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Xu Y, Ai T. Emergency hybrid surgery for transection of pancreas at the head and neck after blunt abdominal trauma: A case report and review of the literature. Medicine (Baltimore) 2024; 103:e37144. [PMID: 38306542 PMCID: PMC10843307 DOI: 10.1097/md.0000000000037144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/11/2024] [Indexed: 02/04/2024] Open
Abstract
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.
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Affiliation(s)
- Yanan Xu
- Department of Traumatology, Chongqing Emergency Medical Center/Chongqing University Central Hospital, Chongqing, China
| | - Tao Ai
- Department of Traumatology, Chongqing Emergency Medical Center/Chongqing University Central Hospital, Chongqing, China
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Biffl WL, Ball CG, Moore EE, West M, Russo RM, Balogh ZJ, Kornblith L, Castelo M. 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. J Trauma Acute Care Surg 2023; 95:719-725. [PMID: 37125949 DOI: 10.1097/ta.0000000000003990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
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.
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Affiliation(s)
- Walter L Biffl
- From the Trauma Department (W.L.B., M.C.), Scripps Memorial Hospital La Jolla, La Jolla, California; Department of Surgery (C.G.B.), University of Calgary, Alberta, Canada; Ernest E. Moore Shock Trauma Center at Denver Health (E.E.M.), Denver, Colorado; Department of Trauma and Acute Care Surgery (M.W.), North Memorial Health Care, Minneapolis, Minnesota; Department of Surgery (R.M.R.), University of California-Davis, Sacramento, California; Department of Traumatology (Z.J.B.), John Hunter Hospital, University of Newcastle, New South Wales, Australia; and Department of Surgery (L.K.), San Francisco General Hospital, San Francisco, California
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3
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Blunt pancreatic trauma: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2023; 94:455-460. [PMID: 36397206 DOI: 10.1097/ta.0000000000003794] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Feliciano DV. 2022 Excelsior Surgical Society/Edward D Churchill Lecture: Extraordinary Evolution of Surgery for Abdominal Trauma. J Am Coll Surg 2023; 236:439-448. [PMID: 36730657 DOI: 10.1097/xcs.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- David V Feliciano
- From the Shock Trauma Center/Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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Rajput MZ, Mellnick VM. The Role of Magnetic Resonance in Evaluating Abdominopelvic Trauma - Part 1: Pancreatic and Hepatobiliary Injuries. Can Assoc Radiol J 2022; 73:680-688. [PMID: 35282708 DOI: 10.1177/08465371221077650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Mohamed Z Rajput
- Mallinckrodt Institute of Radiology, 116142Washington University School of Medicine, St Louis, MO, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, 116142Washington University School of Medicine, St Louis, MO, USA
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Ball CG, Clements TS, Kirkpatrick AW, Vogt K, Biffl W, Hameed M. Inviting a friend to evaluate potential grade III pancreatic injuries: Are they truly occult, or simply missed on CT? Can J Surg 2021; 64:E677-E679. [PMID: 34933945 PMCID: PMC8711555 DOI: 10.1503/cjs.001421] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Chad G Ball
- From the Department of Surgery, University of Calgary, Calgary, Alta., Canada (Ball, Clements, Kirkpatrick); the Department of Surgery, Western University, London, Ont., Canada (Vogt); the Scripps Memorial Hospital, La Jolla, California, USA (Biffl); and the Department of Surgery, University of British Columbia, Vancouver, BC, Canada (Hameed).
| | - Thomas S Clements
- From the Department of Surgery, University of Calgary, Calgary, Alta., Canada (Ball, Clements, Kirkpatrick); the Department of Surgery, Western University, London, Ont., Canada (Vogt); the Scripps Memorial Hospital, La Jolla, California, USA (Biffl); and the Department of Surgery, University of British Columbia, Vancouver, BC, Canada (Hameed)
| | - Andrew W Kirkpatrick
- From the Department of Surgery, University of Calgary, Calgary, Alta., Canada (Ball, Clements, Kirkpatrick); the Department of Surgery, Western University, London, Ont., Canada (Vogt); the Scripps Memorial Hospital, La Jolla, California, USA (Biffl); and the Department of Surgery, University of British Columbia, Vancouver, BC, Canada (Hameed)
| | - Kelly Vogt
- From the Department of Surgery, University of Calgary, Calgary, Alta., Canada (Ball, Clements, Kirkpatrick); the Department of Surgery, Western University, London, Ont., Canada (Vogt); the Scripps Memorial Hospital, La Jolla, California, USA (Biffl); and the Department of Surgery, University of British Columbia, Vancouver, BC, Canada (Hameed)
| | - Walter Biffl
- From the Department of Surgery, University of Calgary, Calgary, Alta., Canada (Ball, Clements, Kirkpatrick); the Department of Surgery, Western University, London, Ont., Canada (Vogt); the Scripps Memorial Hospital, La Jolla, California, USA (Biffl); and the Department of Surgery, University of British Columbia, Vancouver, BC, Canada (Hameed)
| | - Morad Hameed
- From the Department of Surgery, University of Calgary, Calgary, Alta., Canada (Ball, Clements, Kirkpatrick); the Department of Surgery, Western University, London, Ont., Canada (Vogt); the Scripps Memorial Hospital, La Jolla, California, USA (Biffl); and the Department of Surgery, University of British Columbia, Vancouver, BC, Canada (Hameed)
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Biffl WL, Ball CG, Moore EE, Lees J, Todd SR, Wydo S, Privette A, Weaver JL, Koenig SM, Meagher A, Dultz L, Udekwu PO, Harrell K, Chen AK, Callcut R, Kornblith L, Jurkovich GJ, Castelo M, Schaffer KB. Don't mess with the pancreas! A multicenter analysis of the management of low-grade pancreatic injuries. J Trauma Acute Care Surg 2021; 91:820-828. [PMID: 34039927 DOI: 10.1097/ta.0000000000003293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Walter L Biffl
- From the Scripps Memorial Hospital (W.L.B., M.C., K.B.S.), La Jolla, La Jolla, CA; University of Calgary, Calgary (C.G.B.), Alberta, Canada; Ernest E. Moore Shock Trauma Center at Denver Health (E.E.M.), Denver, CO; University of Oklahoma (J.L.), Oklahoma City, OK; Grady Memorial Hospital (S.R.T.), Atlanta, GA; Cooper University Hospital (SW), Camden, NJ; Medical University of South Carolina (A.P.), Charleston, SC; University of California-San Diego (J.L.W.), San Diego, CA; Virginia Tech Carilion School of Medicine (S.M.K.), Carilion Clinic, Roanoke VA; Indiana University School of Medicine- Methodist (A.M.), Indianapolis, IN; Parkland- UT Southwestern Medical Center (L.D.), Dallas, TX; WakeMed Health (P.O.U.), Raleigh, NC; University of Tennessee College of Medicine (K.H.), Chattanooga, TN; UCSF Fresno (A.K.C.), Fresno, CA; and San Francisco General Hospital (R.C., L.K.), San Francisco, CA; University of California-Davis (G.J.J.), Sacramento, CA
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Ball CG, Biffl WL, Vogt K, Hameed SM, Parry NG, Kirkpatrick AW, Kaminsky M. Does drainage or resection predict subsequent interventions and long-term quality of life in patients with Grade IV pancreatic injuries: A population-based analysis. J Trauma Acute Care Surg 2021; 91:708-715. [PMID: 34559164 DOI: 10.1097/ta.0000000000003313] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Chad G Ball
- From the Department of Surgery (C.G.B., A.W.K.), University of Calgary, Calgary, Alberta, Canada; Department of Surgery (W.L.B.), Scripps Clinic Medical Group, La Jolla, California; Department of Surgery (S.M.H.), University of British Columbia, Vancouver, BC, Canada; Department of Surgery (K.V., N.G.P.), Western University, London, Ontario, Canada; and Department of Surgery (M.K.), Cook County Hospital, Chicago, Illinois
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Patlas MN. Invited Commentary: Imaging and Management of Pancreatic Trauma. Radiographics 2021; 41:75-77. [PMID: 33411615 DOI: 10.1148/rg.2021200211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael N Patlas
- From the Department of Radiology, Hamilton General Hospital, McMaster University, 237 Barton St E, Hamilton, ON, Canada L8L 2X2
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Biffl WL, Zhao FZ, Morse B, McNutt M, Lees J, Byerly S, Weaver J, Callcut R, Ball CG, Nahmias J, West M, Jurkovich GJ, Todd SR, Bala M, Spalding C, Kornblith L, Castelo M, Schaffer KB, Moore EE. A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries. J Trauma Acute Care Surg 2021; 90:776-786. [PMID: 33797499 DOI: 10.1097/ta.0000000000003080] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Walter L Biffl
- From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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12
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Joos E, de Jong N, Ball CG, Quigley S, Trottier V, Massé M, Engels PT, Rao J, Gillman LM, Visser R, Widder S, Hameed MS, Vogt KN. 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. J Trauma Acute Care Surg 2021; 90:434-440. [PMID: 33617195 DOI: 10.1097/ta.0000000000003025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Emilie Joos
- From the Division of General Surgery/Department of Surgery (E.J., M.S.H.), University of British Columbia, Vancouver; University of Groningen (N.d.J.), Faculty of Medicine; Department of Surgery (C.G.B., S.Q.), University of Calgary, Calgary; Department of Surgery (V.T., M.M.), Laval University, Québec City; Department of Surgery (P.T.E.), McMaster University, Hamilton; Department of Surgery (J.R.), University of Saskatchewan, Regina; Department of Surgery (L.M.G., R.V.), University of Manitoba, Winnipeg; Department of Surgery (S.W.), University of Alberta, Edmonton; and Department of Surgery (K.N.V.), Western University, London, Canada
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Ordoñez CA, Parra MW, Millán M, Caicedo Y, Padilla N, Guzmán-Rodríguez M, Miñan-Arana F, García A, González-Hadad A, Pino LF, Rodríguez-Holguin F, Serna JJ, Salcedo A, Ferrada R, Ivatury R. Pancreatic damage control: the pancreas is simple don't complicate it. Colomb Med (Cali) 2020; 51:e4164361. [PMID: 33795904 PMCID: PMC7968433 DOI: 10.25100/cm.v51i4.4361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/14/2020] [Accepted: 10/10/2020] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia
- Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Fernando Miñan-Arana
- Universidad Espiritu Santo, Department of Surgery, Guayaquil, Ecuador
- Hospital Dr. Abel Gilbert Ponton, Department of Surgery, Division of Trauma and Acute Care Surgery, Guayaquil, Ecuador
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Fernando Rodríguez-Holguin
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Ricardo Ferrada
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
- Centro Médico Imbanaco, Cali, Colombia
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
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Pancreatic Trauma: Proposal for Management Algorithm. Int Surg 2020. [DOI: 10.9738/intsurg-d-20-00015.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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15
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Ayoob AR, Lee JT, Herr K, LeBedis CA, Jain A, Soto JA, Lim J, Joshi G, Graves J, Hoff C, Hanna TN. Pancreatic Trauma: Imaging Review and Management Update. Radiographics 2020; 41:58-74. [PMID: 33245670 DOI: 10.1148/rg.2021200077] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Andres R Ayoob
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - James T Lee
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Keith Herr
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Christina A LeBedis
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Ashwin Jain
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Jorge A Soto
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Jihoon Lim
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Gayatri Joshi
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Joseph Graves
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Carrie Hoff
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
| | - Tarek N Hanna
- From the Department of Radiology, University of Kentucky, 800 Rose St, MN 109-B, Lexington, KY 40536 (A.R.A., J.T.L.); Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (K.H., J.L., G.J., J.G., C.H., T.N.H.); and Department of Radiology, Boston University, Boston, Mass (C.A.L., A.J., J.A.S.)
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Wiik-Larsen J, Thorsen K, Sandve KO, Søreide K. Incidence and characteristics of pancreatic injuries among trauma patients admitted to a Norwegian trauma centre: a population-based cohort study. Scand J Gastroenterol 2020; 55:1347-1353. [PMID: 33027601 DOI: 10.1080/00365521.2020.1829032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Johannes Wiik-Larsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Knut Olav Sandve
- Department of Radiology, Stavanger University Hospital, Stavanger, Norway.,Stavanger Medical Image Laboratory, Stavanger University Hospital, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Sodagari F, Katz DS, Menias CO, Moshiri M, Pellerito JS, Mustafa A, Revzin MV. Imaging Evaluation of Abdominopelvic Gunshot Trauma. Radiographics 2020; 40:1766-1788. [DOI: 10.1148/rg.2020200018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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19
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Durso AM, Paes FM, Caban K, Danton G, Braga TA, Sanchez A, Munera F. Evaluation of penetrating abdominal and pelvic trauma. Eur J Radiol 2020; 130:109187. [DOI: 10.1016/j.ejrad.2020.109187] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/11/2020] [Accepted: 07/17/2020] [Indexed: 12/17/2022]
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Chikhladze S, Ruess DA, Schoenberger J, Fichtner-Feigl S, Pratschke J, Hopt UT, Bahra M, Wittel UA, Globke B. Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma. Injury 2020; 51:1979-1986. [PMID: 32336477 DOI: 10.1016/j.injury.2020.03.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/11/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- S Chikhladze
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - D A Ruess
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - J Schoenberger
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - S Fichtner-Feigl
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - J Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - U T Hopt
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - M Bahra
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
| | - U A Wittel
- Department of General- and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - B Globke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Germany
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21
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22
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Blame it on the injury: Trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection. J Trauma Acute Care Surg 2020; 87:1289-1300. [PMID: 31765347 DOI: 10.1097/ta.0000000000002495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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23
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Odedra D, Mellnick VM, Patlas MN. Imaging of Blunt Pancreatic Trauma: A Systematic Review. Can Assoc Radiol J 2020; 71:344-351. [PMID: 32063010 DOI: 10.1177/0846537119888383] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Devang Odedra
- Department of Radiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Vincent M Mellnick
- Abdominal Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Michael N Patlas
- Division of Emergency/Trauma Radiology, Department of Radiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
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24
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Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y, Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:56. [PMID: 31867050 PMCID: PMC6907251 DOI: 10.1186/s13017-019-0278-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA USA
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Imitiaz Wani
- Department of Surgery, DHS Hospitals, Srinagar, Kashmir India
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Gustavo Pereira Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Carlos Ordonez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Emmanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Grazia Sibilla
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Hospital, Chiba, Japan
| | - Peter T. Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mazyr, Belarus
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics and Gynecology, University of Buea, Buea, Cameroon
| | - Rao Ivatury
- General and Trauma Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Francesco Favi
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Fernando Machado
- General and Emergency Surgery Department, Montevideo Hospital, Montevideo, Uruguay
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes, UGA-Université Grenoble Alpes, Grenoble, France
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
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Iacobellis F, Laccetti E, Tamburrini S, Altiero M, Iaselli F, Di Serafino M, Gagliardi N, Danzi R, Rengo A, Romano L, Nicola R, Scaglione M. Role of multidetector computed tomography in the assessment of pancreatic injuries after blunt trauma: a multicenter experience. Gland Surg 2019; 8:184-196. [PMID: 31183328 DOI: 10.21037/gs.2019.02.02] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Francesca Iacobellis
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Ettore Laccetti
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy
| | - Stefania Tamburrini
- Department of Radiology, "Ospedale del Mare" ASL NA1 Centro-Napoli, Naples, Italy
| | - Michele Altiero
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy
| | - Francesco Iaselli
- Department of Radiology, "Ospedale del Mare" ASL NA1 Centro-Napoli, Naples, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Nicola Gagliardi
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Roberta Danzi
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy
| | - Alessandro Rengo
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy
| | - Refky Nicola
- Department of Radiology, SUNY-Upstate University and Medical Center, Syracuse, NY, USA
| | - Mariano Scaglione
- Department of Diagnostic Imaging, "Pineta Grande" Hospital, Castel Volturno, CE, Italy.,Department of Radiology, Sunderland Royal Hospital, NHS, Sunderland, UK
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