Surgical management of traumatic pancreatic injuries and their consequences.
Keywords:Pancreatic trauma, Pancreatectomy, Pancreatic fistula, Pseudocyst, Pancreatic abscess, Pancreatic necrosis
Background: Management of pancreatic trauma remains challenging due to difficulty in diagnosis and complexity of surgical interventions. In Egypt, reports on pancreatic trauma are scarce.
Methods: Medical records of adult patients with pancreatic trauma who were admitted at Sohag University Hospital (2012-2019) were retrospectively studied. Patients were categorized into group A of non-operative management (NOM), group B which required upfront exploratory laparotomy due to hemodynamic instability and group C in which surgical management was implemented after thorough preoperative assessment. Pancreatic injuries were ranked by the pancreas injury scale (PIS).
Results: Thirty-two patients (25 males and 7 females) were enrolled, and median age of 36 (range: 23-68) years. Twenty-eight patients (87.5%) had blunt trauma whereas penetrating injury occurred in 4 (12.5%). There were 9 patients in group A, 7 in group B and 16 in group C. High grades of pancreatic injury ≥3 occurred in 4 patients from group B and 5 from group C. Distal pancreatectomy was performed in 7 patients while central resection and panceatico-gastrostomy in one. Grade IV injury occurred only in one patient who received damage-control laparotomy. Post-operative complication were significantly increased in group B compared with C, in correlation worse hemodynamic status and increased severity of PIS. Post-operative mortality occurred in 2 patients (6%), both from group B. Late consequences included pancreatic pseudocyst (4 cases) and walled off pancreatic necrosis (2 cases).
Conclusions: High grades of pancreatic injury and hemodynamic instability correlate with worse outcome after surgery for pancreatic trauma.
Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:56.
Stewart, BT, Sandstrom CK, O’Keefe G, Balmadrid B, Johnson GE. Multidisciplinary Diagnosis and Management of Pancreatic Trauma. Dig Dis Interv. 2018;02:179-92.
Menahem B, Lim C, Lahat E, Salloum C, Osseis M, Lacaze L, et al. Conservative and surgical management of pancreatic trauma in adult patients. Hepatobiliary Surg Nutr. 2016;5:470-7.
Dai X, Lu C, Gao W. Current Diagnosis and Management of Pancreaticoduodenal Injury: A Concise Review. Clin Oncol Gen Oncol. 2017;2:1-5.
Iacono C, Zicari M, Conci S, Valdegamberi A, De Angelis M, Pedrazzani C, et al. Management of pancreatic trauma: A pancreatic surgeon’s point of view. Pancreatol Off J Int Assoc Pancreatol. 2016;16:302-8.
Del Vecchio Blanco G, Gesuale C, Varanese M, Monteleone G, Paoluzi OA. Idiopathic acute pancreatitis: a review on etiology and diagnostic work-up. Clin J Gastroenterol. 2019;12:511-24.
Kang WS, Park YC, Jo YG, Kim JC. Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center. Ann Surg Treat Res. 2018;95:29-36.
Nagesh NS, Gautham SG. Case Series Analysis of Blunt Pancreatic Injury in a Tertiary Center for a Period of 2 Years—Our Experience. Indian J Surg. 2019.
Sedik A, Ibrahim M, Zarrouq A, Elhoushy SW. A case with missed pancreatic injury with massive pancreatic ascites and severe traumatic pancreatic necrosis: a case report and literature review. Int Surg J. 2018;5:3156-60.
Leppäniemi A. Nonoperative management of solid abdominal organ injuries: From past to present. Scand J Surg. 2019;108:95-100.
Kumar A, Panda A, Gamanagatti S. Blunt pancreatic trauma: A persistent diagnostic conundrum? World J Radiol. 2016;8:159-73.
Bozdag Z, Kapan M, Ulger BV, Turkoglu A, Uslukaya O, Oguz A, et al. Factors affecting morbidity and mortality in pancreatic injuries. Eur J Trauma Emerg Surg. 2016;42:231-5.
Melamud K, LeBedis CA, Soto JA. Imaging of Pancreatic and Duodenal Trauma. Radiol Clin. 2015;53:757-71.
Papadoliopoulos I, Bourikos P, Chloptsios C, Ilias G, Moustakis E, Karanasiou V, et al. Pancreatic injury revealed in abdominal ultrasound: A case report. Ulus Travma Ve Acil Cerrahi Derg. 2009;15:396-8.
Lahiri R, Bhattacharya S. Pancreatic trauma. Ann R Coll Surg Engl. 2013;95:241-5.
Sharbidre KG, Galgano, SJ, Morgan DE. Traumatic pancreatitis. Abdom Radiol N. Y. 2020;45:1265-76.
Jurkovich GJ. Pancreatic trauma. J Trauma Acute Care Surg. 2020;88:19-24.
Soon DS, Leang, YJ, Pilgrim CH. Operative versus non-operative management of blunt pancreatic trauma: A systematic review. Trauma. 2019;21:252-8.
Ho VP, Patel NJ, Bokhari F, Madbak FG, Hambley JE, Yon JR, et al. Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82:185-99.
Lin BC, Chen RJ, Hwang TL. Lessons learned from isolated blunt major pancreatic injury: Surgical experience in one trauma centre. Injury. 2019;50:1522-8.
Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:187-96.
El-Badry AM, Ali MM. Combined liver-visceral resection for neoplastic lesions correlates with increased postoperative complications. Int Surg J. 2020;7:1335-41.
Singh RP, Mahajan A, Selhi JS, Garg N, Chahal H, Bajwa M. Management and outcome of patients with pancreatic trauma. Niger J Surg. 2017;23:11-4.
Dalsania R, Willingham FF. Treatment of walled-off pancreatic necrosis. Curr Opin Gastroenterol. 2019;35:478-82.
Ull C, Bensch S, Schildhauer TA, Swol J. Blunt Pancreatic Injury in Major Trauma: Decision-Making between Nonoperative and Operative Treatment. Case Rep Surg. 2018;6197261.
Byrge N, Heilburn M, Winkler N, Sommers D, Evans H, Lindsay M. LM, et al. An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain? J Trauma Acute Care Surg. 2018;85:435-43.
Serra F, Barbato G, Tazzioli G, Gelmini R. Pancreaticogastrostomy as reconstruction choice in pancreatic trauma surgery: Case report and review of the literature. Int J Surg Case Rep. 2019;65:102-6.
Du B, Wang X, Wang X, Shah S, Ke N. A rare case of central pancreatectomy for isolated complete pancreatic neck transection trauma. BMC Surg. 2019;19:91.
El-Badry AM, Redwan AA, Abusedera MA, Ali HM. Enveloped double purse-string versus conventional pancreatico-gastrostomy during Whipple procedure: comparative study at Sohag university onco-surgery program. Int Surg J. 2016;4:58-63.
Mungazi SG, Mbanje C, Chihaka O, Madziva N. Combined pancreatic and duodenal transection injury: A case report. Int J Surg Case Rep. 2017;39:285-7.
Petrone P, Moral Alvarez S, Gonzalez Perez M, Ceballos Esparragon J, Marini CP. Pancreatic trauma: Management and literature review. Cirugia Espanola. 2017;95:123-30.