Pancreatic injury in damage control laparotomies: Is pancreatic resection safe during the initial laparotomy?

Surgical techniques for modular one-stage emergent pancreaticoduodenectomy for blunt abdominal trauma: experiences from three centres and a review of the literature

BACKGROUND

In this study, we report the use of a complex surgical intervention termed modular one-stage emergent pancreaticoduodenectomy (MOEPD) for the treatment of acute Grade IV or V pancreaticoduodenal injuries in haemodynamically stable patients. We summarize the experiences of surgeons performing MOEPD in 12 patients from 3 centres.

METHODS

From 2015 to 2021, the clinical data of patients with blunt abdominal trauma who underwent MOEPD were extracted from three Chinese centres. The patients' perioperative variables were assessed.

RESULTS

All twelve MOEPD cases were analysed. All patients had Grade IV or V pancreatoduodenal injuries and received intensive antishock treatment for haemodynamic stabilization. The mean age of the patients was approximately 45.2 years (22-74 years). Ten patients (83.3%) were male. In contrast to the ten patients who underwent pancreaticoduodenectomy (PD), two patients underwent laparoscopic pancreaticoduodenectomy (LPD). Two patients presented with a combination of severe abdominal injuries. None the patients died in the perioperative period. Five patients (41.7%) experienced postoperative complications. A postoperative pancreatic fistula (POPF) was detected in 16.7% of patients, both of whom recovered within 3-4 weeks with conservative drainage. All patients were released from the institutions after an average of 31.8 days (21-53 days). There was no statistically significant difference in the incidence of complications between the 20 reviewed studies and this group (60.7% vs. 41.7%, P = 0.33), but the mortality rate was lower in this group (26.6% vs. 0%, P = 0.04).

CONCLUSIONS

The experiences at these 3 centres suggest that MOEPD may be a lifesaving procedure for haemodynamically stable patients with acute Grade IV or V pancreatoduodenal injuries, despite the small sample size of this study.

CLINICAL TRIAL NUMBER

Not applicable.

A Case of Pancreaticoduodenectomy for Grade V Traumatic Pancreatic Injury in an Elderly Patient

Traumatic pancreatic injury is a rare condition, but cases involving main pancreatic duct injury often require surgical intervention and are associated with high mortality rates. Recently, two-stage surgical approaches, with initial damage control surgery followed by delayed pancreatic resection and reconstruction, have been increasingly reported. However, we argue that not all cases need a two-stage approach; instead, surgical strategies should be tailored based on the patient's vital signs. Furthermore, in pancreatic surgery, effective collaboration between trauma surgeons and hepatopancreatobiliary (HPB) surgeons is essential. Here, we report a case of a grade V traumatic pancreatic injury in an elderly patient that was successfully managed with one-stage pancreaticoduodenectomy, performed through coordinated efforts between trauma and HPB surgeons, resulting in a favorable outcome.

Pancreaticoduodenectomy in trauma patients with grade IV-V duodenal or pancreatic injuries: a post hoc analysis of an EAST multicenter trial

Introduction

The utility of pancreaticoduodenectomy (PD) for high-grade traumatic injuries remains unclear and data surrounding its use are limited. We hypothesized that PD does not result in improved outcomes when compared with non-PD surgical management of grade IV-V pancreaticoduodenal injuries.

Methods

This is a retrospective, multicenter analysis from 35 level 1 trauma centers from January 2010 to December 2020. Included patients were ≥15 years of age with the American Association for the Surgery of Trauma grade IV-V duodenal and/or pancreatic injuries. The study compared operative repair strategy: PD versus non-PD.

Results

The sample (n=95) was young (26 years), male (82%), with predominantly penetrating injuries (76%). There was no difference in demographics, hemodynamics, or blood product requirement on presentation between PD (n=32) vs non-PD (n=63). Anatomically, PD patients had more grade V duodenal, grade V pancreatic, ampullary, and pancreatic ductal injuries compared with non-PD patients (all p<0.05). 43% of all grade V duodenal injuries and 40% of all grade V pancreatic injuries were still managed with non-PD. One-third of non-PD duodenal injuries were managed with primary repair alone. PD patients had more gastrointestinal (GI)-related complications, longer intensive care unit length of stay (LOS), and longer hospital LOS compared with non-PD (all p<0.05). There was no difference in mortality or readmission. Multivariable logistic regression analysis determined PD to be associated with a 3.8-fold greater odds of GI complication (p=0.010) compared with non-PD. In a subanalysis of patients without ampullary injuries (n=60), PD patients had more anastomotic leaks compared with the non-PD group (3 (30%) vs 2 (4%), p=0.028).

Conclusion

While PD patients did not have worse hemodynamics or blood product requirements on admission, they sustained more complex anatomic injuries and had more GI complications and longer LOS than non-PD patients. We suggest that the role of PD should be limited to cases of massive destruction of the pancreatic head and ampullary complex, given the likely procedure-related morbidity and adverse outcomes when compared with non-PD management.

Level of evidence

IV, Multicenter retrospective comparative study.

Pancreaticoduodenectomy in high-grade pancreatic and duodenal trauma

INTRODUCTION

High-grade pancreaticoduodenal injuries are highly morbid and may require complex surgical management. Pancreaticoduodenectomy (Whipple procedure) is sometimes utilized in the management of these injuries, but guidelines on its use are lacking. This paper aims to present our 14-year experience in management of high-grade pancreaticoduodenal injuries at our busy, urban trauma center.

METHODS

A retrospective review was performed on patients (ages >15 years) presenting with high-grade (AAST-OIS Grades IV and V) injuries to the pancreas or duodenum at our Southeastern Level 1 trauma center. Inclusion criteria included high-grade injury and requirement of Whipple procedure based on surgeon discretion. Patients were divided into two groups: (1) those who underwent Whipple procedures during the index operation and (2) Whipple candidates. Whipple candidates included patients who received Whipples in a staged fashion or who would have benefited from the procedure but either died or were salvaged to another procedure. Demographics, injury patterns, management, and outcomes were compared. Primary outcome was survival to discharge.

RESULTS

Of 66,272 trauma patients in this study period, 666 had pancreatic or duodenal injuries, and 20 met inclusion criteria. Of these, 6 had Whipples on the index procedure and 14 were Whipple candidates (among whom 7 had staged Whipples, 6 died before completing a Whipple, and 1 was salvaged). Median (IQR) age was 28 (22.75-40) years. Patients were 85 % male, 70 % Black. GSWs comprised 95 % of injuries. All patients had at least one concomitant injury, most commonly major vascular injury (75 %), colonic injury (65 %), and hepatic injury (60 %). In-hospital mortality among Whipple patients was 15 %.

CONCLUSIONS

Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy are rare but life-threatening. In such patients, hemorrhage was the leading cause of death in the first 24 h. Approximately half underwent damage control surgery with staged Whipple Procedures. However, pancreaticoduodenectomy at the initial operation is feasible in highly selective patients, depending on the extent of injury, physiologic status, and resuscitation.

Management and Outcome of Blunt Pancreatic Trauma: A Retrospective Cohort Study

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.

Blunt pancreatic trauma: A Western Trauma Association critical decisions algorithm

BACKGROUND

The Western Trauma Association (WTA) has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations, or scarcity of experience and cases. Blunt pancreatic trauma falls under one of these clinically complex and rare scenarios. This algorithm is the result of an extensive literature review and input from the WTA membership and WTA Algorithm Committee members.

METHODS

Multiple evidence-based guideline reviews, case reports, and expert opinion were compiled and reviewed.

RESULTS

The algorithm is attached with detailed explanation of each step, supported by data if available.

CONCLUSION

Blunt pancreatic trauma is rare and presents many treatment challenges.

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.

Does drainage or resection predict subsequent interventions and long-term quality of life in patients with Grade IV pancreatic injuries: A population-based analysis

BACKGROUND

Clinical equipoise remains significant for the treatment of Grade IV pancreatic injuries in stable patients (i.e., drainage vs. resection). The literature is poor in regards to experience, confirmed main pancreatic ductal injury, nuanced multidisciplinary treatment, and long-term patient quality of life (QOL). The primary aim was to evaluate the management and outcomes (including long-term QOL) associated with Grade IV pancreatic injuries.

METHODS

All severely injured adult patients with pancreatic trauma (1995-2020) were evaluated (Grade IV injuries compared). Concordance of perioperative imaging, intraoperative exploration, and pathological reporting with a main pancreatic ductal injury was required. Patients with resection of Grade IV injuries were compared with drainage alone. Long-term QOL was evaluated (Standard Short Form-36).

RESULTS

Of 475 pancreatic injuries, 36(8%) were confirmed as Grade IV. Twenty-four (67%) underwent a pancreatic resection (29% pancreatoduodenectomy; 71% extended distal pancreatectomy [EDP]). Patient, injury and procedure demographics were similar between resection and drainage groups (p > 0.05). Pancreas-specific complications in the drainage group included 92% pancreatic leaks, 8% pseudocyst, and 8% walled-off pancreatic necrosis. Among patients with controlled pancreatic fistulas beyond 90 days, 67% required subsequent pancreatic operations (fistulo-jejunostomy or EDP). Among patients whose fistulas closed, 75% suffered from recurrent pancreatitis (67% eventually undergoing a Frey or EDP). All patients in the resection group had fistula closure by 64 days after injury. The median number of pancreas-related health care encounters following discharge was higher in the drainage group (9 vs. 5; p = 0.012). Long-term (median follow-up = 9 years) total QOL, mental and physical health scores were higher in the initial resection group (p = 0.031, 0.022 and 0.017 respectively).

CONCLUSION

The immediate, intermediate and long-term experiences for patients who sustain Grade IV pancreatic injuries indicate that resection is the preferred option, when possible. The majority of drainage patients will require additional, delayed pancreas-targeted surgical interventions and report poorer long-term QOL.

LEVEL OF EVIDENCE

Epidemiology/Prognostic, Level III.

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.

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries

BACKGROUND

Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time.

METHODS

Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate.

RESULTS

Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs.

CONCLUSION

Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice.

LEVEL OF EVIDENCE

Retrospective diagnostic/therapeutic study, level III.

Pancreatic Trauma: Proposal for Management Algorithm

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.

Blame it on the injury: Trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection

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.

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.

How to deploy a uniform and simplified acute-phase management strategy for traumatic pancreatic injury in any situation

Aim

Management of traumatic pancreatic injury is challenging, and mortality and morbidity remain high. Because pancreatic injury is uncommon and strong recommendations for pancreatic injury management are lacking, management is primarily based on institutional practices. We propose our strategy of pancreatic injury management.

Methods

We retrospectively reviewed patients with pancreatic injury and evaluated our strategy and outcomes.

Results

From January 2013 to December 2019, 18 patients were included with traumatic pancreatic injury. The median Injury Severity Score was 22 (25–75% interquartile range, 17–34) and probability of survival was 0.87 (25–75% interquartile range, 0.78–0.93). Patients were grouped according to the American Association for the Surgery of Trauma injury grades: grade I, n = 3 (16.7%); II, n = 6 (33.3%); III, n = 7 (38.9%); and IV, n = 2 (11.1%). All patients underwent endoscopic pancreatic ductal evaluation within 1–2 days after admission. Abbreviated surgery because of hemodynamic instability and subsequent open abdominal management were undertaken in one patient with pancreas head injury and two patients with pancreas body/tail injury. Management was by laparotomy for closed suction drain insertion with main ductal endoscopic drainage in six patients, endoscopic ductal drainage only in six patients, and distal pancreatectomy with closed suction drainage and endoscopic drainage in five patients. One patient with grade I injury underwent observation only. Median length of closed suction drainage was 12 days and that of hospital stay was 36 days. The observed mortality during the study period was 0%. Late formation of pseudo‐pancreatic cyst was observed in two patients (11.1%).

Conclusion

Our uniform, simplified strategy offers good outcomes for any pancreatic injury site and any concomitant injuries, even in hemodynamically unstable patients.

Pancreaticodudonectomy in trauma: One or two stages?

INTRODUCTION

Duodenopancreatic trauma is rare and presents high morbidity and mortality rates. Pancreaticoduodenectomy (PD) is the only possible treatment indicated for the most complex injuries (grades IV and V). Although, it is commonly a one-stage procedure, damage control surgery corroborates with a two-stage PD performed on unstable trauma victims.

OBJECTIVES

Compare the mortality rate of one and two-stage PD in trauma patients.

MATERIALS AND METHODS

A systematic electronic search of PubMed, Elsevier, LILACS, Scielo, and Capes was conducted on all studies written in English, Portuguese and Spanish with no restriction to publication dates. Review articles, case reports, editorials, animal studies, pediatric and non-trauma scenarios were excluded.

RESULTS

We selected twenty-two publications, with a total of 149 duodenopancreatic trauma victims who underwent PD, with an overall mortality rate of 42 patients (28.2%). Two-stage PD was exclusively performed on unstable patients (N = 31) with a mortality rate of 38.7%. In a sample of 79 patients submitted to a one-stage PD, 38 patients (48.1%) were unstable with a mortality rate of 34.2%. One-stage PD for stable patients had a mortality rate of 14.6% DISCUSSION: Since 1983, hemodynamic state impacts on surgery methods and strategies for trauma patients. Prior to that, one stage PD was not restricted to stable patients.

CONCLUSION

There were no differences in mortality rates when comparing two and one-stage PD in hemodynamic unstable patients, who had duodenopancreatic lesions (grades IV or V).

Epidemiological state, predictive model for mortality, and optimal management strategy for pancreatic injury: A multicentre nationwide cohort study

BACKGROUND

Data for establishing the optimal management modalities for pancreatic injury are lacking. Herein, we aimed to describe the epidemiology, identify mortality predictors, and determine the optimal management strategy for pancreatic injury.

METHODS

We identified patients with pancreatic injury between 2004 and 2017 recorded in the Japan Trauma Data Bank. The primary outcome was mortality. Multivariable logistic regression analyses were used to identify factors significantly associated with mortality and to develop a predictive model. Patients were also classified according to the Organ Injury Scaling of the American Association for the Surgery of Trauma (AAST grade I/II or III/IV). Outcomes were compared based on significant confounder-adjusted treatment strategy.

RESULTS

Overall, 743 (0.25%) patients had pancreatic injury. Traffic accident was the most common aetiology. The overall mortality rate was 17.5%, while it was 4.7% for isolated pancreatic injury. AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were independently associated with mortality. A predictive model for mortality comprising these four variables showed excellent performance, with an area under the receiver operating characteristic curve of 0.89 (95% confidence interval [CI], 0.85-0.93). The in-hospital mortality was higher in patients who underwent celiotomy than in those who did not among those with AAST grade I/II (15.1% vs. 5.3%) and III/IV (13.8% vs. 12.3%). After adjusting for confounders, these differences were not significant with the adjusted odds ratios of 1.41 (95% CI, 0.55-3.60) and 0.54 (95% CI, 0.17-1.67) for AAST grade I/II and III/IV, respectively.

CONCLUSIONS

AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were prognostic factors of mortality after pancreatic injury. Confounder-adjusted analysis did not show that operative management was superior to non-operative management for survival. Non-operative management may be a reasonable strategy for select pancreatic injury patients, especially in institutions where expertise in interventional endoscopy is available.

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 Injuries in Abdominal Trauma in US Adults: Analysis of the National Trauma Data Bank on Management, Outcomes, and Predictors of Mortality

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.

Endoscopic transpapillary drainage in disconnected pancreatic duct syndrome after acute pancreatitis and trauma: long-term outcomes in 31 patients

Background

Conventionally, disconnected pancreatic duct syndrome is treated surgically. Endoscopic management is associated with lesser morbidity and mortality than that observed with surgery and shows similar success rates. However, limited data are available in this context. We evaluated the efficacy of endotherapeutic management for this syndrome.

Methods

We prospectively obtained data of patients with disconnected pancreatic duct syndrome between September 2008 and January 2016. Demographic and clinical data were assessed, and factors affecting clinical outcomes were statistically analyzed.

Results

Thirty-one patients underwent 40 endoscopic transpapillary procedures, and 1 patient developed an infection after prosthesis insertion. Etiological contributors to disconnected pancreatic duct syndrome were abdominal trauma (52%) and acute necrotizing pancreatitis (48%). The median interval between the appearance of pancreatic leaks and disconnected pancreatic duct syndrome was 6.6 months (range 0.5–84 months). The median follow-up after the last treatment procedure was 38 months (range 17–99 months). Patients with complete main pancreatic duct disruption in the body/tail showed a low risk of pancreatic atrophy (P = 0.009). This study highlighted the significant correlation between endoscopic transpapillary drainage and clinical success (P = 0.014).

Conclusions

Disconnected pancreatic duct syndrome is not an uncommon sequel of pancreatic injury, and much of the delayed diagnosis is attributable to a lack of knowledge regarding this disease. Endoscopic transpapillary intervention with ductal stenting is an effective and safe treatment for this condition.

[Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]

BACKGROUND

Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management.

METHOD

A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit.

CONCLUSION

Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.

Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification

AIM

To benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries.

METHODS

A prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied.

RESULTS

Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant.

CONCLUSION

This ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons.

Pancreatic trauma: Management and literature review

Pancreatic injury is an uncommon event often difficult to diagnose at an early stage. After abdominal trauma, the surgeon must always be aware of the possibility of pancreatic trauma due to the complications associated with missed pancreatic injuries. Due to its retroperitoneal position, asociated organs and vascular injuries are almost always present, which along with frequent extra abdominal injuries explain the high morbidity and mortality. The aim of this study is to present a concise description of the incidence of these injuries, lesional mechanisms, recommended diagnostic methods, therapeutic indications including nonoperative management, endoscopy and surgery, and an analysis of pancreas-specific complications and mortality rates in these patients based on a 60-year review of the literature, encompassing 6,364 patients. Due to pancreatic retroperitoneal position, asociated organs and vascular injuries are almost always present, which along with frequent extraaabdominal injuries explain the high morbidity and mortality of these patients.

Predictors of successful non-operative management of grade III & IV blunt pancreatic trauma

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.

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Non-operative measures should be attempted in a select group of high grade (grade III/IV) pancreatic trauma.

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Controlled leak walled off as a pseudocyst, absent necrosis&organ injuries predict high success rate for NOM.

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Dedicated nutritional, gastrointestinal and interventional radiological support are the key components of care.

Management of pancreatic injuries during damage control surgery: an observational outcomes analysis of 79 patients treated at an academic Level 1 trauma centre

BACKGROUND

This study evaluated factors influencing mortality in a large cohort of patients who sustained pancreatic injuries and underwent DCS.

METHODS

A prospective database of consecutive patients with pancreatic injuries treated at a Level 1 academic trauma centre was reviewed to identify those who underwent DCS between 1995 and 2014.

RESULTS

Seventy-nine (71 men, median age: 26 years, range 16-73 years, gunshot wounds = 62, blunt = 14, stab = 3) patients with pancreatic injuries (35 proximal, 44 distal) had DCS. Fifty-nine (74.7 %) patients had AAST grade 3, 4 or 5 pancreatic injuries. The 79 patients had a total of 327 associated injuries (mean: 3 per patient, range 0-6) and underwent a total of 187 (range 1-7) operations. Vascular injuries (60/327, 18.3 %) occurred in 41 patients. Twenty-seven (34.2 %) patients died without having a second operation. The remaining 52 patients had two or more laparotomies (range 2-7). Overall 28 (35 %) patients underwent a pancreatic resection either during DCS (n = 18) or subsequently as a secondary procedure (n = 10) including a Whipple (n = 6) when stable. Overall 43 (54.4 %) patients died. Mortality was related to associated vascular injuries overall (p < 0.01), major visceral venous injuries (p < 0.01) and combined vascular and total number of associated organs injured (p < 0.04).

CONCLUSIONS

Despite the magnitude of their combined injuries and the degree of physiological insult, DCS salvaged 45 % of critically injured patients who later underwent definitive pancreatic surgery. Mortality correlated with associated vascular injuries overall, major visceral venous injuries and the combination of vascular plus the total number of associated organs injured.

Blunt pancreatic trauma: A persistent diagnostic conundrum?

Blunt pancreatic trauma is an uncommon injury but has high morbidity and mortality. In modern era of trauma care, pancreatic trauma remains a persistent challenge to radiologists and surgeons alike. Early detection of pancreatic trauma is essential to prevent subsequent complications. However early pancreatic injury is often subtle on computed tomography (CT) and can be missed unless specifically looked for. Signs of pancreatic injury on CT include laceration, transection, bulky pancreas, heterogeneous enhancement, peripancreatic fluid and signs of pancreatitis. Pan-creatic ductal injury is a vital decision-making parameter as ductal injury is an indication for laparotomy. While lacerations involving more than half of pancreatic parenchyma are suggestive of ductal injury on CT, ductal injuries can be directly assessed on magnetic resonance imaging (MRI) or encoscopic retrograde cholangio-pancreatography. Pancreatic trauma also shows temporal evolution with increase in extent of injury with time. Hence early CT scans may underestimate the extent of injures and sequential imaging with CT or MRI is important in pancreatic trauma. Sequential imaging is also needed for successful non-operative management of pancreatic injury. Accurate early detection on initial CT and adopting a multimodality and sequential imaging strategy can improve outcome in pancreatic trauma.

Severe pancreatoduodenal injury

Case

A 30-year-old male involved in a traffic accident was brought to our hospital. He was in shock with a rigid abdomen, and a computed tomography scan showed severe pancreatoduodenal injury. He was successfully treated with damage control surgery consisting of peripancreatic packing at the initial surgery followed by a two-stage pancreaticoduodenectomy.

Outcome

The postoperative course was complicated by a hepatic abscess, but there were no pancreaticoduodenectomy-related complications. The patient was transferred to a local hospital on postoperative day 55.

Conclusion

Three step strategy consisting of peripancreatic packing followed by a two-stage pancreaticoduodenectomy is an effective treatment strategy for severe pancreatoduodenal injury.

Endoscopic and operative treatment of delayed complications after pancreatic trauma: An analysis of 27 civilians treated in an academic Level 1 Trauma Centre

BACKGROUND

This study evaluated the efficacy of endoscopic treatment of delayed local complications including pseudocysts and persistent pancreatic fistulae in a cohort of civilian patients who had previously sustained a pancreatic injury.

METHOD

A large institutional database was interrogated to identify patients who developed a delayed pancreatic complication among those with pancreatic injuries treated between January 1990 and December 2013. The degree of the pancreatic duct injury was graded using a new duct injury grading system and endoscopic therapeutic outcome assessed according to the grade of injury.

RESULTS

During the period under review, 432 consecutive patients were treated for pancreatic injuries of whom 27 (20 men, 7 women, median age 31, range 15-68 years) presented with delayed complications related to the initial pancreatic injury. Sixteen patients had non-resolving symptomatic pancreatic pseudocysts, 10 had persistent pancreatic fistulae and 1 had a symptomatic duct stricture. Fourteen patients with grade 2a, 3a, 3b or 4c main pancreatic duct injuries were successfully treated endoscopically with either pancreatic duct stenting or pseudocyst drainage while 13 patients with grade 4a or 4b duct injuries who had complete duct division with a disconnected duct syndrome failed endoscopic management and required surgical intervention. The 27 patients underwent a total of 49 endoscopic procedures (47 elective, 2 emergency) of whom 4 developed complications related to the endoscopic treatment. All 4 resolved, 2 after urgent endoscopic re-intervention.

CONCLUSION

In this preliminary analysis the Cape Town pancreatic ductal injury grading classification showed a close correlation with outcome after endoscopic and operative intervention.

Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries

BACKGROUND

This single-centre study evaluated the efficacy of damage control surgery and delayed pancreatoduodenectomy and reconstruction in patients who had combined severe pancreatic head and visceral venous injuries.

METHODS

Prospectively recorded data of patients who underwent an initial damage control laparotomy and a subsequent pancreatoduodenectomy for severe pancreatic injuries were evaluated to assess optimal operative sequencing.

RESULTS

During the 20-year study period, 312 patients were treated for pancreatic injuries of whom 14 underwent a pancreatoduodenectomy. Six (five men, one woman, median age 20, range 16-39 years) of the 14 patients were in extremis with exsanguinating venous bleeding and non-reconstructable AAST grade 5 pancreatoduodenal injuries and underwent a damage control laparotomy followed by delayed pancreatoduodenectomy and reconstruction when stable. During the initial DCS, the blood loss compared to the subsequent laparotomy and definitive procedure was 5456 ml, range 2318-7665 vs 1250 ml, range 850-3600 ml (p < 0.01). The mean total fluid administered in the operating room was 11,150 ml, range 8450-13,320 vs 6850 ml, range 3350-9020 ml (p < 0.01). The mean operating room time was 113 min, range 90-140 vs 335 min, range 260-395 min (p < 0.01). During the second laparotomy five patients had a pylorus-preserving pancreatoduodenectomy and one a standard Whipple resection. Four of the six patients survived. Two patients died in hospital, one of MOF and coagulopathy and the other of intra-abdominal sepsis and multi-organ failure. Median duration of intensive care was 6 days, (range 1-20 days) and median duration of hospital stay was 29 days, (range 1-94 days).

CONCLUSION

Damage control laparotomy and delayed secondary pancreatoduodenectomy is a live-saving procedure in the small cohort of patients who have dire pancreatic and vascular injuries. When used appropriately, the staged resection and reconstruction allows survival in a previously unsalvageable group of patients who have severe physiological derangement.

Morbidity and mortality after distal pancreatectomy for trauma: a critical appraisal of 107 consecutive patients undergoing resection at a Level 1 Trauma Centre

BACKGROUND

This study evaluated 30-day morbidity and mortality and assessed pancreas-specific complications in patients with major pancreatic injuries who underwent a distal pancreatectomy.

STUDY DESIGN

Records of 107 consecutive patients who underwent a distal pancreatectomy at a Level 1 Trauma Centre in Cape Town between January 1982 and December 2011 were reviewed. Primary endpoints were postoperative morbidity and death. Complications were graded according to the Clavien-Dindo severity classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions.

RESULTS

A total of 107 patients [94 men, median age 26, median RTS 7.8, 69 penetrating injuries (63 gunshot wounds, 6 stabs wounds), 38 blunt injuries] underwent distal pancreatectomy. Overall mortality was 12%, 16% for gunshot injuries, 8% for blunt trauma and 0% in patients who had stab wounds. Eighty patients had a post-operative complication. A pancreatic leak (n=26) was the most common pancreatic related complication. Median postoperative stay in 28 patients with no or grade I complications was 9 days; in 11 patients with grade II complications was 18 days; in 14 grade IIIa, 31 days; in 19 grade IIIb, 38 days; in 8 grade IVa, 33 days in 14 grade IVb, and in 13 grade V the duration of postoperative stay was 14±39.4 days.

CONCLUSIONS

Overall mortality for distal pancreatectomy was 12%. Pancreatic leak was a common cause of morbidity. Length of hospitalisation increased with increasing Clavien-Dindo severity grading. There was a significant difference in the duration of hospitalisation in patients with no or grade I complications compared to those with grade II-IV injuries (p<0.05).

Non-operative versus operative treatment for blunt pancreatic trauma in children

BACKGROUND

Pancreatic trauma in children is a serious condition with high morbidity. Blunt traumatic pancreatic lesions in children can be treated non-operatively or operatively. For less severe, grade I and II, blunt pancreatic trauma a non-operative or conservative approach is usually employed. Currently, the optimal treatment, of whether to perform operative or non-operative treatment of severe, grade III to V, blunt pancreatic injury in children is unclear.

OBJECTIVES

To assess the benefits and harms of operative versus non-operative treatment of blunt pancreatic trauma in children.

SEARCH METHODS

We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (Issue 5, 2013), MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED and CPCI-S) and ZETOC. In addition, we searched bibliographies of relevant articles, conference proceeding abstracts and clinical trials registries. We conducted the search on the 21 June 2013.

SELECTION CRITERIA

We planned to select all randomised clinical trials investigating non-operative versus operative treatment of blunt pancreatic trauma in children, irrespective of blinding, publication status or language of publication.

DATA COLLECTION AND ANALYSIS

We used relevant search strategies to obtain the titles and abstracts of studies that were relevant for the review. Two review authors independently assessed trial eligibility.

MAIN RESULTS

The search found 83 relevant references. We excluded all of the references and found no randomised clinical trials investigating treatment of blunt pancreatic trauma in children.

AUTHORS' CONCLUSIONS

This review shows that strategies regarding non-operative versus operative treatment of severe blunt pancreatic trauma in children are not based on randomised clinical trials. We recommend that multi-centre trials evaluating non-operative versus operative treatment of paediatric pancreatic trauma are conducted to establish firm evidence in this field of medicine.

The evolution of damage control surgery

The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.

Surgical management and outcome of civilian gunshot injuries to the pancreas

BACKGROUND

Pancreatic injuries are uncommon but result in substantial morbidity and mortality. This study evaluated the factors associated with morbidity and mortality in civilian patients with pancreatic gunshot wounds.

METHODS

This was a single-institution, retrospective review of patients with gunshot wounds of the pancreas treated from 1976 to 2009 in Cape Town, South Africa. Univariable and multivariable analyses were performed.

RESULTS

A total of 219 patients (205 male, median age 27 years) had pancreatic American Association for the Surgery of Trauma grade I-II (111 patients) and grade III-V (108) gunshot injuries to the pancreatic head (72), neck (8), body (75) and tail (64). The patients underwent 239 laparotomies, including drainage of the pancreas (169), distal pancreatectomy (59) and pancreaticoduodenectomy (11). Some 218 patients had 642 associated intra-abdominal and 91 vascular injuries. Forty-three (19.6 per cent) required an initial damage control procedure. A total of 150 patients (68.5 per cent) had 407 postoperative complications (median 4, range 1-7). The 46 patients (21.0 per cent) who died had a median of 3 (range 1-7) complications. Median (range) intensive care unit and total hospital stay were 5 (1-153) and 11 (1-255) days respectively. Multivariable analyses identified age, high-grade pancreatic injury, associated vascular injuries and need for repeat laparotomy as predictors of morbidity. Age, shock on admission, need for damage control surgery, high-grade pancreatic injuries and associated vascular injuries were significant factors associated with mortality.

CONCLUSION

Morbidity and mortality rates were high after gunshot injuries to the pancreas. Initial shock and severe injury combined with need for damage control surgery were associated with the highest risk of death.

The management of pancreatic trauma

Pancreatic trauma is an uncommon occurrence and so a consensus about optimal management is not readily available. Isolated pancreatic injury occurs only occasionally, as in the majority of cases there is concurrent visceral or vascular injury. Morbidity and mortality are related to delay in diagnosis, concurrent organ injury or the presence and extent of pancreatic duct injury.

Article Commentary: Management of Left Pancreatic Trauma

Left pancreatic traumas (LPTs) are rare but serious lesions occurring in 1 to 6 per cent of abdominal trauma patients and mainly resulting from blunt traumas. LPT severity is primarily dependent on the associated injuries and secondarily related to main pancreatic duct injury responsible for complications: acute pancreatitis, pseudocysts, pancreatic fistulas, or abscesses. The guidelines for blunt LPT management can be presented as follows. In case of emergency laparotomy, pancreas exploration is mandatory to detect pancreatic duct lesions. In the absence of main pancreatic duct lesions, simple drainage is advocated. In case of distal injury to the main pancreatic duct, a left pancreatectomy is mandatory. In the absence of initial laparotomy, the diagnosis is more and more based on CT and magnetic resonance cholangiopancreatography, which tend to replace endoscopic retrograde cholangiopancreatography (ERCP) as a first-intent diagnostic modality. In case of distal injury to the main pancreatic duct, spleen-preserving distal pancreatectomy is recommended. In the absence of main pancreatic duct lesions, nonoperative treatment is advocated. When LPTs are discovered at the time of complications, pancreatic fistulas and/or pseudocysts are associated with main pancreatic lesions, which can be treated by pancreatic duct stenting at ERCP and/or internal endoscopic cystogastrostomy. However, in such cases, spleen-preserving distal pancreatectomy remains the treatment of choice. Pancreatic ductal lesions resulting from LPT have to be diagnosed early to avoid late complications. Distal pancreatectomy remains the treatment of choice in case of severe pancreatic ductal lesions because the role of ERCP stenting and endoscopic techniques needs further evaluation.

The systemic inflammatory response following femoral canal reaming using the reamer-irrigator-aspirator (RIA) device

We evaluated the peripheral release of inflammatory mediators after femoral fracture and subsequent intramedullary reaming using the RIA reamers. IL-6 was elevated after trauma, and reaming with RIA induced a measurable second hit response. However, despite a higher ISS, the levels of IL-6 in the RIA group were similar to the levels measured in a group of patients where reaming of the femoral canal was performed using conventional reamers. There was one death related to fat embolism syndrome in the conventional reamers group. However, the overall incidence of complications was low and similar between the 2 groups of studied patients. In polytrauma patients, large scale studies are desirable to evaluate further the immuno-inflammatory response using the RIA reamers prior to the instrumentation of the femoral canal.

Endoscopic retrograde cholangiopancreatography in patients with pancreatic trauma

BACKGROUND

: Pancreatic injury occurs in from 3% to 12% of patients with abdominal trauma. In many instances, a lack of impressive findings in the first 24 hours leads to a delay in diagnosis. Because pancreatic duct disruption is the major cause of traumatic pancreatitis, we evaluated our experience with endoscopic retrograde cholangiopancreatography (ERCP) in patients suspected of having of having pancreatic injury.

METHODS

: We reviewed the medical records of 26 patients evaluated perioperatively by ERCP for suspected pancreatic duct injury. The examinations were performed in the endoscopy suite or radiography special procedures or operating rooms under direct fluoroscopic control using fiberoptic or videooptic duodenoscopes.

RESULTS

: Seventeen men and nine women with a mean age of 32.8 +/- 2.2 years suffered severe abdominal trauma. ERCP was performed in these patients a mean of 19 +/- 11.3 days after trauma. Seven patients underwent ERCP just before or at laparotomy. Eight of 26 (31%) patients were found to have intact pancreatic and bile ducts, whereas 18 (69%) patients had substantial findings unsuspected by pre-ERCP imaging. Nine of these 18 patients with documented ductal injury underwent endoscopic treatment alone without further surgical intervention, including pancreatic sphincterotomies and/or pancreatic ductal stenting.

CONCLUSIONS

: ERCP is feasible and strongly indicated in the care of many patients with pancreatic trauma. Patient care and overall surgical and hospital needs may be substantially impacted by the use of both diagnostic and therapeutic endoscopic retrograde colongiopancreatography.