Evolving management of pancreatic injury. Curr Opin Crit Care. 2011;17:613-617. [PMID: 21986464 DOI: 10.1097/mcc.0b013e32834cd374]

Laparoscopic Management of Blunt Pancreatic Trauma in Adults and Pediatric Patients: A Systematic Review

Background

Pancreatic trauma is an uncommon injury that occurs usually in a young population and is frequently overlooked and not readily appreciated on initial examination. Nowadays, the diagnosis and management of pancreatic trauma are still controversial, and there is no gold standard for the treatment. The aim of this study is to describe our experience in the management of blunt pancreatic trauma with a laparoscopic approach and review the literature on laparoscopic management of pancreatic trauma.

Methods

A systematic literature review was performed, and 40 cases were reported and analysed; 10 cases were excluded because the complete data were not retrievable. We also reported our experience with the case of an 18-year-old male diagnosed with a deep laceration of the pancreas between body and tail, involving the main pancreatic duct, and with a concomitant hematoma. The patient underwent exploratory laparoscopy with abdominal toilet, necrosectomy, and suture of main pancreatic duct; the total blood loss was less than 200 ml, and the total operative time was 180 minutes. The patient recovered uneventfully and was discharged on the 6th postoperative day.

Results

30 patients with pancreatic trauma, 10 adults and 20 pediatrics (mean age 28.2 years and 10.5 years), underwent a total laparoscopic approach: 2 distal pancreatic-splenectomy, 22 spleen-preserving distal pancreatectomy, and 6 laparoscopic drainage. The mean operative time for the adult and pediatric populations was 160.6 and 214.5 minutes, the mean estimated blood loss was 400 ml and 75 ml, and the mean hospital stay was 14.9 and 9 days, respectively.

Conclusion

Laparoscopic management for pancreatic trauma can be considered feasible and safe when performed by an experienced laparoscopic pancreatic team, and in such a setting, it can be considered a viable alternative to open surgery, offering the well-known benefits of minimally invasive surgery.

Pancreaticoduodenectomy as an option for treating a hemodynamically unstable traumatic pancreatic head injury with a pelvic bone fracture in Korea: a case report

Pancreatic trauma occurs in 0.2% of patients with blunt trauma and 5% of severe abdominal injuries, which are associated with high mortality rates (up to 60%). Traumatic pancreatoduodenectomy (PD) has significant morbidity and appreciable mortality owing to complicating factors, associated injuries, and shock. The initial reconstruction in patients with severe pancreatic injuries aggravates their status by causing hypothermia, coagulopathy, and acidosis, which increase the risk for early mortality. A staging operation in which PD follows damage control surgery is a good option for hemodynamically unstable patients. We report the case of a patient who was treated by staging PD for an injured pancreatic head.

Diagnóstico y tratamiento del traumatismo de páncreas

Pancreatic trauma is a rare but potentially lethal entity which requires a high level of clinical suspicion. Early diagnosis and assessment of the integrity of the pancreatic duct are essential since ductal injury is a crucial predictor of morbimortality. Overall mortality is 19%, which can rise to 30% in cases of ductal injury. The diagnostic and therapeutic approach is multidisciplinary and guided by a surgeon, imaging specialist and ICU physician. Laboratory analysis shows that pancreatic enzymes are frequently elevated, which is a low specificity finding. In hemodynamically stable patients, the posttraumatic condition of the pancreas is firstly evaluated by the multidetector computed tomography. Moreover, in case of suspicion of ductal injury, more sensitive studies such as Endoscopic Retrograde Cholangiopancreatography or cholangioresonance are needed. This narrative review aims to analyze the etiopathogenesis and pathophysiology of pancreatic trauma and discuss its diagnosis and treatment. Also, the most clinically relevant complications will be summarized.

Delayed presentation of isolated ductal rupture of pancreatic head from blunt abdominal trauma managed conservatively: A case report

Introduction

and Importance: Blunt abdominal injury causing significant and isolated major pancreatic injury is rare in adolescents and young adults, with a controversial approach to its management.

Case presentation

We present our experience of diagnosis and management of the ductal injury of the pancreatic head (Grade III) in the setting of blunt abdominal trauma in a 20-year-old male diagnosed by a series of various tests including magnetic resonance cholangiopancreatography (MRCP) and managed by pigtail drainage and octreotide alone; contrary to the previous recommendations of management of high-grade pancreatic trauma through surgical approach or endoscopic retrograde cholangiopancreatography (ERCP) and stenting.

Clinical discussion

Isolated ductal rupture of the pancreatic head can have delayed presentation within a window of time and can be diagnosed by a series of tests including hematological, biochemical, and radiological investigations. Conservative treatment is generally recommended for Grade I and II whereas a surgical approach is preferred for higher grade pancreatic injury.

Conclusions

Pancreatic ductal injury must be kept in mind when present with vague symptoms in the setting of blunt abdominal trauma. Magnetic resonance cholangiopancreatography (MRCP) is the investigation of choice for the diagnosis of pancreatic ductal injury. Even higher-grade pancreatic injury (grade III) can be managed with a conservative approach with pigtail drainage and an appropriate dosage of octreotide.

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Isolated ductal rupture of the pancreatic duct is very rare with delayed manifestations.

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MRCP is the investigation of choice for diagnosis.

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Conservative approach with pigtail drainage and octreotide can be successful in grade III injury.

Missed pancreatic injury in patients undergoing conservative management of blunt abdominal trauma: Causes, sequelae and management

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.

Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma

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.

The bridge stenting-based internal drainage in pancreatic trauma patients with main pancreatic duct injury

Pancreatic trauma is associated with high mortality and morbidity, especially in main pancreatic duct (MPD) injuries. Here, we introduce a novel technique via the placement of bridge stenting-based internal drainage (BSID) along the injured MPD to restore pancreatic tissue integrity. Twelve patients with MPD injury underwent unobstructed BSID as physical support for healing. Six patients with peripheral organ injuries underwent operative end-to-end anastomosis of the MPD by using a polyurethane central venous catheter for the BSID, and the other six patients with isolated proximal MPD rupture received BSID via endoscopic pancreatic stent placement. The BSID technique was successfully performed in all pancreatic trauma patients without the need for a second open surgery. With this simplified BSID-based operation, a short procedure duration (242.7 ± 38.71 min in the surgical group and 100.2 ± 16.24 min in the endoscopic group) and a short hospital stay (13.0 ± 7.05 days) were achieved. However, a few complications (41.67%) still occurred, including pancreatitis, fistula, abscess, pseudocyst, cholangitis, and haemorrhage. Except for the deceased case, all postoperative courses were marked by decreases in the peripancreatic fluid collection, blood amylase recovery, and normal endocrine function. The BSID approach is a feasible surgical approach for the treatment of MPD injury and can be used endoscopically in isolated MPD injuries for its safety and convenience.

Detection of traumatic pancreatic duct disruption in the modern era

BACKGROUND

Pancreatic trauma management hinges upon the presence or absence of pancreatic duct injury, but the optimal method of assessment is unclear. This study endeavored to evaluate the methods of pancreatic duct assessment in modern practice.

METHODS

Patients presenting to LAC + USC Medical Center (01/2008-06/2015) with a pancreatic injury were identified (ICD-9 codes). Demographics, clinical data, technique of duct evaluation, and outcomes were analyzed.

RESULTS

71 patients with pancreatic injury were identified. 21 patients (30%) underwent CT scan (sensitivity 76%). Sixteen (76%) then underwent laparotomy while 5 (24%) were managed successfully nonoperatively. Most (n = 50, 70%) underwent immediate laparotomy. Overall, 66 patients (93%) were managed operatively. The majority were assessed intraoperatively for ductal injury with visual inspection alone (n = 62, 94%). Four (6%) underwent intraoperative pancreatography via duodenotomy/cholecystotomy, which were all inconclusive.

CONCLUSION

In the evaluation of pancreatic duct injury, intraoperative pancreatography is frequently inconclusive and should have a limited role. Clinical suspicion for ductal injury based on intraoperative visual inspection alone should guide the management of pancreatic injuries.

Blunt Trauma Pancreas in Children: Is Non-Operative Management Appropriate for All Grades?

PURPOSE

Blunt trauma of pancreas in children is uncommon and its management varies from observational to early operative intervention. We analysed the feasibility and outcome of non-operative management in all grades of paediatric pancreatic injuries.

METHODS

A total of 15 patients of pancreatic trauma seen in a Paediatric Surgery Unit were retrospectively analyzed.

RESULTS

Age of the patients ranged from 3-11 years (mean, 7.7 years). The mode of injury was local trauma in 9 children. Only 3 patients had associated injuries and all were haemodynamically stable. Serum amylase levels were raised in 12 patients at admission which ranged from 400-1,000 IU. Computed tomography scan made a correct diagnosis in 14 patients. Grades of the injury varied from grade I-V (1, 3, 6, 4, 1 patients respectively). Fourteen patients were managed conservatively. One patient underwent laparotomy for suspected superior mesenteric hematoma. The average duration of enteral feeds was 3.7 days and of hospital stay was 9.4 days. Six patients formed pancreatic pseudocysts; two were managed conservatively while the other four underwent cystogastrostomy. The patients were followed up for a period of 1-12 years. All remained asymptomatic and none had exocrine or endocrine deficiencies.

CONCLUSION

Non-operative treatment for isolated blunt trauma of pancreas in children may be safely followed for all the grades of injury; if associated injuries requiring surgical intervention are ruled out with a good quality imaging and the patients are hemodynamically stable. It did not increase the hospital stay and morbidity and avoided operative intervention on acutely injured pancreas.

Conservative treatment using an endoscopic pancreatic stent in a patient with delayed diagnosis of pancreatic injury after blunt trauma: A case report

The diagnostic evaluation of pancreatic injuries has improved dramatically in recent years. However, it is sometimes difficult to diagnose pancreatic injuries. Surgical treatment after delayed diagnosis is associated with increased risks of mortality and morbidity. A 47-year-old man was referred to our emergency department after experiencing blunt abdominal trauma 5 d earlier. The patient was diagnosed with a grade-III pancreatic injury. His hemodynamic status remained stable. He was managed successfully using endoscopic pancreatic stenting and percutaneous drainage catheter insertion.

Post-traumatic pancreatico-dural fistula: Case report and management challenges

Pancreatic injury can occur following high-energy blunt trauma to the torso. Although several types of pancreatic fistulas have been described in literature, we report to our knowledge, the first case of a pancreatico-dural fistula of traumatic origin.

A 20-year-old male sustained a severe blow to the thoraco-abdominal region in the setting of a motorcycle accident. A total body scan revealed an AAST (American Association for the Surgery of Trauma) grade 4 splenic injury. A laparotomy with splenectomy and abdominal packing was performed. This was later followed by thoracolumbar instrumentation for posterior fixation of a T11–T12 transdiscal type C fracture with anterior subluxation of T11, according to the AO classification. Subsequent management was complicated by the persistence of a pseudomeningocele despite multiple surgical drainage procedures and a concomitant increase in retroperitoneal fluid collections. High levels of amylase and lipase in the pseudomeningocele fluid confirmed the presence of a pancreatico-dural fistula, due to a Wirsung duct rupture.

This case report illiustrates the challenges in the management of this rare condition.

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.

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.

Management of pancreatic trauma: A pancreatic surgeon's point of view

BACKGROUND

Pancreatic trauma occurs in 0.2% of patients with blunt trauma and 1-12% of patients with penetrating trauma. Traumatic pancreatic injuries are characterised by high morbidity and mortality, which further increase with delayed diagnoses. The diagnosis of pancreatic trauma is challenging. Signs and symptoms can be non-specific or even absent.

METHODS

A critical review of studies reporting the management and outcomes of pancreatic trauma was performed.

RESULTS

The management of pancreatic trauma depends on the haemodynamic stability of the patient, the degree and location of parenchymal injury, the integrity of the main pancreatic duct, and the associated injuries to other organs. Nevertheless, the involvement of the main pancreatic duct is the most important predictive factor of the outcome. The majority of pancreatic traumas are managed by medical treatment (parenteral nutrition, antibiotic therapy and somatostatin analogues), haemostasis, debridement of devitalised tissue and closed external drainage. If a proximal duct injury is diagnosed, endoscopic transpapillary stent insertion can be a viable option, while surgical resection by pancreaticoduodenectomy is restricted to an extremely small number of selected cases. Injuries of the distal parenchyma or distal duct may be managed with distal pancreatectomy with spleen preservation. At the pancreatic neck, when pancreatic transection occurs without damage to the parenchyma, a parenchyma-sparing procedure is feasible.

CONCLUSION

The management of pancreatic injuries is complex and often requires a multidisciplinary approach. Here, we propose a management algorithm that is based on parenchymal damage and the site of duct injury.

Blunt abdominal trauma: imaging and intervention

Interventional radiology, particularly percutaneous angioembolization, plays an important role in the management of blunt abdominal trauma involving solid organs and pelvic fractures. The traumatic injuries of the central nervous system, heart, and great vessels often lead to death at the site of trauma. Although patients with visceral organ injuries can also die at the site of trauma, these patients often reach the hospital thus giving us an opportunity to treat them with surgical or radiological intervention depending on the clinical condition of the patient. The management of these patients with trauma is now well codified-patients who remain unstable despite resuscitation should be shifted either to an operating room for laparotomy if the ultrasound (US) revealed hemoperitoneum or to a interventional room for angioembolization in cases of pelvic fractures. In all other cases, computed tomography is essential. Currently, multidetector computed tomography with contrast is the gold standard imaging modality for the diagnosis of traumatic abdominal injuries; it helps in assessing the extent of injuries, and further management can be planned.

Endoscopic management for pancreatic injuries due to blunt abdominal trauma decreases failure of nonoperative management and incidence of pancreatic-related complications

INTRODUCTION

The actual benefit of endoscopic techniques in the non-operative management (NOM) of pancreatic injury is still unclear, with its role and effectiveness in the NOM of pancreatic injury remains defined and doubted. The purpose of this study was to evaluate the feasibility and long-term results of endoscopic techniques in the NOM of blunt pancreatic injury, and to determine whether NOM can be performed safely for selective patients with pancreatic injury.

PATIENTS AND METHODS

The records and follow-up data of all patients with blunt pancreatic injuries over 16-year period from October 1, 1996, to September 30, 2012 at our department were retrospectively reviewed. Failure of NOM (FNOM) occurred if laparotomy was required after attempted NOM.

RESULTS

132 patients (32% of all patients with blunt pancreatic injury) underwent NOM, including 58 who underwent endoscopic management (EM) and 74 who were observed without EM (NO-EM). FNOM of overall NOM was 20%, including 30% of NO-EM and 9% of EM. There was no significant difference in FNOM for NO-EM versus EM for grade I, however, a significant decrease in FNOM was noted with the addition of EM for grade II and III. EM was a statistically significant independent risk factor. Regular follow-up of 1 year showed that, for patients from grade I to III, 53 patients (42%) from operative management (OM) and 34 patients (46%) of the NO-EM developed various pancreatic-related complications, while only 15 patients (26%) of the EM developed such complications, and the difference was significant.

CONCLUSION

Application of strictly defined selection criteria for NOM and EM in patients with blunt pancreatic injury resulted in one of the lowest FNOM rates (9%) and pancreatic-related complications incidence (25%). Selective application of EM for hemodynamically stable patients with blunt pancreatic injury will extend the indications for, and improve success of NOM.

Pancreatic trauma: A concise review

Traumatic injury to the pancreas is rare and difficult to diagnose. In contrast, traumatic injuries to the liver, spleen and kidney are common and are usually identified with ease by imaging modalities. Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities, and these injuries are often overlooked in cases with extensive multiorgan trauma. The most evident findings of pancreatic injury are post-traumatic pancreatitis with blood, edema, and soft tissue infiltration of the anterior pararenal space. The alterations of post-traumatic pancreatitis may not be visualized within several hours following trauma as they are time dependent. Delayed diagnoses of traumatic pancreatic injuries are associated with high morbidity and mortality. Imaging plays an important role in diagnosis of pancreatic injuries because early recognition of the disruption of the main pancreatic duct is important. We reviewed our experience with the use of various imaging modalities for diagnosis of blunt pancreatic trauma.

Evaluation of blunt pancreatic injury with contrast-enhanced ultrasonography in comparison with contrast-enhanced computed tomography

The aim of the present study was to evaluate acute blunt pancreatic injury using contrast-enhanced ultrasonography (CEUS) in comparison with contrast-enhanced computed tomography (CECT). Superficial and deep lesions were established by blunt pancreatic injury in 40 Chinese Guangxi Bama miniature pigs. Conventional ultrasound (US), CEUS and CECT were performed to detect traumatic lesions in the pancreas. A total of 40 lesions were established, including 20 deep lesions and 20 superficial lesions. US identified 21 of the 40 lesions, including 7 of the 20 superficial and 14 of the 20 deep lesions. CEUS identified 34 of the 40 lesions, including 14 of the 20 superficial and 20 of the 20 deep lesions. CECT identified 33 of the 40 lesions, including 13 of the 20 superficial and 20 of the 20 deep lesions. The detection rate of acute blunt pancreatic injury using CEUS was significantly higher compared with that using US (85 vs. 52.5%, P<0.05), however there was no significant difference in the detection rate of pancreatic lesions between CEUS and CECT (85 vs. 82.5%, P>0.05). CEUS improves the diagnostic levels of conventional US and is comparable with CECT scans in the diagnosis of blunt pancreatic injury.