma (5 men and 4 women). The patient median age was 40 years (range, 17–75 years). The overall mortality rate was 22.2%, and the postoperative mortality rate was 16.7%. Superficial trauma was present in 2 patients. Deep trauma without injury to the main pancreatic duct was present in 1 patient, and this patient was treated successfully with endoscopic nasopancreatic drainage. Active bleeding was present in 2 patients and controlled by interventional radiology. Deep trauma with injury to the main pancreatic duct was present in 6 patients. Among them, 1 patient died after conservative treatment with endoscopic nasopancreatic drainage. The other 5 patients underwent surgery (pancreatic resection in 4 and necrosectomy in 1).
Conclusion
The herein-described algorithm recommends interventional radiology for active arterial bleeding, conservative management for trauma without ductal injury, and surgery for trauma with ductal injury. This algorithm may provide a basis for future establishment of guidelines.
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Chikhladze S, Ruess DA, Schoenberger J, Fichtner-Feigl S, Pratschke J, Hopt UT, Bahra M, Wittel UA, Globke B. Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma. Injury 2020; 51:1979-1986. [PMID: 32336477 DOI: 10.1016/j.injury.2020.03.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/11/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Pancreatic trauma (PT) involving the main pancreatic duct is rare, but represents a challenging clinical problem with relevant morbidity and mortality. It is generally classified according to the American Association for the Surgery of Trauma (AAST) and often presents as concomitant injury in blunt or penetrating abdominal trauma. Diagnosis may be delayed because of a lack of clinical or radiological manifestation. Treatment options for main pancreatic duct injuries comprise highly complex surgical procedures. PATIENTS AND METHODS We retrospectively analyzed clinical data from 12 patients who underwent surgery in two tertiary centers in Germany during 2003-2016 for grade III-V PT with affection of the main pancreatic duct, according to the AAST classification. RESULTS The median age was 23 (range: 7-44) years. In nine patients blunt abdominal trauma was the reason for PT, whereas penetrating trauma only occurred in three patients. MRI outperformed classical trauma CT imaging with regard to detection of duct involvement. Complex procedures as i.e. an emergency pancreatic head resection, distal pancreatectomy or parenchyma sparing pancreatogastrostomy were performed. Compared to elective pancreatic surgery the complication rate in the emergency setting was higher. Yet, parenchyma-sparing procedures demonstrated safety. CONCLUSIONS Often extension of diagnostics including MRI and/or ERP at an early stage is necessary to guide clinical decision-making. If, due to main duct injuries, surgical therapy for PT is required, we suggest consideration of an organ preservative pancreatogastrostomy in grade III/IV trauma of the pancreatic body or tail.
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Affiliation(s)
- S Chikhladze
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - D A Ruess
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - J Schoenberger
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - S Fichtner-Feigl
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - J Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - U T Hopt
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - M Bahra
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - U A Wittel
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - B Globke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
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Blame it on the injury: Trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection. J Trauma Acute Care Surg 2020; 87:1289-1300. [PMID: 31765347 DOI: 10.1097/ta.0000000000002495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following distal pancreatectomy (DP). There is a lack of information regarding the impact of trauma on POPF rates when compared with elective resection. We hypothesize that trauma will be a significant risk factor for the development of POPF following DP. METHODS A retrospective, single-institution review of all patients undergoing DP from 1999 to 2017 was performed. Outcomes were compared between patients undergoing DP for traumatic injury to those undergoing elective resection. Univariate and multivariable analyses were performed using SAS (version 9.4). RESULTS Of the 372 patients who underwent DP during the study period, 298 met inclusion criteria: 38 DPs for trauma (TDP), 260 elective DPs (EDP). Clinically significant grade B or C POPFs occurred in 17 (44.7%) of 38 TDPs compared with 41 (15.8%) of 260 EDPs (p < 0.0001). On multivariable analysis, traumatic injury was found to be independently predictive of developing a grade B or C POPF (odds ratio, 4.3; 95% confidence interval, 2.10-8.89). Age, sex, and wound infection were highly correlated with traumatic etiology and therefore were not retained in the multivariable model. When analyzing risk factors for each group (trauma vs. elective) separately, we found that TDP patients who developed POPFs had less sutured closure of their duct, higher infectious complications, and longer hospital stays, while EDP patients that suffered POPFs were more likely to be male, younger in age, and at a greater risk for infectious complications. Lastly, in a subgroup analysis involving only patients with drains left postoperatively, trauma was an independent predictor of any grade of fistula (A, B, or C) compared with elective DP (odds ratio, 8.6; 95% confidence interval, 3.09-24.15), suggesting that traumatic injury is risk factor for pancreatic stump closure disruption following DP. CONCLUSION To our knowledge, this study represents the largest cohort of patients comparing pancreatic leak rates in traumatic versus elective DP, and demonstrates that traumatic injury is an independent risk factor for developing an ISGPF grade B or C pancreatic fistula following DP. LEVEL OF EVIDENCE Prognostic study, Therapeutic, level III.
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Abstract
Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.
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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: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [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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Marks RM, Potter DD. Delayed endoscopic management of a high-grade common bile duct injury: A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2019.101314] [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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Soon DSC, Leang YJ, Pilgrim CHC. Operative versus non-operative management of blunt pancreatic trauma: A systematic review. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618788111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Motor vehicle crashes are common causes of blunt abdominal trauma in the 21st century. While splenic trauma occurs very frequently and thus there is a well-established treatment paradigm, traumatic pancreatic injuries are relatively infrequent, occurring in only 3–5% of traumas. This low incidence means physicians have reduced experience with this condition and there is still ongoing debate with regards to the best practice in managing pancreatic trauma. During severe trauma, the pancreas can be injured as a consequence of blunt and penetrating injury. This has an estimated mortality rate ranging from 9 to 34%. Methods A systematic review was performed using three scientific databases: Embase, Medline and Cochrane and in-line with the PRISMA statement. We included only articles published in English, available as full text and describing only adults. Keywords included: pancrea*, trauma, blunt, operative management and non-operative management. Results Three studies were found that directly compared operative versus non-operative management in blunt pancreatic trauma. Length of stay, mortality and rate of re-intervention were lower in the non-operative group compared to the operative group. However, the average grade of pancreatic injury was lower in the non-operative group compared to the operative group. Discussion Our results revealed that patients who undergo non-operative management tend to have lower grade of injuries and patients with higher grade of injury tend to be managed in an operative fashion. This could be likely due to the fact that higher grade of pancreatic injuries is often accompanied by other injuries such as hollow viscus injury and therefore require operative intervention. Conclusion Non-operative management is a safe approach for low-grade blunt pancreatic trauma without ductal injuries. However, more evidence is required to improve our understanding and treatment plans. We suggest a large international multicentre study combining data from multiple international trauma centres to collect adequate data.
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Affiliation(s)
- David SC Soon
- Department of Surgery, Peninsula Health, Frankston, Australia
| | - Yit J Leang
- Department of Surgery, Peninsula Health, Frankston, Australia
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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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Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: Results from an International Consensus Conference. J Trauma Acute Care Surg 2019; 84:517-531. [PMID: 29261593 DOI: 10.1097/ta.0000000000001774] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Approach and Management of Traumatic Retroperitoneal Injuries. Cir Esp 2018; 96:250-259. [PMID: 29656797 DOI: 10.1016/j.ciresp.2018.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 11/23/2022]
Abstract
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.
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Juricic M, Pinnagoda K, Lakhal W, Sales De Gauzy J, Abbo O. Pancreatic fracture: a rare complication following scoliosis surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:2095-2099. [PMID: 29101470 DOI: 10.1007/s00586-017-5318-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/02/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
Abstract
STUDY DESIGN Grand Round case report. OBJECTIVE We report a pancreatic fracture associated with Wirsung duct disruption, following a scoliosis surgery in a cerebral palsy adolescent. Spinal fusion surgery is the standard treatment for severe neuromuscular scoliosis. Many complications such as digestive ones account for its complexity. Postoperative acute pancreatitis is well described, although its pathophysiology remains unclear. To our knowledge, pancreatic fracture following scoliosis correction has never been described to date. Clinical presentation is not specific, and management is not consensual. CASE REPORT A 14-year-old adolescent had posterior spinal fusion for neuromuscular scoliosis due to cerebral palsy. During the postoperative course, she developed progressive nonspecific abdominal symptoms. The abdominal CT scan demonstrated a pancreatic fracture and a surgical exploration was decided as perforations of the bowel were highly suspected. Drains were placed around the pancreatic area as the retrogastric region was out of reach due to local inflammation. Conservative management led to the occurrence of a pseudocyst in the following weeks as the pancreatic leakage progressively dropped. DISCUSSION Two hypotheses have been proposed: direct iatrogenic trauma from lumbar pedicle screws and pancreatic rupture related to the correction of the spinal deformity. As the latter seems the most likely, spinal surgeons should be aware of this occurrence following severe scoliosis correction. CONCLUSION Spinal fusion for severe neuromuscular scoliosis is a difficult procedure, with a high rate of complications. Among them, pancreatic fracture should be considered when abdominal pain persists in the postoperative period. Conservative management is advocated especially in case of a poor general condition.
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Affiliation(s)
- Mélodie Juricic
- Pediatric Orthopedic Department, Hôpital des Enfants de Toulouse, CHU Toulouse, 330, Avenue de Grande Bretagne, 31059, Toulouse Cedex 9, France
| | - Kalitha Pinnagoda
- General Pediatric Surgery Department, Hôpital des Enfants de Toulouse, CHU Toulouse, 330, Avenue de Grande Bretagne, 31059, Toulouse Cedex 9, France
| | - Walid Lakhal
- Pediatric Orthopedic Department, Hôpital des Enfants de Toulouse, CHU Toulouse, 330, Avenue de Grande Bretagne, 31059, Toulouse Cedex 9, France
| | - Jérome Sales De Gauzy
- Pediatric Orthopedic Department, Hôpital des Enfants de Toulouse, CHU Toulouse, 330, Avenue de Grande Bretagne, 31059, Toulouse Cedex 9, France
| | - Olivier Abbo
- General Pediatric Surgery Department, Hôpital des Enfants de Toulouse, CHU Toulouse, 330, Avenue de Grande Bretagne, 31059, Toulouse Cedex 9, France.
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