Lessons learned from isolated blunt major pancreatic injury: Surgical experience in one trauma centre

An analysis of 77 cases of pancreatic injuries at a level one trauma center: Outcomes of conservative and surgical treatments

Backgrounds/Aims

Traumatic pancreatic injury (TPI) is rare as an isolated injury. There is a trend to perform conservative treatment even in patients with complete duct dissection and successful treatment. This study reviewed our 20 years of experience in the management of TPI and assessed patient outcomes according to age group and treatment strategy.

Methods

A retrospective analysis of patients diagnosed and treated with TPI at a level-I trauma center from 2000-2019. Patients were divided into two groups: adults and pediatrics. Conservative treatment cases were subjected to subgroup analysis. Level of evidence: IV.

Results

Of a total of 77 patients, the mean age was 24.89 ± 15.88 years. Fifty-six (72.7%) patients had blunt trauma with motor vehicle accident. Blunt trauma was the predominant mechanism in 42 (54.5%) patients. Overall, 38 (49.4%) cases had grade I or II injury, 24 (31.2%) had grade III injury, and 15 (19.5%) had grade IV injury. A total of 30 cases had non-operative management (NOM). Successful NOM was observed in 16 (20.8%) cases, including eight (32.0%) pediatric cases and eight (15.4%) adult cases. Higher American association for the surgery of trauma (AAST) grade of injury was associated with NOM failure (16.7% for grade I/II, 100% for grade III, and 66.7% for grade IV injury; p = 0.001). An independent factor for NOM failure was female sex (69.2% in females vs. 29.4% in males; p = 0.03).

Conclusions

High AAST grade TPI is associated with a high rate of NOM failure in both pediatric and adults.

Spleen-preserving distal pancreatectomy following grade III pancreatic injury in a delayed presentation: a technical challenge

Pancreatic injuries are often overlooked in view of subtle clinical signs, and high index of suspicion is required to manage these injuries. Management strategies vary depending on the grade of injury and associated solid organ injuries and vascular injuries. Early surgery is advised in patients with duct disruption to avoid complications related to duct disruption. We present a case of 19-year-old man with delayed presentation following pancreatic trauma. During the surgery, changes of pancreatitis were noted and posterior wall of the stomach was adherent to pancreas, and inflammatory changes in vicinity of pancreas posed a significant challenge while dissecting pancreas away from the splenic vein. Spleen-preserving distal pancreatectomty (SPDP) was done. SPDP is time-consuming and technically challenging procedure especially in patients with delayed presentation. It is safe and feasible to consider spleen preservation in pancreatic trauma when patient is haemodynamically stable and expertise is available.

Nonresection management of the pancreas for grade III and IV blunt pancreatic injuries in children: a single center's experience

Background

The treatment of high-grade (III/IV/V) blunt pancreatic injuries remains controversial. The study aims to summarize and evaluate nonresection management of the pancreas for grade III and IV blunt pancreatic injuries in children.

Methods

Twenty children [6.9 (3–12) years] treated at our center between January 2010 and June 2018 were included in this study. Their medical records and the outpatient follow-up data within 12 weeks after discharge were retrospectively reviewed. Long-term follow-up was conducted by telephone in February 2020.

Results

Nine children developed complications, including 8 pancreatic pseudocysts and 1 abdominal infection, after treatment at external hospitals and were transferred to our center with an average length of stay of 33.8 (8–63) days. Eleven children were admitted to our hospital directly after injury, with an average length of stay of 47.5 (23–69) days. One child underwent emergency laparotomy for hemorrhagic shock and Roux-en-Y drainage of the distal pancreas. The remaining 10 children received conservative treatment: 7 developed pancreatic pseudocysts, 2 developed abdominal infections, and 1 recovered uneventfully. For children with pancreatic pseudocysts (15/20, 75.0%), 4 recovered after conservative treatment, 4 recovered after percutaneous puncture, 5 recovered after external drainage of the cyst, and 2 recovered after alimentary tract anastomosis. Three children (3/20, 15.0%) who developed abdominal infection recovered after abdominal irrigation and drainage. No child was admitted to the ICU or died. Four children (4/20, 20.0%) developed local pancreatic atrophy within 12 weeks after discharge, but no other long-term complications were observed.

Conclusions

Nonresection management of the pancreas could be a feasible option for children with grade III and IV blunt pancreatic injuries. Regular long-term follow-up is essential in terms of pancreatic function, especially in patients with pancreatic atrophy.