An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

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.

Emergency hybrid surgery for transection of pancreas at the head and neck after blunt abdominal trauma: A case report and review of the literature

INTRODUCTION

A complete disruption of main pancreatic duct (MPD) presents a significant challenge to the surgeon. Historically, the standard surgical approach for addressing a complete disruption of the MPD involved distal pancreatic resection and pancreaticojejunostomy Roux-en-Y anastomosis. Nevertheless, there have been no reported cases of hybrid surgery being employed for the complete disruption of the MPD.

PATIENT CONCERNS

A 63-year-old male patient presented with blunt trauma in the upper abdomen and was transferred to our trauma center 10 hours after injury. Upon arrival at the emergency department, he was conscious, hemodynamically stable, and complained of upper abdominal pain and distention. Physical examination revealed right upper abdominal tenderness and slight abdominal tension. Abdominal contrast-enhanced CT scan revealed a complete transection of pancreatic parenchyma at the junction of the head and neck.

DIAGNOSES

Complete transection of pancreatic parenchyma at the junction of the head and neck combined with complete disruption of the MPD, AIS grade IV.

INTERVENTIONS

The hybrid surgery was initially utilized for complete MPD disruption, incorporating endoscope-assisted stent placement in the MPD along with primary repair of the pancreatic parenchyma and duct.

OUTCOMES

The postoperative period went smoothly, and the patient recovered and was discharged 4 weeks after operation. The MPD stent was removed under endoscope 4 months after operation, and Endoscopic Retrograde Pancreatography examination showed that the MPD was patency and slight MPD stenosis without pancreatic leakage. At the most recent follow-up, the patient had returned to normal life and work without any pancreatic endocrine or exocrine dysfunction.

LESSONS

The hybrid surgery, incorporating endoscope-assisted MPD stent placement and primary repair of the pancreatic parenchyma and duct, emerges as a promising alternative for complete MPD disruption in hemodynamically stable patients. The challenge in this hybrid surgery is the precise localization of the distal end of the MPD.

Current use and utility of magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and pancreatic duct stents: A secondary analysis from the Western Trauma Association multicenter trials group on pancreatic injuries

INTRODUCTION

The single most important predictor of pancreas-specific complications (PSCs) after pancreatic trauma is injury to the main pancreatic duct (MPD). Pancreatography has been recommended to evaluate the integrity of the MPD. In addition, pancreatic duct stents have been proposed to prevent or treat PSC. The primary purpose of this study was to determine the accuracy of magnetic resonance cholangiopancreatography (MRCP) in diagnosing MPD injury. We further sought to determine whether stents were effective in preventing PSC or facilitated the resolution of pancreatic leaks or fistulae.

METHODS

A secondary analysis of a multicenter retrospective review of pancreatic injuries in patients 15 years and older from 2010 to 2018, focusing on patients who underwent MRCP or endoscopic retrograde cholangiopancreatography (ERCP), was performed. Final pancreatic injury grade was determined based on all available assessments, ultimately adjudicated by the site principal investigator. Data were analyzed using various statistical tests where appropriate.

RESULTS

Thirty-three centers reported on 1,243 patients. A total of 216 underwent pancreatography-137 had MRCP and 115 ERCP, with 36 having both. The sensitivity of MRCP for MPD injury was 37%, the specificity was 94%, the positive predictive value was 77%, and the negative predictive value was 73%. When compared with ERCP, MRCP findings were discordant in 64% of cases. Pancreatic stents were placed in 77 patients; 48 (62%) were to treat PSC, with no clear benefit. Twenty-nine had prophylactic stents placed. There did not appear to be benefit in reduced PSC compared with the entire study group or among patients with high-grade pancreatic injuries.

CONCLUSION

The accuracy of MRCP to evaluate the integrity of the MPD does not appear to be superior to computed tomography scan. Consequently, the results of MRCP should be interpreted with caution. The current data do not support prophylactic use of pancreatic stents; they should be studied in a prospective trial.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

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.

The Role of Magnetic Resonance in Evaluating Abdominopelvic Trauma - Part 1: Pancreatic and Hepatobiliary Injuries

Trauma is an important cause of mortality, particularly in the young. While computed tomography (CT) is the mainstay of body imaging in the setting of trauma, magnetic resonance (MR) imaging can be useful in stable patients. Although more commonly used in spinal and musculoskeletal trauma, MR also has a role in abdominopelvic trauma. Broadly, its uses include clarification of equivocal cases, monitoring complications of trauma, particularly with solid organ injury, or as a primary imaging modality for patients with low suspicion for injury for whom avoiding ionizing radiation is a priority-namely, in pediatric and pregnant patients. In this two-part review article, we will review clinical scenarios where this may be encountered, utilizing case examples. This first installment will focus on pancreatic and hepatobiliary injuries. Pancreatic trauma may be difficult to diagnose on CT, and MR may aid in demonstrating pancreatic duct disruption, allowing for accurate grading according to American Association for the Surgery of Trauma (AAST) criteria. It may also be a useful modality for monitoring evolution of pancreatic injuries and/or pseudocyst development, guiding potential stenting, and/or drainage. Biliary injuries are also optimally evaluated with MR, particularly when aided by the use of hepatobiliary contrast material. This can allow for accurate delineation of biliary ductal anatomy and aid in planning percutaneous or endoscopic treatment of bile leaks.

Inviting a friend to evaluate potential grade III pancreatic injuries: Are they truly occult, or simply missed on CT?

Traumatic inuries to the pancreas are notoriously challenging to diagnose and treat. Detecting a main pancreatic ductal injury can be particularly difficult on screening computed tomography (CT). Twenty-four blinded faculty clinicians from 4 differing specialties and 6 institutions reviewed 9 video CT cases of potential pancreatic ductal injuries. Clinician performance in detection of confirmed grade III pancreatic injuries varied widely among specialties. This heterogeneity confirms the critical need for multidisciplinary care and image interpretation for even “minor” (i.e., not grade IV or V) potential pancreatic injuries to optimize outcomes for injured patients. The ubiquitous availability of electronic devices allows real-time collegial second opinions to be easily available.

Don't mess with the pancreas! A multicenter analysis of the management of low-grade pancreatic injuries

INTRODUCTION

Current guidelines recommend nonoperative management (NOM) of low-grade (American Association for the Surgery of Trauma-Organ Injury Scale Grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low-quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity.

METHODS

Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression.

RESULTS

Twenty-nine centers submitted data on 728 patients with LGPI (76% men; mean age, 38 years; 37% penetrating; 51% Grade I; median Injury Severity Score, 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (odds ratio [OR], 2.30; 95% confidence interval [95% CI], 1.16-15.28), low volume (OR, 2.88; 1.65, 5.06), and penetrating injury (OR, 3.42; 95% CI, 1.80-6.58). Resection was very close to significance (OR, 2.06; 95% CI, 0.97-4.34) (p = 0.0584).

CONCLUSION

The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for high-grade pancreatic injuries. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be used whenever possible and studied prospectively, particularly in penetrating trauma.

LEVEL OF EVIDENCE

Therapeutic Study, level IV.

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.

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.

Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers

BACKGROUND

Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers.

METHODS

This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity.

RESULTS

Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury.

CONCLUSION

Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system.

LEVEL OF EVIDENCE

Therapeutic/care management, level V; Prognostic and epidemiological, level IV.

Pancreatic damage control: the pancreas is simple don't complicate it

Pancreatic trauma is a rare but potentially lethal injury because often it is associated with other abdominal organ or vascular injuries. Usually, it has a late clinical presentation which in turn complicates the management and overall prognosis. Due to the overall low prevalence of pancreatic injuries, there has been a significant lack of consensus among trauma surgeons worldwide on how to appropriately and efficiently diagnose and manage them. The accurate diagnosis of these injuries is difficult due to its anatomical location and the fact that signs of pancreatic damage are usually of delayed presentation. The current surgical trend has been moving towards organ preservation in order to avoid complications secondary to exocrine and endocrine function loss and/or potential implicit post-operative complications including leaks and fistulas. The aim of this paper is to propose a management algorithm of patients with pancreatic injuries via an expert consensus. Most pancreatic injuries can be managed with a combination of hemostatic maneuvers, pancreatic packing, parenchymal wound suturing and closed surgical drainage. Distal pancreatectomies with the inevitable loss of significant amounts of healthy pancreatic tissue must be avoided. General principles of damage control surgery must be applied when necessary followed by definitive surgical management when and only when appropriate physiological stabilization has been achieved. It is our experience that viable un-injured pancreatic tissue should be left alone when possible in all types of pancreatic injuries accompanied by adequate closed surgical drainage with the aim of preserving primary organ function and decreasing short and long term morbidity.

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.

Pancreatic Trauma: Imaging Review and Management Update

Traumatic injuries of the pancreas are uncommon and often difficult to diagnose owing to subtle imaging findings, confounding multiorgan injuries, and nonspecific clinical signs. Nonetheless, early diagnosis and treatment are critical, as delays increase morbidity and mortality. Imaging has a vital role in diagnosis and management. A high index of suspicion, as well as knowledge of the anatomy, mechanism of injury, injury grade, and role of available imaging modalities, is required for prompt accurate diagnosis. CT is the initial imaging modality of choice, although the severity of injury can be underestimated and assessment of the pancreatic duct is limited with this modality. The time from injury to definitive diagnosis and the treatment of potential pancreatic duct injury are the primary factors that determine outcome following pancreatic trauma. Disruption of the main pancreatic duct (MPD) is associated with higher rates of complications, such as abscess, fistula, and pseudoaneurysm, and is the primary cause of pancreatic injury-related mortality. Although CT findings can suggest pancreatic duct disruption according to the depth of parenchymal injury, MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography facilitate direct assessment of the MPD. Management of traumatic pancreatic injury depends on multiple factors, including mechanism of injury, injury grade, presence (or absence) of vascular injury, hemodynamic status of the patient, and associated organ damage. ^©RSNA, 2020 See discussion on this article by Patlas.

Incidence and characteristics of pancreatic injuries among trauma patients admitted to a Norwegian trauma centre: a population-based cohort study

BACKGROUND

Pancreatic injuries are rare. Reports are lacking from defined European populations covering all ages and genders and in areas with a low prevalence of penetrating trauma. We aimed to review pancreatic injuries identified within a defined population.

METHODS

Observational cohort study from a prospectively maintained trauma registry and all patients coded for a pancreatic injury between January 1, 2004 and December 31, 2018.

RESULTS

A total of 14 patients with pancreatic injury were identified over a 15-year time period. Pancreatic injuries represented 0,19% (14/7207) of all trauma patients and 3,1% (14/454) of patients with documented abdominal injuries. Nine patients 64% (9/14) were children, representing 1% (9/869) of all injured children in the registry and 11,4% (9/79) of children with documented abdominal injuries. Median age was 10,5 years (range 3-58). Ten were male (71%) and 86% (12/14) suffered blunt trauma. Median AAST-OIS was 2 (1-4). Single organ injury occurred in 43% (6/14). Concomitant liver injury was the most frequent associated intra-abdominal injury found in 29% (4/14). Four patients (29%) had associated injuries in other body regions, all thoracic injuries. Median ISS was 9,5 (4-41).Operative management was needed for four of the pancreatic injuries, one spleen-preserving distal pancreatectomy, one spleen-sacrificing distal pancreatectomy and two peripancreatic drainages. One patient died within 30-days, but the death was unrelated to the pancreatic injury.

CONCLUSIONS

Incidence of pancreatic injuries is low, even among trauma patients with documented abdominal injuries. Most pancreatic injuries occurred in children. Injuries requiring surgery was rare.

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.

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.

Imaging of Blunt Pancreatic Trauma: A Systematic Review

PURPOSE

Despite several published reports on the value of imaging in acute blunt pancreatic trauma, there remains a large variability in the reported performance of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). The purpose of this study is to present a systematic review on the utility of these imaging modalities in the acute assessment of blunt pancreatic trauma. In addition, a brief overview of the various signs of pancreatic trauma will be presented.

METHODS

Keyword search was performed in MEDLINE, EMBASE, and Web of Science databases for relevant studies in the last 20 years (1999 onward). Titles and abstracts were screened, followed by full-text screening. Inclusion criteria were defined as studies reporting on the effectiveness of imaging modality (US, CT, or MRI) in detecting blunt pancreatic trauma.

RESULTS

After initial search of 743 studies, a total of 37 studies were included in the final summary. Thirty-six studies were retrospective in nature. Pancreatic injury was the primary study objective in 21 studies. Relevant study population varied from 5 to 299. Seventeen studies compared the imaging findings against intraoperative findings. Seven studies performed separate analysis for pancreatic ductal injuries and 9 studies only investigated ductal injuries. The reported sensitivities for the detection of pancreatic injuries at CT ranged from 33% to 100% and specificity ranged from 62% to 100%. Sensitivity at US ranged from 27% to 96%. The sensitivity at MRI was only reported in 1 study and was 92%.

CONCLUSION

There remains a large heterogeneity among reported studies in the accuracy of initial imaging modalities for blunt pancreatic injury. Although technological advances in imaging equipment would be expected to improve accuracy, the current body of literature remains largely divided. There is a need for future studies utilizing the most advanced imaging equipment with appropriately defined gold standards and outcome measures.

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

Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.

Role of multidetector computed tomography in the assessment of pancreatic injuries after blunt trauma: a multicenter experience

Pancreatic injuries can occur from either penetrating or blunt abdominal trauma. While there are rare, especially in the setting of blunt abdominal trauma, they are associated with a mortality of up to 30%, and a morbidity of 60%. Multidetector computed tomography (MDCT) is the preferred imaging modality in patients with acute blunt abdominal trauma and for the detection of acute pancreatic injury. Magnetic resonance (MR) and magnetic resonance cholangiopancreatography (MRCP) plays an important role in the follow-up of pancreatic injury. In this brief review, we discuss the main MDCT acute imaging findings as well as the complications. Finally, we discuss the role of MR and MRCP in follow up of patients with pancreatic injuries.