Pancreatico-enterostomy for isolated main pancreatic duct disruption

Closed traumatism of the distal pancreas (A case series of 6 patients)

INTRODUCTION AND IMPORTANCE

The aim of this retrospective study was to present six cases of trauma to the distal pancreas, highlighting the challenges associated with their diagnosis and management, while underlining their seriousness and the various complications potentially encountered. Our case series highlights individual patient outcomes, demonstrating the diversity of clinical presentations and the importance of customized treatment strategies.

CASE SERIES

Between January 2015 and December 2020, six cases of distal pancreas trauma were identified. In two cases, the diagnosis was made based on emergency abdominal CT scans, while in the other four patients, the diagnosis was made directly intraoperatively, mainly because of the severity of the associated lesions, which necessitated laparotomy for exploration.

CLINICAL DISCUSSION

Out of 115 cases of closed abdominal trauma, injury to the distal pancreas was identified in 6 patients, (5.2 %), with a mean age of 21 years. Despite the use of abdominal CT scans for all patients, pancreatic trauma was directly diagnosed intraoperatively in 4 cases (67 %). All patients presented with concomitant abdominal injuries (100 %), and 3 patients (50 %) exhibited multiple severe injuries. Additionally, a significant elevation in pancreatic serum markers was observed in 3 patients (50 %). The pancreatic injuries predominantly involved the tail of the pancreas (67 %), while the body was affected in one patient, and the isthmus was completely transected in another. Three of our patients developed a pancreatic fistula (50 %) and two patients (33 %) passed away; the first had severe associated lesions, and the second, despite undergoing several iterative laparotomies, succumbed to postoperative complications following a left pancreatectomy.

CONCLUSION

Closed traumatism of the distal pancreas, although rare, is a significant problem. It is often diagnosed during emergency laparotomy but can sometimes be found on preoperative CT scans. When the patient's condition permits, it is highly advisable to undergo a left pancreatectomy. Simple external drainage is reserved for certain specific situations.

Imaging of Blunt Pancreatic Trauma: A Systematic Review

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.

Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines

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.

Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center

Purpose

Pancreatic trauma is infrequent because of its central, deep anatomical position. This contributes to a lack of surgeon experience and many debates exist about its standard care. This study aimed to investigate the postoperative pancreatic fistula (POPF) and mortality of pancreatic trauma after operation.

Methods

We reviewed records in the trauma registry of our institution submitted from January 2006 to December 2016. The grade of pancreatic injury, surgical management, morbidity, mortality, and other clinical variables included in the analyses.

Results

Data from a total of 26,072 trauma patients admitted to the Emergency Department were analyzed. Pancreatic trauma was observed in 114 of these patients (0.44%). Laparotomy was performed in 81 patients (2 pan creatico duodenectomies, 2 pancreaticogastrostomies, peripancreatic drainage in 41 patients, distal pancreatectomies in 34 patients, and 9 patients who underwent surgery for damage control). The incidence of POPF was 38.3%. The overall mortality was 8.8% (7 of 81). In multivariate analysis, pancreas injury grade IV (≥4) (adjusted odds ratio [AOR], 4.071; P = 0.029) and preoperative peritonitis signs (AOR, 2.903; P = 0.039) were independent risk factors for POPF. All patients who died had also another major abdominal injury (≥grade 3). Multiorgan failure was a major cause of death (6 of 7, 85.7%). The mortality rate of isolated pancreas injury was 0%.

Conclusion

The pancreas injury grade and preoperative peritonitis were significant risk factors of POPF. The mortality rate of isolated pancreatic trauma was very low.

Management of pancreatic trauma

INTRODUCTION

Pancreatic trauma (PT) is associated with high morbidity and mortality; the therapeutic options remain debated.

MATERIAL AND METHODS

Retrospective study of PT treated in the University Hospital of Grenoble over a 22-year span. The decision for initial laparotomy depended on hemodynamic status as well as on associated lesions. Main pancreatic duct lesions were always searched for. PT lesions were graded according to the AAST classification.

RESULTS

Of a total of 46 PT, 34 were grades II or I. Hemodynamic instability led to immediate laparotomy in 18 patients, for whom treatment was always drainage of the pancreatic bed; morbidity was 30%. Eight patients had grade III injuries, six of whom underwent immediate operation: three underwent splenopancreatectomy without any major complications while the other three who had simple drainage required re-operation for peritonitis, with one death related to pancreatic complications. Four patients had grades IV or V PT: two pancreatoduodenectomies were performed, with no major complication, while one patient underwent duodenal reconstruction with pancreatic drainage, complicated by pancreatic and duodenal fistula requiring a hospital stay of two months. The post-trauma course was complicated for all patients with main pancreatic duct involvement. Our outcomes were similar to those found in the literature.

CONCLUSION

In patients with distal PT and main pancreatic duct involvement, simple drainage is associated with high morbidity and mortality. For proximal PT, the therapeutic options of drainage versus pancreatoduodenectomy must be weighed; pancreatoduodenectomy may be unavoidable when the duodenum is injured as well. Two-stage (resection first, reconstruction later) could be an effective alternative in the emergency setting when there are other associated traumatic lesions.

[Disconnected panreatic duct syndrome]

Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotizing pancreatitis treated medically, by percutaneous drainage, or necrosectomy. There are no clear epidemiological data on the real incidence of DPDS; approximately 10 to 30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic and surgical management have been described. We have performed a sytematic review of the literature on DPDS.

Traumatic Transection of Pancreas at the Neck: Feasibility of Parenchymal Preserving Strategy

BACKGROUND

To assess the feasibility and safety of a pancreas preserving operative technique in the management of isolated complete pancreatic neck transection following blunt abdominal trauma.

METHODS

Two patients with isolated blunt fracture of the pancreatic neck underwent pancreas preserving procedure comprising of oversewing of the proximal pancreas and Roux-en-Y pancreatico jejunostomy to the distal remnant. A feeding jejunostomy tube was placed for postoperative nutritional support in these patients. Both patients received subcutaneous octreotide 300 µg/day.

RESULTS

Their ages ranged from 15 years to 20 years, mode of injury was bicycle handle-bar injury (n = 2). Both had pancreatic transection at neck in the line of superior mesenteric vessels. One had ascites. These patients had pancreas parenchyma preserving surgery - internal drainage of the left remnant in a Roux-en-Y jejunal loop. The postoperative course was uneventful in these and both are well on follow-up.

CONCLUSIONS

Pancreas preserving strategy - suture of head side of pancreas and an internal drainage of left remnant with a Roux-en-Y jejunal loop is feasible and safe and should be considered in selected cases. Substantial amount of normal pancreatic parenchyma is preserved.