The current management of pancreatic trauma

Pancreaticodudonectomy in trauma: One or two stages?

INTRODUCTION

Duodenopancreatic trauma is rare and presents high morbidity and mortality rates. Pancreaticoduodenectomy (PD) is the only possible treatment indicated for the most complex injuries (grades IV and V). Although, it is commonly a one-stage procedure, damage control surgery corroborates with a two-stage PD performed on unstable trauma victims.

OBJECTIVES

Compare the mortality rate of one and two-stage PD in trauma patients.

MATERIALS AND METHODS

A systematic electronic search of PubMed, Elsevier, LILACS, Scielo, and Capes was conducted on all studies written in English, Portuguese and Spanish with no restriction to publication dates. Review articles, case reports, editorials, animal studies, pediatric and non-trauma scenarios were excluded.

RESULTS

We selected twenty-two publications, with a total of 149 duodenopancreatic trauma victims who underwent PD, with an overall mortality rate of 42 patients (28.2%). Two-stage PD was exclusively performed on unstable patients (N = 31) with a mortality rate of 38.7%. In a sample of 79 patients submitted to a one-stage PD, 38 patients (48.1%) were unstable with a mortality rate of 34.2%. One-stage PD for stable patients had a mortality rate of 14.6% DISCUSSION: Since 1983, hemodynamic state impacts on surgery methods and strategies for trauma patients. Prior to that, one stage PD was not restricted to stable patients.

CONCLUSION

There were no differences in mortality rates when comparing two and one-stage PD in hemodynamic unstable patients, who had duodenopancreatic lesions (grades IV or V).

Outcomes after Distal Pancreatectomy for Trauma in the Modern Era

Multiple stump closure techniques after distal pancreatectomy (DP) for trauma have been described, and all are associated with a significant fistula rate. With increasing emphasis on abbreviated laparotomy, stapled pancreatectomy has become more common. This study describes the outcomes of patients with different closure techniques of the pancreatic stump after resection following pancreatic trauma. Retrospective analysis of 50 trauma patients, who sustained grade III pancreatic injuries with subsequent DP and stapled stump closure, were conducted from 1995 to 2011. Demographic, operative, and outcome data were analyzed to characterize patients, and to directly compare closure techniques. After 12 patients were excluded because of early death (<72 hours), final analyses included 38 patients: 19 (50%) had stapled closure alone and 19 (50%) had stapling with adjunct, including additional closure with sutures, fibrin sealants, or a combination of sutures with fibrin sealants/omental coverage. Twenty-four patients (63%) had postoperative complications, most commonly pancreatic fistula (n = 11, 29%). There were no significant differences with regard to pancreatic fistula or other abdominal complications between closure groups, or were any factors associated with increased likelihood of complications. DP remains a morbid operation after trauma regardless of closure technique. Stapled closure alone is perhaps the method of choice in this setting due to the time constraints directly related to outcomes.

Morbidity and mortality after distal pancreatectomy for trauma: a critical appraisal of 107 consecutive patients undergoing resection at a Level 1 Trauma Centre

BACKGROUND

This study evaluated 30-day morbidity and mortality and assessed pancreas-specific complications in patients with major pancreatic injuries who underwent a distal pancreatectomy.

STUDY DESIGN

Records of 107 consecutive patients who underwent a distal pancreatectomy at a Level 1 Trauma Centre in Cape Town between January 1982 and December 2011 were reviewed. Primary endpoints were postoperative morbidity and death. Complications were graded according to the Clavien-Dindo severity classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions.

RESULTS

A total of 107 patients [94 men, median age 26, median RTS 7.8, 69 penetrating injuries (63 gunshot wounds, 6 stabs wounds), 38 blunt injuries] underwent distal pancreatectomy. Overall mortality was 12%, 16% for gunshot injuries, 8% for blunt trauma and 0% in patients who had stab wounds. Eighty patients had a post-operative complication. A pancreatic leak (n=26) was the most common pancreatic related complication. Median postoperative stay in 28 patients with no or grade I complications was 9 days; in 11 patients with grade II complications was 18 days; in 14 grade IIIa, 31 days; in 19 grade IIIb, 38 days; in 8 grade IVa, 33 days in 14 grade IVb, and in 13 grade V the duration of postoperative stay was 14±39.4 days.

CONCLUSIONS

Overall mortality for distal pancreatectomy was 12%. Pancreatic leak was a common cause of morbidity. Length of hospitalisation increased with increasing Clavien-Dindo severity grading. There was a significant difference in the duration of hospitalisation in patients with no or grade I complications compared to those with grade II-IV injuries (p<0.05).