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Sullivan TM, Sippel GJ, Gestrich-Thompson WV, Jensen AR, Burd RS. 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 PMCID: PMC10932928 DOI: 10.1097/ta.0000000000004107] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [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)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Genevieve J. Sippel
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | | | - Aaron R. Jensen
- Department of Surgery, University of California San Francisco, San Francisco, CA
- Division of Pediatric Surgery, UCSF Benioff Children’s Hospitals, San Francisco, CA
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
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Satyam S, Singh S, Sah PK. Disconnected Pancreatic Duct Syndrome: A Case Series. Euroasian J Hepatogastroenterol 2022; 12:60-63. [PMID: 35990868 PMCID: PMC9357522 DOI: 10.5005/jp-journals-10018-1357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Disconnected pancreatic duct syndrome (DPDS) is a condition where there is a ductal disconnection between viable secreting distal pancreatic tissues and the gastrointestinal tract. It may follow acute or chronic pancreatitis, abdominal trauma, and pancreatic surgery, leading to necrosis or structural disintegration of the pancreatic duct.
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Affiliation(s)
- Satyam Satyam
- Department of Radiodiagnosis, MAMC and LNH, New Delhi, India
- Satyam Satyam, Department of Radiodiagnosis, MAMC and LNH, New Delhi, India, e-mail:
| | - Sapna Singh
- Department of Radiodiagnosis, MAMC and LNH, New Delhi, India
| | - Punit Kumar Sah
- Department of Radiodiagnosis, MAMC and LNH, New Delhi, India
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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: 2.8] [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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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: 3.5] [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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Hosseininejad SM, Bozorgi F, Assadi T, Montazar SH, Jahanian F, Hoseini V, Shamsaee M, Tabarestani M. The predictive role of amylase and lipase levels on pancreas injury diagnosis in patients with blunt abdominal trauma. Horm Mol Biol Clin Investig 2020; 41:hmbci-2019-0066. [PMID: 32374282 DOI: 10.1515/hmbci-2019-0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 04/04/2020] [Indexed: 12/26/2022]
Abstract
Objectives Despite the low incidence of pancreatic injury in the abdominal blunt trauma (BTA), its early diagnosis is very important; since pancreatic injury is associated with high rates of morbidity and mortality. However, due to the high association of pancreatic injury with injury of other abdominal organs, its diagnosis may be delayed and complicated. The use of imaging modalities is also subject to limitations for reasons such as cost, unavailability, and harmfulness. Consequently, the present study aimed to investigate the predictive role of amylase and lipase enzyme levels in the final diagnosis of pancreatic injury in patients with BTA. Methods In a prospective diagnostic study, 384 patients with BTA referring to Imam Khomeini hospital of Sari (north of Iran) were enrolled according to the inclusion and exclusion criteria. Initial patient data including age and sex were recorded. Blood samples were analyzed in the laboratory to measure complete blood count (CBC), amylase and lipase enzyme levels. Patients were followed up during hospitalization and focal ultrasound for abdominal trauma (FAST), CT-Scan and laparotomy results were recorded. Finally, the data was analyzed using SPSS version 22. Results The level of amylase enzyme was significantly higher in males (p = 0.04), but the level of lipase enzyme was not significantly different between two genders (p > 0.05). The most common symptoms and signs in patients were pain, tenderness, and hematoma, respectively. The frequency of pancreatic injury in all patients with blunt abdominal trauma was 7.5% based of FAST, 7% based on CT-Scan and 12.4% based on laparotomy. Comparison of laboratory findings based on FAST, CT-Scan and laparotomy results showed that the level of amylase and lipase enzymes in patients with internal organ and pancreatic damage were higher than in patients without internal organ injury (p < 0.05). But based on FAST results; patients with pancreatic injury and injury of other organs had no significant difference (p > 0.05). However, comparison of laboratory findings based on CT-Scan and laparotomy results showed a significant increase in the level of amylase and lipase enzymes in patients with pancreatic trauma compared to patients with injury of other organs (p < 0.001). Conclusions The results of this study showed that pancreatic injury in blunt trauma is associated with a significant increase in levels of amylase and lipase enzymes. In addition, an increase in levels of amylase and lipase enzymes is associated with internal organ damage. Serum amylase and lipase levels can be used as useful biomarkers to decide whether to perform CT-Scan or laparotomy.
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Affiliation(s)
- Seyed Mohammad Hosseininejad
- Department of Emergency Medicine, Diabetes Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Farzad Bozorgi
- Department of Emergency Medicine, Gut And Liver Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Touraj Assadi
- Department of Emergency Medicine, Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Seyyed Hosein Montazar
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Fatemeh Jahanian
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Vahid Hoseini
- Department of Emergency Medicine, Gut And Liver Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Mahboobeh Shamsaee
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
| | - Mohammad Tabarestani
- Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Islamic Republic of Iran
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Abstract
Post-traumatic pancreatitis can develop secondary to blunt or penetrating abdominal trauma, post-endoscopic retrograde cholangiopancreatography, or following pancreatic surgery. Clinical findings are often nonspecific, and imaging findings can be subtle on presentation. Early diagnosis of pancreatic duct injury is critical and informs management strategy; imaging plays important role in diagnosis of ductal injury and identification of delayed complications such as retroperitoneal fluid collections, pancreatic fistula, ductal strictures, and recurrent pancreatitis. Delayed diagnosis of pancreatic injury is associated with high mortality and morbidity, and therefore, heightened clinical suspicion is important in order for the radiologist to effectively impact patient care. There are accepted scoring systems for classification of post-traumatic pancreatic injuries and these should be included in radiology reports. Pancreatitis following ERCP appears similar on imaging to other causes of acute pancreatitis unless concomitant perforation occurs. Postoperative pancreatitis may be difficult to diagnose given associated or overlapping expected postoperative findings. Postoperative pancreatic fistulas typically arise from either a leaking pancreatic resection surface or the pancreatoenteric anastomosis and are more common in patients with a "soft" pancreas. Preoperative imaging biomarkers like duct diameter, pancreatic glandular steatosis and parenchymal fibrosis can help predict risk of development of postoperative pancreatic fistula. This review will illustrate the imaging features and the most important imaging findings in patients with post-traumatic pancreatitis.
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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: 2.0] [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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Lin BC, Chen RJ, Hwang TL. Lessons learned from isolated blunt major pancreatic injury: Surgical experience in one trauma centre. Injury 2019; 50:1522-1528. [PMID: 31164222 DOI: 10.1016/j.injury.2019.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 05/25/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study was to present our surgical experience of isolated blunt major pancreatic injury (IBMPI), and to compare its characteristic outcomes with that of multi-organ injury. MATERIALS AND METHODS From 1994-2015, 31 patients with IBMPI and 54 patients with multi-organ injury, who underwent surgery, were retrospectively studied. RESULTS Of the 31 patients with IBMPI, 22 were male and 9 were female. The median age was 30 years (interquartile range, 20-38). Twenty-one patients were classified as the American Association for the Surgery of Trauma-Organ Injury Scale Grade III, and 10 patients as Grade IV. Patients with IBMPI had significantly lower shock-at-triage rates, lower injury severity scores, longer injury-to-surgery time, and shorter length of hospital stay than those with multi-organ injury. There were no statistically significant differences in sex, age, trauma mechanism, laboratory data, surgical procedures, and complications between the two groups. Eight patients with IBMPI underwent endoscopic retrograde pancreatography, and 5 patients with complete major pancreatic duct (MPD) disruption underwent pancreatectomy eventually. The remaining 3 patients had partial MPD injury and two of them received a pancreatic duct stent for the treatment of existing postoperative pancreatic fistula. Spleen-sacrificing distal pancreatectomy (SSDP) was performed in 13 patient with IBMPI, followed by spleen-preserving distal pancreatectomy (n = 12), peripancreatic drainage (n = 4), and central pancreatectomy with Roux-en-Y reconstruction (n = 2). The overall complication rates, related to the SSDP, SPDP, peripancreatic drainage, and central pancreatectomy, were 10/13 (77%), 4/12 (33%), 3/4 (75%), and 2/2 (100%), respectively. Three patients died resulting in a 10% mortality rate, and the other 16 patients developed intra-abdominal complications resulting in a 52% morbidity rate. In the subgroup analysis of the 25 patients who underwent distal pancreatectomy, SPDP was associated with a shorter injury-to-surgery time than SSDP. CONCLUSIONS Patients with IBMPI have longer injury-to-surgery times, compared to those with multi-organ injury. Of the distal pancreatectomy patients, the time interval from injury to surgery was a significant associated factor in preserving or sacrificing the spleen.
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Affiliation(s)
- Being-Chuan Lin
- Division of Trauma & Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan.
| | - Ray-Jade Chen
- Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Tsann-Long Hwang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan
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Rosenfeld EH, Vogel A, Russell RT, Maizlin I, Klinkner DB, Polites S, Gaines B, Leeper C, Anthony S, Waddell M, St Peter S, Juang D, Thakkar R, Drews J, Behrens B, Jafri M, Burd RS, Beaudin M, Carmant L, Falcone RA, Moody S, Naik-Mathuria BJ. Comparison of diagnostic imaging modalities for the evaluation of pancreatic duct injury in children: a multi-institutional analysis from the Pancreatic Trauma Study Group. Pediatr Surg Int 2018; 34:961-966. [PMID: 30074080 DOI: 10.1007/s00383-018-4309-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Determining the integrity of the pancreatic duct is important in high-grade pancreatic trauma to guide decision making for operative vs non-operative management. Computed tomography (CT) is generally an inadequate study for this purpose, and magnetic resonance cholangiopancreatography (MRCP) is sometimes obtained to gain additional information regarding the duct. The purpose of this multi-institutional study was to directly compare the results from CT and MRCP for evaluating pancreatic duct disruption in children with these rare injuries. METHODS Retrospective study of data obtained from eleven pediatric trauma centers from 2010 to 2015. Children up to age 18 with suspected blunt pancreatic duct injury who had both CT and MRCP within 1 week of injury were included. Imaging findings of both studies were directly compared and analyzed using descriptive statistics, Chi square, Wilcoxon rank-sum, and McNemar's tests. RESULTS Data were collected for 21 patients (mean age 7.8 years). The duct was visualized more often on MRCP than CT (48 vs 5%, p < 0.05). Duct disruption was confirmed more often on MRCP than CT (24 vs 0%), suspected based on secondary findings equally (38 vs 38%), and more often indeterminate on CT (62 vs 38%). Overall, MRCP was not superior to CT for determining duct integrity (62 vs 38%, p = 0.28). CONCLUSIONS In children with blunt pancreatic injury, MRCP is more useful than CT for identifying the pancreatic duct but may not be superior for confirmation of duct integrity. Endoscopic retrograde cholangiogram (ERCP) may be necessary to confirm duct disruption when considering pancreatic resection. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Eric H Rosenfeld
- Texas Children's Hospital and the Michael E DeBakey Department of Surgery, 6701 Fannin Street # 1210, Houston, TX, 77030, USA.
| | - Adam Vogel
- Texas Children's Hospital and the Michael E DeBakey Department of Surgery, 6701 Fannin Street # 1210, Houston, TX, 77030, USA
| | - Robert T Russell
- University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Ilan Maizlin
- University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | | | | | | | | | | | | | | | - David Juang
- Children's Mercy Hospital, Kansas City, MO, USA
| | | | - Joseph Drews
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Brandon Behrens
- Randall Children's Hospital at Legacy Emanuel Medical Center, Portland, OR, USA
| | - Mubeen Jafri
- Randall Children's Hospital at Legacy Emanuel Medical Center, Portland, OR, USA
| | | | - Marianne Beaudin
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | - Laurence Carmant
- Centre Hospitalier Universitaire Sainte-Justine, Montreal, QC, Canada
| | | | | | - Bindi J Naik-Mathuria
- Texas Children's Hospital and the Michael E DeBakey Department of Surgery, 6701 Fannin Street # 1210, Houston, TX, 77030, USA
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Lin BC, Chen RJ, Hwang TL. Spleen-preserving versus spleen-sacrificing distal pancreatectomy in adults with blunt major pancreatic injury. BJS Open 2018; 2:426-432. [PMID: 30511043 PMCID: PMC6253790 DOI: 10.1002/bjs5.89] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/30/2018] [Indexed: 12/26/2022] Open
Abstract
Background The aim of this study was to analyse outcomes of spleen‐preserving (SPDP) and spleen‐sacrificing (SSDP) distal pancreatectomy in adults with severe blunt pancreatic injuries. Methods This was an observational study of adult patients who underwent distal pancreatectomy for grade III or IV blunt pancreatic injury between 1991 and 2015. Outcomes of SPDP and SSDP were compared. Results Fifty‐one patients were included, of whom 23 underwent SPDP and 28 SSDP. The median Injury Severity Score (ISS) was 13·0 (i.q.r. 9·0–18·0). No significant differences were observed between the groups regarding sex, trauma mechanism, shock at triage, laboratory data, location, ISS, associated injury, length of stay, mortality or morbidity. Age (27·0 versus 36·5 years; P = 0·012) and time interval from injury to distal pancreatectomy (15·0 versus 44·0 h; P = 0·022) differed significantly between SPDP and SSDP groups respectively. The mortality rate was 4 per cent (1 of 23) versus 11 per cent (3 of 28) respectively (P = 0·617). Nine patients (39 per cent) developed abdominal morbidity after SPDP, compared with 17 (61 per cent) after SSPD (P = 0·125). In the SPDP group, eight patients had grade B postoperative pancreatic fistula (POPF), two of whom required further intervention. In the SSDP group, six of ten patients with grade B POPF required CT‐guided drainage, and a further five patients required reoperation for other causes. There were more reinterventions after SSDP: 11 of 28 (39 per cent) versus 3 of 23 (13 per cent) in the SPDP group (P = 0·037). Conclusion SPDP was performed more often in younger patients and at a shorter interval after severe blunt pancreatic injury. SPDP was associated with fewer reinterventions.
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Affiliation(s)
- B-C Lin
- Division of Trauma and Emergency Surgery, Department of Surgery Chang Gung University Tao-Yuan City Taiwan
| | - R-J Chen
- Department of Surgery Taipei Medical University Hospital Taipei Taiwan
| | - T-L Hwang
- Department of General Surgery, Chang Gung Memorial Hospital Chang Gung University Tao-Yuan City Taiwan
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Diagnostic and therapeutic role of endoscopic retrograde pancreatography in the management of traumatic pancreatic duct injury patients: Single center experience for 34 years. Int J Surg 2017; 42:152-157. [DOI: 10.1016/j.ijsu.2017.03.054] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/06/2017] [Accepted: 03/17/2017] [Indexed: 12/13/2022]
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Lin BC, Wong YC, Chen RJ, Liu NJ, Wu CH, Hwang TL, Hsu YP. Major pancreatic duct continuity is the crucial determinant in the management of blunt pancreatic injury: a pancreatographic classification. Surg Endosc 2017; 31:4201-4210. [PMID: 28281124 DOI: 10.1007/s00464-017-5478-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 02/15/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND To evaluate the management and outcomes of blunt pancreatic injuries based on the integrity of the major pancreatic duct (MPD). METHODS Between August 1996 and August 2015, 35 patients with blunt pancreatic injuries underwent endoscopic retrograde pancreatography (ERP). Medical charts were retrospectively reviewed for demography, ERP timing, imaging findings, management, and outcome. RESULTS Of the 35 patients, 21 were men and 14 were women, with ages ranging from 11 to 70 years. On the basis of the ERP findings, we propose a MPD injury classification as follows: class 1 indicates normal MPD; class 2, partial injury with intact MPD continuity; and class 3, complete injury with disrupted MPD continuity. Both classes 2 and 3 are subdivided into classes a, b, and c, which represent the pancreatic tail, body, and head, respectively. In this report, 14 cases belonged to class 1, 10 belonged to class 2, and 11 belonged to class 3. Of the 14 patients with class 1 injuries, 10 underwent nonsurgical treatment and 4 underwent pancreatic duct stenting. Of the 10 patients with class 2 injuries, 4 underwent nonsurgical treatment and 6 underwent pancreatic duct stenting. Two of the 11 patients with class 3 injuries underwent pancreatic duct stenting; one in the acute stage developed sepsis that led to death even after converting to distal pancreatectomy plus splenectomy. Of the 11 patients with class 3 injuries, spleen-preserving distal pancreatectomy was performed in 6, distal pancreatectomy plus splenectomy in 2, and Roux-en-Y pancreaticojejunostomy after central pancreatectomy in 2. The overall pancreatic-related morbidity rate was 60% and the mortality rate was 2.8%. CONCLUSION Based on our experience, class 1 and 2 injuries could be treated by nonsurgical means and pancreatic duct stenting could be an adjunctive therapy in class 2b and 2c injuries. Operation is warranted in class 3 injuries.
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Affiliation(s)
- Being-Chuan Lin
- Division of Trauma & Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei-Shan, Tao-Yuan City, 333, Taiwan, ROC.
| | - Yon-Cheong Wong
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan, ROC
| | - Ray-Jade Chen
- Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan, ROC
| | - Nai-Jen Liu
- Department of Gastroenterology, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan, ROC
| | - Cheng-Hsien Wu
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan, ROC
| | - Tsann-Long Hwang
- Department of General Surgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan City, Taiwan, ROC
| | - Yu-Pao Hsu
- Division of Trauma & Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei-Shan, Tao-Yuan City, 333, Taiwan, ROC
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15
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Affiliation(s)
- A N Smolyar
- Department of acute liver and pancreatic surgical diseases, Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
| | - K T Agakhanova
- Department of acute liver and pancreatic surgical diseases, Sklifosovsky Research Institute of Emergency Care, Moscow, Russia
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16
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Alsaad AA, Dhannoon SM, Phillips MB. Disconnected pancreatic duct syndrome: a multidisciplinary management dilemma. BMJ Case Rep 2016; 2016:bcr-2016-217099. [PMID: 27803085 DOI: 10.1136/bcr-2016-217099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Disconnected pancreatic duct syndrome is a circumferential interruption of the pancreatic duct. It usually occurs secondary to pancreatitis and carries significant diagnostic and management challenges. We present a case of disconnected pancreatic duct syndrome that represented a diagnostic and management dilemma for both medical and surgical teams. The aim of this article is to share a successful management experience of disconnected pancreatic duct syndrome with other physicians and to perform a brief but focused literature review on this challenging condition.
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Affiliation(s)
- Ali A Alsaad
- Department of Internal Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sarah M Dhannoon
- Department of Internal Medicine, University of Central Florida, Orlando, Florida, USA
| | - Michael B Phillips
- Department of Internal Medicine, Mayo Clinic Florida, Jacksonville, Florida, USA
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17
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Björnsson B, Kullman E, Gasslander T, Sandström P. Early endoscopic treatment of blunt traumatic pancreatic injury. Scand J Gastroenterol 2016; 50:1435-43. [PMID: 26096464 DOI: 10.3109/00365521.2015.1060627] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Blunt pancreatic trauma is a rare and challenging situation. In many cases, there are other associated injuries that mandate urgent operative treatment. Morbidity and mortality rates are high and complications after acute pancreatic resections are common. The diagnosis of pancreatic injuries can be difficult and often requires multimodal approach including Computed Tomography scans, Magnetic resonance imaging and Endoscopic retrograde cholangiopancreaticography (ERCP). The objective of this paper is to review the application of endoprothesis in the settings of pancreatic injury. A review of the English literature available was conducted and the experience of our centre described. While the classical recommended treatment of Grade III pancreatic injury (transection of the gland and the pancreatic duct in the body/tail) is surgical resection this approach carries high morbidity. ERCP was first reported as a diagnostic tool in the settings of pancreatic injury but has in recent years been used increasingly as a treatment option with promising results. This article reviews the literature on ERCP as treatment option for pancreatic injury and adds further to the limited number of cases reported that have been treated early after the trauma.
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Affiliation(s)
- Bergthor Björnsson
- Department of Surgery, County Council of Östergötland , Linköping , Sweden
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18
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Kumar A, Panda A, Gamanagatti S. Blunt pancreatic trauma: A persistent diagnostic conundrum? World J Radiol 2016; 8:159-173. [PMID: 26981225 PMCID: PMC4770178 DOI: 10.4329/wjr.v8.i2.159] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 12/15/2015] [Indexed: 02/06/2023] Open
Abstract
Blunt pancreatic trauma is an uncommon injury but has high morbidity and mortality. In modern era of trauma care, pancreatic trauma remains a persistent challenge to radiologists and surgeons alike. Early detection of pancreatic trauma is essential to prevent subsequent complications. However early pancreatic injury is often subtle on computed tomography (CT) and can be missed unless specifically looked for. Signs of pancreatic injury on CT include laceration, transection, bulky pancreas, heterogeneous enhancement, peripancreatic fluid and signs of pancreatitis. Pan-creatic ductal injury is a vital decision-making parameter as ductal injury is an indication for laparotomy. While lacerations involving more than half of pancreatic parenchyma are suggestive of ductal injury on CT, ductal injuries can be directly assessed on magnetic resonance imaging (MRI) or encoscopic retrograde cholangio-pancreatography. Pancreatic trauma also shows temporal evolution with increase in extent of injury with time. Hence early CT scans may underestimate the extent of injures and sequential imaging with CT or MRI is important in pancreatic trauma. Sequential imaging is also needed for successful non-operative management of pancreatic injury. Accurate early detection on initial CT and adopting a multimodality and sequential imaging strategy can improve outcome in pancreatic trauma.
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19
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Reply to “Revised Atlanta Classification for Acute Pancreatitis”. AJR Am J Roentgenol 2016; 206:W37. [DOI: 10.2214/ajr.15.15360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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20
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Moschetta M, Telegrafo M, Malagnino V, Mappa L, Ianora AAS, Dabbicco D, Margari A, Angelelli G. Pancreatic trauma: The role of computed tomography for guiding therapeutic approach. World J Radiol 2015; 7:415-420. [PMID: 26644827 PMCID: PMC4663380 DOI: 10.4329/wjr.v7.i11.415] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/12/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the role of computed tomography (CT) for diagnosing traumatic injuries of the pancreas and guiding the therapeutic approach.
METHODS: CT exams of 6740 patients admitted to our Emergency Department between May 2005 and January 2013 for abdominal trauma were retrospectively evaluated. Patients were identified through a search of our electronic archive system by using such terms as “pancreatic injury”, “pancreatic contusion”, “pancreatic laceration”, “peri-pancreatic fluid”, “pancreatic active bleeding”. All CT examinations were performed before and after the intravenous injection of contrast material using a 16-slice multidetector row computed tomography scanner. The data sets were retrospectively analyzed by two radiologists in consensus searching for specific signs of pancreatic injury (parenchymal fracture and laceration, focal or diffuse pancreatic enlargement/edema, pancreatic hematoma, active bleeding, fluid between splenic vein and pancreas) and non-specific signs (inflammatory changes in peri-pancreatic fat and mesentery, fluid surrounding the superior mesenteric artery, thickening of the left anterior renal fascia, pancreatic ductal dilatation, acute pseudocyst formation/peri-pancreatic fluid collection, fluid in the anterior and posterior pararenal spaces, fluid in transverse mesocolon and lesser sac, hemorrhage into peri-pancreatic fat, mesocolon and mesentery, extraperitoneal fluid, intra-peritoneal fluid).
RESULTS: One hundred and thirty-six/Six thousand seven hundred and forty (2%) patients showed CT signs of pancreatic trauma. Eight/one hundred and thirty-six (6%) patients underwent surgical treatment and the pancreatic injures were confirmed in all cases. Only in 6/8 patients treated with surgical approach, pancreatic duct damage was suggested in the radiological reports and surgically confirmed in all cases. In 128/136 (94%) patients who underwent non-operative treatment CT images showed pancreatic edema in 97 patients, hematoma in 31 patients, fluid between splenic vein and pancreas in 113 patients. Non-specific CT signs of pancreatic injuries were represented by peri-pancreatic fat stranding and mesentery fluid in 89% of cases, thickening of the left anterior renal fascia in 65%, pancreatic ductal dilatation in 18%, acute pseudocyst/peri-pancreatic fluid collection in 57%, fluid in the pararenal spaces in 45%, fluid in transverse mesocolon and lesser sac in 29%, hemorrhage into peri-pancreatic fat, mesocolon and mesentery in 66%, extraperitoneal fluid in 66%, intra-peritoneal fluid in 41% cases.
CONCLUSION: CT represents an accurate tool for diagnosing pancreatic trauma, provides useful information to plan therapeutic approach with a detection rate of 75% for recognizing ductal lesions.
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Abstract
CLINICAL/METHODOLOGICAL ISSUE The acute radiological diagnostics of polytrauma patients has become an essential part of the interdisciplinary treatment in the emergency room. The incidence of polytrauma patients with an injury severity score (ISS) >16 is approximately 450 cases/million inhabitants/year in Europe. Injuries of the parenchymal organs are of utmost importance for the prognosis and treatment of these patients. The injury patterns are complex and a great deal of experience is necessary to be able to obtain the correct diagnosis within minutes. This review article deals with the radiological diagnostics and grading of the severity of injuries to the spleen, liver, pancreas and kidneys. STANDARD RADIOLOGICAL METHODS The use of ultrasound for the evaluation of polytraumatized patients will be discussed. The most important trauma-associated findings for the above mentioned organs using multidetector computed tomography (MDCT) will be described and illustrated by dedicated case findings. METHODOLOGICAL INNOVATIONS Ultrasound contrast agents can supply valuable, additional diagnostic information in the evaluation of polytraumatized patients. Computed tomography has become established as the most relevant imaging modality in severe trauma. Innovative organ-adapted and contrast application protocols improve the diagnostic performance of MDCT. PRACTICAL RECOMMENDATIONS The use of focused assessment sonography for trauma (FAST) scanning as a screening tool is in agreement with the other clinical disciplines of the trauma team. The use of MDCT is trauma-dependent and the classification of the severity of the different parenchymal organ injuries is ultimately decisive for further treatment and prognosis of trauma victims.
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Affiliation(s)
- C R Krestan
- Abteilung für Allgemeine Radiologie und Kinderradiologie, Klinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien AKH, Währinger Gürtel 18-20, 1090, Wien, Österreich,
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22
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Sheikh F, Fallon S, Bisset G, Podberesky D, Zheng J, Orth R, Zhang W, Falcone RA, Naik-Mathuria B. Image-guided prediction of pseudocyst formation in pediatric pancreatic trauma. J Surg Res 2015; 193:513-8. [DOI: 10.1016/j.jss.2014.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 03/21/2014] [Accepted: 04/04/2014] [Indexed: 02/07/2023]
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Mahajan A, Kadavigere R, Sripathi S, Rodrigues GS, Rao VR, Koteshwar P. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury 2014; 45:1384-1393. [PMID: 24702828 DOI: 10.1016/j.injury.2014.02.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 01/28/2014] [Accepted: 02/06/2014] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date. METHODS A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations. RESULTS 33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n=28, 85%) vs. normal (n=5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3h. CONCLUSIONS Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.
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Affiliation(s)
- Abhishek Mahajan
- Department of Radiodiagnosis and Imaging, Tata Memorial Center, Mumbai 400012, India.
| | - Rajagopal Kadavigere
- Department of Radiodiagnosis and Imaging, Kasturba Medical College, Manipal 576104, India.
| | - Smiti Sripathi
- Department of Radiodiagnosis and Imaging, Kasturba Medical College, Manipal 576104, India.
| | | | - Vedula Rajanikanth Rao
- Department of Radiodiagnosis and Imaging, Kasturba Medical College, Manipal 576104, India.
| | - Prakashini Koteshwar
- Department of Radiodiagnosis and Imaging, Kasturba Medical College, Manipal 576104, India.
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24
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Lv HX, Zhong XY, Cui YF. Diagnosis and treatment of traumatic pancreatic injuries. Shijie Huaren Xiaohua Zazhi 2013; 21:1817-1822. [DOI: 10.11569/wcjd.v21.i19.1817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pancreatic trauma accounted for 1%-5% of all blunt abdominal injuries and 12% of penetrating abdominal injuries. Although pancreatic trauma is uncommon, its mortality is high. Early accurate diagnosis, selection of suitable means of treatment based on the degree of injury, and management of complications are issues that should be stressed in the treatment of pancreatic trauma. This article discusses the clinical diagnosis, treatment and complications of pancreatic trauma.
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25
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Kumar S, Sagar S, Subramanian A, Albert V, Pandey RM, Kapoor N. Evaluation of amylase and lipase levels in blunt trauma abdomen patients. J Emerg Trauma Shock 2013; 5:135-42. [PMID: 22787343 PMCID: PMC3391837 DOI: 10.4103/0974-2700.96482] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 06/06/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There are studies to prove the role of amylase and lipase estimation as a screening diagnostic tool to detect diseases apart from acute pancreatitis. However, there is sparse literature on the role of serum and urine amylase, lipase levels, etc to help predict the specific intra-abdominal injury after blunt trauma abdomen (BTA). AIM To elucidate the significance of elevation in the levels of amylase and lipase in serum and urine samples as reliable parameters for accurate diagnosis and management of blunt trauma to the abdomen. MATERIALS AND METHODS A prospective analysis was done on the trauma patients admitted in Jai Prakash Narayan Apex Trauma Center, AIIMS, with blunt abdomen trauma injuries over a period of six months. Blood and urine samples were collected on days 1, 3, and 5 of admission for the estimation of amylase and lipase, liver function tests, serum bicarbonates, urine routine microscopy for red blood cells, and complete hemogram. Clinical details such as time elapsed from injury to admission, type of injury, trauma score, and hypotension were noted. Patients were divided into groups according to the single or multiple organs injured and according to their hospital outcome (dead/discharged). Wilcoxon's Rank sum or Kruskal-Wallis tests were used to compare median values in two/three groups. Data analysis was performed using STATA 11.0 statistical software. RESULTS A total of 55 patients with median age 26 (range, 6-80) years, were enrolled in the study. Of these, 80% were males. Surgery was required for 20% of the patients. Out of 55 patients, 42 had isolated single organ injury [liver or spleen or gastrointestinal tract (GIT) or kidney]. Patients with pancreatic injury were excluded. In patients who suffered liver injuries, urine lipase levels on day 1, urine lipase/amylase ratio along with aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) on days 1, 3, and 5, were found to be significant. Day 1 serum amylase, AST, ALT, hemoglobin, and hematocrit levels were found significant in patients who had spleen injury. Serum amylase levels on day 5 and ALP on day 3 were significant in patients who had GIT injury. Urine amylase levels on day 5 were found to be statistically significant in patients who had kidney injury. In patients with isolated organ injury to the liver or spleen, the levels of urine amylase were elevated on day 1 and gradually decreased on days 3 and 5, whereas in patients with injury to GIT, the urine amylase levels were observed to gradually increase on days 3 and 5. CONCLUSION Although amylase and lipase levels in the serum and urine are not cost-effective clinical tools for routine diagnosis of extra-pancreatic abdominal injuries in BTA, but when coupled with other laboratory tests such as liver enzymes, they may be significant in predicting specific intra-abdominal injury.
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Affiliation(s)
- Subodh Kumar
- Department of Surgery, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
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26
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Evaluating blunt pancreatic trauma at whole body CT: current practices and future directions. Emerg Radiol 2013; 20:517-27. [DOI: 10.1007/s10140-013-1133-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 05/14/2013] [Indexed: 12/18/2022]
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27
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Gordon RW, Anderson SW, Ozonoff A, Rekhi S, Soto JA. Blunt pancreatic trauma: evaluation with MDCT technology. Emerg Radiol 2013; 20:259-66. [PMID: 23604978 DOI: 10.1007/s10140-013-1114-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 02/25/2013] [Indexed: 12/26/2022]
Abstract
The purpose of this paper is to determine the relative frequency of multi-detector CT (MDCT) findings of pancreatic injury in blunt trauma and to determine their diagnostic accuracy in predicting main pancreatic duct injury. Fifty-three patients (31 male, 22 female; mean 44.1 years) with blunt trauma and admission MDCT findings suspicious for pancreatic injury or who underwent MDCT and had a discharge diagnosis of pancreatic trauma were included in this study. Two radiologists reviewed all images and recorded findings suspicious for pancreatic injury, which were subsequently compared to surgical findings to generate diagnostic accuracy. MDCT imaging findings suggestive of pancreatic injury included low attenuation peripancreatic fluid (n = 51), hyperattenuating peripancreatic fluid (n = 13), pancreatic contusion (n = 7), active hemorrhage (n = 2), and pancreatic laceration (n = 16). Diagnostic accuracy of the various imaging findings varied for diagnosing main duct injury; there were highly sensitive, nonspecific imaging findings such as the presence of low attenuation peripancreatic fluid (sensitivity, 100 %; specificity 4.9 %) as well as insensitive, specific findings such as visualizing a pancreatic laceration involving >50 % of the parenchymal width (sensitivity, 50 %; specificity, 95.1 %). In the setting of blunt abdominal trauma, MDCT imaging findings can be grouped into two categories for determining integrity of the main pancreatic duct: indirect, highly sensitive but nonspecific findings and direct, specific but insensitive findings. Awareness of the clinical implications of the various MDCT imaging findings of pancreatic trauma is useful in interpreting their significance.
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Affiliation(s)
- Robert W Gordon
- Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
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Salvadori PS, Costa MC, Romano RFT, Galvão BVT, Monjardim RDF, Bretas EAS, Rios LT, Shigueoka DC, Caldana RP, D'Ippolito G. Quando a fase de equilíbrio pode ser suprimida nos exames de tomografia computadorizada de abdome? Radiol Bras 2013. [DOI: 10.1590/s0100-39842013000200008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar a necessidade de realização da fase de equilíbrio nos exames de tomografia computadorizada de abdome. MATERIAIS E MÉTODOS: Realizou-se estudo retrospectivo, transversal e observacional, avaliando 219 exames consecutivos de tomografia computadorizada de abdome com contraste intravenoso, realizados num período de três meses, com diversas indicações clínicas. Para cada exame foram emitidos dois pareceres, um avaliando o exame sem a fase de equilíbrio (primeira análise) e o outro avaliando todas as fases em conjunto (segunda análise). Ao final de cada avaliação, foi estabelecido se houve mudança nos diagnósticos principais e secundários, entre a primeira e a segunda análise. Foi utilizada a extensão do teste exato de Fisher para avaliar a modificação dos diagnósticos principais (p < 0,05 como significante). RESULTADOS: Entre os 219 casos avaliados, a supressão da fase de equilíbrio provocou alteração no diagnóstico principal em apenas um exame (0,46%; p > 0,999). Com relação aos diagnósticos secundários, cinco exames (2,3%) foram modificados. CONCLUSÃO: Para indicações clínicas como estadiamento tumoral, abdome agudo e pesquisa de coleção abdominal, a fase de equilíbrio não acrescenta contribuição diagnóstica expressiva, podendo ser suprimida dos protocolos de exame.
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Abstract
The morbidity, mortality, and economic costs resulting from trauma in general, and blunt abdominal trauma in particular, are substantial. The "panscan" (computed tomographic [CT] examination of the head, neck, chest, abdomen, and pelvis) has become an essential element in the early evaluation and decision-making algorithm for hemodynamically stable patients who sustained abdominal trauma. CT has virtually replaced diagnostic peritoneal lavage for the detection of important injuries. Over the past decade, substantial hardware and software developments in CT technology, especially the introduction and refinement of multidetector scanners, have expanded the versatility of CT for examination of the polytrauma patient in multiple facets: higher spatial resolution, faster image acquisition and reconstruction, and improved patient safety (optimization of radiation delivery methods). In this article, the authors review the elements of multidetector CT technique that are currently relevant for evaluating blunt abdominal trauma and describe the most important CT signs of trauma in the various organs. Because conservative nonsurgical therapy is preferred for all but the most severe injuries affecting the solid viscera, the authors emphasize the CT findings that are indications for direct therapeutic intervention.
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Affiliation(s)
- Jorge A Soto
- Department of Radiology, Boston University Medical Center, FGH Building, 3rd Floor, 820 Harrison Ave, Boston, MA 02118, USA.
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30
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Lee PH, Lee SK, Kim GU, Hong SK, Kim JH, Hyun YS, Park DH, Lee SS, Seo DW, Kim MH. Outcomes of hemodynamically stable patients with pancreatic injury after blunt abdominal trauma. Pancreatology 2012; 12:487-92. [PMID: 23217286 DOI: 10.1016/j.pan.2012.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 07/17/2012] [Accepted: 09/21/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND To date there is no systematical report about blunt pancreatic injury focused on hemodynamically stable patients. This study reports on our experience in this rare subgroup at a tertiary referral hospital. METHODS A total of 58 adult patients were identified during a 10-year period and their clinical data were analyzed. Injury to the main pancreatic duct (MPD) was basically confirmed by pancreatography or surgical findings. RESULTS MPD disruption was confirmed in 36 patients (62%) and was more frequent in the pancreatic neck and body. The median time from trauma to confirmation was 14 days [interquartile range (IQR) 3-23 days] including time from admission to confirmation of 10.5 days [IQR 3-20 days]. Patients with MPD injury showed higher injury severity score, more frequent pancreas-specific complications and longer hospital stays. The sensitivity and specificity of initial computed tomography (CT) for MPD injury were 63.9% (23/36) and 81.8% (18/22), respectively. The mortality rate was 7%, and all deaths were directly attributed to pancreatic injury. Complications occurred in 22 patients (37%) and 17 developed during hospitalization. Time from trauma to confirmation of MPD disruption (odds ratio 1.132; 95% confidence interval 1.021-1.255, P=0.019) was the only independent factor associated with unfavorable events among patients with high-grade injury. CONCLUSIONS MPD injury was not infrequent in hemodynamically stable patients. Physicians were more responsible for the delay in diagnosis of MPD disruption, which was primarily associated with adverse outcomes. A rapid, multidisciplinary approach may lead to better outcomes in hemodynamically stable patients with blunt pancreatic injury.
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Affiliation(s)
- Pil Hyung Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Ito Y, Kenmochi T, Irino T, Egawa T, Hayashi S, Nagashima A, Hiroe N, Kitano M, Kitagawa Y. Endoscopic management of pancreatic duct injury by endoscopic stent placement: a case report and literature review. World J Emerg Surg 2012; 7:21. [PMID: 22788538 PMCID: PMC3422996 DOI: 10.1186/1749-7922-7-21] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 07/12/2012] [Indexed: 12/26/2022] Open
Abstract
Recently, the diagnostic evaluation of pancreatic injury has improved dramatically. On the other hand, it is occasionally difficult to diagnose pancreatic injury, because there are no specific signs, symptoms, or laboratory findings. Radiological imaging also often fails to identify pancreatic injury in the acute phase. Delayed diagnosis results in significant morbidity and mortality. Most cases of pancreatic injury with suspicion or pancreatic duct disruption require surgery. Endoscopic retrograde cholangiopancreatography is one of the most accurate modalities for ductal evaluation and therapy and might enable one to avoid unnecessary surgery. We describe endoscopic management of pancreatic duct injury by endoscopic stent placement. A 45-year-old woman was admitted after a traffic accident. A computed tomography scan showed pancreatic parenchyma disruption at the pancreatic head. Endoscopic retrograde cholangiopancreatography demonstrated disruption of the pancreatic duct with extravasation into the peripancreatic fluid collection. A 5-French endoscopic nasopancreatic drainage (ENPD) tube was placed. Her symptoms dramatically improved. ENPD tube was exchanged for a 5-French 5-cm pancreatic stent. Subsequent follow-up CT revealed remarkable improvement. On the 26th day, the patient was discharged from the hospital without symptoms or complications. In this report, a pancreatic stent may lead to rapid clinical improvement and enable surgery to be avoided. On the other hand, the reported complications of long-term follow-up make the role of stenting uncertain. Thus, close attention should be paid to stenting management in the follow-up period. A pancreatic stent is useful for pancreatic ductal injury. If pancreatic ductal injury is managed appropriately, a pancreatic stent may improve the clinical condition, and also prevent unnecessary surgery.
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Affiliation(s)
- Yasuhiro Ito
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1, Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa, 230-8765, Japan.
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Affiliation(s)
- JML Williamson
- Department of Surgery, Bristol Royal Infirmary, University Hospitals Bristol NHS Trust, Bristol BS2 8HW
| | - RCN Williamson
- Department of Hepato-pancreato-biliary Surgery, Hammersmith Hospital, London
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Pata G, Casella C, Di Betta E, Grazioli L, Salerni B. Extension of nonoperative management of blunt pancreatic trauma to include grade III injuries: a safety analysis. World J Surg 2009; 33:1611-1617. [PMID: 19495865 DOI: 10.1007/s00268-009-0082-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In hemodynamically stable patients after blunt pancreatic trauma, the main pancreatic duct (MPD) disruption (American Association for the Surgery of Trauma [AAST] grade III-IV-V lesions) is usually treated surgically or by endoscopic stent placement, whereas injuries without duct involvement (grade I-II) are liable to medical treatment. To date, no evidence has been reported regarding nonoperative management (NoM) of grade III injuries. We aimed to evaluate the safety of extending medical management to include cases of distal MPD involvement (grade III). PATIENTS AND METHODS Data were collected on patients admitted after blunt pancreatic trauma between January 1999 and December 2007. Patients exhibiting hemodynamic instability or hollow organ perforations were excluded from this study, as they were surgically managed. In all remaining cases NoM was attempted. Antibiotic prophylaxis and early total enteral nutrition were routinely adopted. Grade III patients received octreotide during hospitalization and for 6 months after discharge. RESULTS Eleven patients (2 with grade I injury, 3 with grade II injury, and 6 with grade III injury, all diagnosed by contrast-enhanced helical CT) were included. Nonsurgical management was carried out in all of these patients. Among grade III patients, one developed a peripancreatic abscess; another, a pancreatic fistula. Both were successfully treated nonoperatively. The average length of hospital stay was similar in grade I-II and grade III patients. After a median follow-up of 57 months no mortality or pancreatic sequelae had occurred. CONCLUSIONS Under the aforementioned conditions, an attempt to extend NoM to include patients with AAST-grade III lesions can be justified. However, such a strategy demands continuous patient monitoring, because should the case worsen, surgery might become necessary.
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Affiliation(s)
- Giacomo Pata
- Department of Medical and Surgical Sciences, 1st Division of General Surgery, University of Brescia, Viale Europa, 11, 25123, Brescia, Italy.
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Rekhi S, Anderson SW, Rhea JT, Soto JA. Imaging of blunt pancreatic trauma. Emerg Radiol 2009; 17:13-9. [PMID: 19396480 DOI: 10.1007/s10140-009-0811-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 03/30/2009] [Indexed: 12/26/2022]
Abstract
Blunt pancreatic trauma is an exceedingly rare but life-threatening injury with significant mortality. Computed tomography (CT) is commonly employed as the initial imaging modality in blunt trauma patients and affords a timely diagnosis of pancreatic trauma. The CT findings of pancreatic trauma can be broadly categorized as direct signs, such as a pancreatic laceration, which tend to be specific but lack sensitivity and indirect signs, such as peripancreatic fluid, which tend to be sensitive but lack specificity. In patients with equivocal CT findings or ongoing clinical suspicion of pancreatic trauma, magnetic resonance cholangiopancreatography (MRCP) may be employed for further evaluation. The integrity of the main pancreatic duct is of crucial importance, and though injury of the duct may be strongly suggested upon initial CT, MRCP provides clear delineation of the duct and any potential injuries. This article aims to review and illustrate the CT and magnetic resonance imaging findings of blunt pancreatic trauma and delineate the integration of these modalities into the appropriate imaging triage of severely injured blunt trauma patients.
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Affiliation(s)
- Satinder Rekhi
- Department of Radiology, Boston University Medical Center, Boston, MA, USA
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