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Ball CG, Biffl WL, Moore EE, Hagopian EJ. Should surgeon-performed intraoperative ultrasound be the preferred test for detecting main pancreatic duct injuries in operative trauma cases? J Trauma Acute Care Surg 2024; 96:461-465. [PMID: 37599421 DOI: 10.1097/ta.0000000000004107] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND The diagnostic performance of multiple tests for detecting the presence of a main pancreatic duct injury remains poor. Given the central importance of main duct integrity for both subsequent treatment algorithms and patient outcomes, poor test reliability is problematic. The primary aim was to evaluate the comparative test performance of computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative ultrasound (IOUS) for detecting main pancreatic duct injuries. METHODS All severely injured adult patients with pancreatic trauma (2010-2021) were evaluated. Patients who received an IOUS pancreas-focused evaluation, with Grades III, IV, and V injuries (main duct injury) were compared with those with Grade I and Grade II trauma (no main duct injury). Test performances were analyzed. RESULTS Of 248 pancreatic injuries, 74 underwent an IOUS. The additional mix of diagnostic studies (CT, MRCP, ERCP) was variable across grade of injury. Of these 74 IOUS cases for pancreatic injuries, 48 (64.8%) were confirmed as Grades III, IV, or V main duct injuries. The patients were predominantly young (median age = 33, IQR:21-45) blunt injured (70%) males (74%) with severe injury demographics (injury severity score = 28, (IQR:19-36); 30% hemodynamic instability; 91% synchronous intra-abdominal injuries). Thirty-five percent of patients required damage-control surgery. Patient outcomes included a median 13-day hospital length of stay and 1% mortality rate. Test performance was variable across groups (CT = 58% sensitive/77% specific; MRCP = 71% sensitive/100% specific; ERCP = 100% sensitive; IOUS = 98% sensitive/100% specific). CONCLUSION Intraoperative ultrasound is a highly sensitive and specific test for detecting main pancreatic duct injuries. This technology is simple to learn, readily available, and should be considered in patients who require concurrent non-damage-control abdominal operations. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level III.
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Affiliation(s)
- Chad G Ball
- From the Department of Surgery (C.G.B.), University of Calgary, Calgary, Alberta, Canada; Department of surgery, Division of general surgery, Scripps Clinic Medical Group (W.L.B.), La Jolla, California; Department of surgery, Division of general surgery, University of Colorado (E.E.M.), Denver, Colorado; Department of surgery, Division of general surgery, Hackensack Meridian School of Medicine (E.J.H.), Nutley, New Jersey
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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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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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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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Ball CG. Getting going: Incorporating ultrasound into an HPB practice. Surg Open Sci 2022; 8:47-49. [PMID: 35308135 PMCID: PMC8927842 DOI: 10.1016/j.sopen.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/25/2022] [Indexed: 11/15/2022] Open
Abstract
The incorporation of ultrasound into a hepatopancreatobiliary surgical practice is both exciting and potentially intimidating. Although it is relatively straightforward to obtain detailed intraoperative ultrasound training from a small variety of formal programs, didactic curriculum, and mentorship experiences, seamless integration of this new knowledge into a hepatopancreatobiliary practice can be more challenging than expected. Although this is particularly true when a graduate begins a new practice, it is also relevant when incorporating hepatopancreatobiliary ultrasound into a mature group practice environment. This review outlines knowing your environment, certification and competency, credentialing and privileging, transition to independent practice, and maintaining competence.
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Affiliation(s)
- Chad G. Ball
- Corresponding author: Tel.: + 1 403 944 3417; fax: + 1 403 944 8799.
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