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Li KW, Chen WS, Wang K, Yang C, Deng YX, Wang XY, Hu YP, Liu YX, Li WQ, Ding WW. Open or Not Open the Retroperitoneum: A Pandora's Box for Blunt High-Grade Pancreatic Trauma? J Surg Res 2024; 293:79-88. [PMID: 37734295 DOI: 10.1016/j.jss.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/19/2023] [Accepted: 08/14/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION The optimal management strategy for pancreatic trauma remains unclear. We aimed to determine whether the initial nonoperative management (NOM) strategy based on percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement would improve outcomes for blunt high-grade pancreatic trauma. METHODS Patients with blunt abdominal trauma who were hemodynamically stable without signs of diffuse peritonitis were consecutively enrolled at a high-volume center. The primary outcome was the occurrence of severe complications (Clavien‒Dindo classification ≥ Ⅲb) for patients who underwent initial laparotomy (LAP) versus NOM. Modified Poisson regression was used to model the primary outcome. Propensity score matching and weighting models were included into a regression-based sensitivity analysis. RESULTS Of 119 patients with grade III/IV pancreatic trauma, 29 patients underwent initial NOM, and 90 underwent initial LAP. The incidence of severe complications in the LAP group was higher than that in the NOM group (65/90 [72.2%] versus 9/29 [31.0%], P < 0.001). In the multivariable modified Poisson regression model, the relative risk for severe complications was decreased in the NOM group (relative risk, 0.52; 95% confidence interval, 0.30-0.90; P = 0.020). The results of the sensitivity analysis were consistent with those of the multivariable analysis. The mean number of reinterventions per patient was 1.8 in the NOM group and 2.6 in the LAP group (P = 0.067). CONCLUSIONS For blunt high-grade pancreatic trauma patients with stable hemodynamics and no diffuse peritonitis, the NOM strategy was associated with a lower risk of severe complications (Clavien‒Dindo classification ≥ Ⅲb) and did not require more invasive reintervention procedures. In high-volume centers with sufficient expertise, percutaneous drainage combined with endoscopic retrograde cholangiopancreatography guided stent placement may serve as an initial reasonable option for selected patients.
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Affiliation(s)
- Kai-Wei Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Wen-Song Chen
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Kai Wang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Chao Yang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yun-Xuan Deng
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Xin-Yu Wang
- Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yue-Peng Hu
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
| | - Yu-Xiu Liu
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China; Division of Data and Statistics, Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
| | - Wei-Qin Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
| | - Wei-Wei Ding
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China; Division of Trauma and Acute Care Surgery, Department of Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China.
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García Reyes V, Scarlatto B, Manzanares W. Diagnóstico y tratamiento del traumatismo de páncreas. Med Clin (Barc) 2023; 160:450-455. [PMID: 37005125 DOI: 10.1016/j.medcli.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 04/03/2023]
Abstract
Pancreatic trauma is a rare but potentially lethal entity which requires a high level of clinical suspicion. Early diagnosis and assessment of the integrity of the pancreatic duct are essential since ductal injury is a crucial predictor of morbimortality. Overall mortality is 19%, which can rise to 30% in cases of ductal injury. The diagnostic and therapeutic approach is multidisciplinary and guided by a surgeon, imaging specialist and ICU physician. Laboratory analysis shows that pancreatic enzymes are frequently elevated, which is a low specificity finding. In hemodynamically stable patients, the posttraumatic condition of the pancreas is firstly evaluated by the multidetector computed tomography. Moreover, in case of suspicion of ductal injury, more sensitive studies such as Endoscopic Retrograde Cholangiopancreatography or cholangioresonance are needed. This narrative review aims to analyze the etiopathogenesis and pathophysiology of pancreatic trauma and discuss its diagnosis and treatment. Also, the most clinically relevant complications will be summarized.
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Tamrat G, Kejela S. Delayed distal pancreatectomy for isolated complete pancreatic disruption secondary to “trivial” blunt abdominal injury: A case report and literature review. Clin Case Rep 2022; 10:e6295. [PMID: 36093448 PMCID: PMC9446079 DOI: 10.1002/ccr3.6295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 08/08/2022] [Accepted: 08/17/2022] [Indexed: 11/12/2022] Open
Abstract
Pancreatic injury is a formidable diagnostic and therapeutic challenge owing to its relative rarity. Most injuries are from motor vehicle related injuries in blunt trauma patients. We present a 22‐year‐old male patient presented after sustaining a kick to the abdomen. He developed progressive abdominal pain with vomiting with delayed generalization of the pain and involuntary guarding. On initial exploratory laparotomy, suction drainage was inserted, and patient underwent delayed spleen sparing distal pancreatectomy on the 25th post‐admission day. Patient had smooth postoperative course and was discharged on the 7th postoperative day.
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Affiliation(s)
- Girmaye Tamrat
- Department of Surgery College of Health Sciences Addis Ababa University Addis Ababa Ethiopia
| | - Segni Kejela
- Department of Surgery College of Health Sciences Addis Ababa University Addis Ababa Ethiopia
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Jin H, Chuang TY, Rasheed H. Case report of an isolated pancreatic transection from low impact blunt abdominal trauma necessitating resective surgery. Int J Surg Case Rep 2022. [PMCID: PMC9178486 DOI: 10.1016/j.ijscr.2022.107276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction and importance Isolated pancreatic injury from blunt force trauma is an extremely rare entity accounting for less than 1 % of trauma presentations. This case highlights the diagnostic difficulties of identifying a ductal injury and presents a rare instance of an isolated pancreatic transection from a relatively low-impact blunt abdominal trauma. Case presentation A 30 year old lady presented to the emergency department 24 h following a low impact abdominal trauma. CT scan showed a complete pancreatic transection with significant peripancreatic free fluid. MRCP showed the main pancreatic duct to be in alignment on either side of the transection plane, however given the significant surrounding free fluid she was taken to the operating theatre for exploration and resective surgery. Intraoperative findings were that of a complete pancreatic transection involving the main pancreatic duct. Discussion Current management guidelines focus on the correct evaluation of main pancreatic duct integrity. Timely intervention is essential for improving mortality and morbidity outcomes. Reported sensitivity and specificity for imaging modalities vary between studies, likely reflecting inherent challenges in accurately identifying pancreatic duct injuries. Multi-modal assessment is recommended to reach a timely diagnosis and hence, institute the appropriate therapy. Conclusion Low-energy trauma can result in isolated injuries of the pancreas. Multi-modal imaging should be encouraged for evaluation of main pancreatic duct integrity. This will facilitate timely decision making regarding the need for definitive surgery. High grade pancreatic injuries can occur in isolation from a relatively low impact blunt abdominal trauma. MRCP may be equivocal or show preserved pancreatic ductal integrity despite the presence of complete transection. Patients can appear clinically stable despite the presence of a severe pancreatic injury in the early stages of the disease. Early diagnosis and surgical intervention (where appropriate) is essential to reduce morbidity and mortality. Multi-disciplinary approach involving radiology, gastroenterology and general surgery should be employed.
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Affiliation(s)
- Harry Jin
- Corresponding author at: Department of Vascular Surgery, Townsville University Hospital, 100 Angus Smith Drive, Douglas 4814, Queensland, Australia.
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Yang C, Wang X, Wu C, Wang Y, Wang K, Ding W. A case-control study of risk factors for survival after laparotomy in patients with pancreatic trauma. Asian J Surg 2021; 45:125-130. [PMID: 33863629 DOI: 10.1016/j.asjsur.2021.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Pancreatic trauma results in significant morbidity and mortality. However, few studies have investigated the postoperative prognostic factors in patients with pancreatic trauma. MATERIAL AND METHODS A retrospective study was conducted on consecutive patients with pancreatic trauma who underwent surgery in a national referral trauma center. Clinical data were retrieved from the electronic medical system. Univariate and binary logistic regression analyses were performed to identify the perioperative clinical parameters that may predict the factors of mortality of the patients. RESULTS A total of 150 patients underwent laparotomy due to pancreatic trauma during the study period. 128(85.4%) patients survived and 22 (14.6%) patients died due to pancreatic injury (10 patients died of recurrent intra-abdominal active hemorrhage and 12 died of multiple organ failure). Univariate analysis showed that age, hemodynamic status, and injury severe score (ISS) as well as postoperative serum levels of C-reactive protein (CRP), procalcitonin, albumin, creatinine and the volume of intraoperative blood transfusion remained strongly predictive of mortality (P < 0.05). Binary logistic regression analysis showed that the independent risk factors for prognosis after pancreatic trauma were age (P = 0.010), preoperative hemodynamic instability (P = 0.015), postoperative CRP ≥154 mg/L (P = 0.014), and postoperative serum creatinine ≥177 μmol/L (P = 0.027). CONCLUSIONS In this single-center retrospective study, we demonstrated that preoperative hemodynamic instability, severe postoperative inflammation (CRP ≥154 mg/L) and acute renal failure (creatinine ≥177 μmol/L) were associated with a significant risk of mortality after pancreatic trauma.
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Affiliation(s)
- Chao Yang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, PR China
| | - Xinyu Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, PR China
| | - Cuili Wu
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, PR China
| | - Yongle Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, PR China
| | - Kai Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, PR China
| | - Weiwei Ding
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu Province, PR China; Division of Trauma and Surgical Intensive Care Unit, The First School of Clinical Medicine, Southern Medical University, Guangdong Province, PR China.
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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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Soon DSC, Leang YJ, Pilgrim CHC. Operative versus non-operative management of blunt pancreatic trauma: A systematic review. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618788111] [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]
Abstract
Introduction Motor vehicle crashes are common causes of blunt abdominal trauma in the 21st century. While splenic trauma occurs very frequently and thus there is a well-established treatment paradigm, traumatic pancreatic injuries are relatively infrequent, occurring in only 3–5% of traumas. This low incidence means physicians have reduced experience with this condition and there is still ongoing debate with regards to the best practice in managing pancreatic trauma. During severe trauma, the pancreas can be injured as a consequence of blunt and penetrating injury. This has an estimated mortality rate ranging from 9 to 34%. Methods A systematic review was performed using three scientific databases: Embase, Medline and Cochrane and in-line with the PRISMA statement. We included only articles published in English, available as full text and describing only adults. Keywords included: pancrea*, trauma, blunt, operative management and non-operative management. Results Three studies were found that directly compared operative versus non-operative management in blunt pancreatic trauma. Length of stay, mortality and rate of re-intervention were lower in the non-operative group compared to the operative group. However, the average grade of pancreatic injury was lower in the non-operative group compared to the operative group. Discussion Our results revealed that patients who undergo non-operative management tend to have lower grade of injuries and patients with higher grade of injury tend to be managed in an operative fashion. This could be likely due to the fact that higher grade of pancreatic injuries is often accompanied by other injuries such as hollow viscus injury and therefore require operative intervention. Conclusion Non-operative management is a safe approach for low-grade blunt pancreatic trauma without ductal injuries. However, more evidence is required to improve our understanding and treatment plans. We suggest a large international multicentre study combining data from multiple international trauma centres to collect adequate data.
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Affiliation(s)
- David SC Soon
- Department of Surgery, Peninsula Health, Frankston, Australia
| | - Yit J Leang
- Department of Surgery, Peninsula Health, Frankston, Australia
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Søreide K, Weiser TG, Parks RW. Clinical update on management of pancreatic trauma. HPB (Oxford) 2018; 20:1099-1108. [PMID: 30005994 DOI: 10.1016/j.hpb.2018.05.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma. METHODS Systematic literature review until May 2018. RESULTS Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries. CONCLUSION Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.
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Affiliation(s)
- Kjetil Søreide
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Clinical Medicine, University of Bergen, Norway; Department of Gastrointestinal Surgery, Stavanger University Hospital, Norway.
| | - Thomas G Weiser
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Stanford University Department of Surgery, Section of Trauma and Critical Care, Stanford, CA, USA
| | - Rowan W Parks
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK
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