Role of repeat computed tomography after emergency endoscopic retrograde pancreatography in the diagnosis of traumatic injury to pancreatic ducts

The management of pancreatic injuries

Pancreatic injuries are relatively uncommon, but considerable morbidity and mortality may result if associated vascular and duodenal injuries are present or if the extent of the injury is underestimated and appropriate intervention is delayed. Optimal management includes the need for early diagnosis and accurate definition of the site and extent of injury. Prognosis is influenced by the cause and complexity of the pancreatic injury, the amount of blood lost, duration of shock, the rapidity of resuscitation and the quality and appropriateness of surgical intervention. Early mortality results from uncontrolled or major bleeding due to associated injuries while late mortality is generally a consequence of infection or multiple organ failure. Initial management of pancreatic trauma is similar to that of any patient with a severe abdominal injury. Stable patients with a suspected pancreatic injury should have non-invasive imaging including a CT scan or MRI. Urgent laparotomy is required in patients with evidence of major intraperitoneal bleeding, associated visceral trauma, or peritonitis. Operative intervention is guided by the integrity of the main pancreatic duct. External drainage is adequate for parenchymal injuries with an intact duct, while duct injuries of the neck, body and tail require a distal pancreatectomy. Pancreatic head injuries are more complex. If the duodenum is reparable and the ampulla is intact, external drainage suffices. Rarely, complex injuries may require a pancreatoduodenectomy after damage control surgery if the patient has multiple injuries and is unstable. Postoperative pancreatic complications including fistula and pseudocysts are common but can usually be treated endoscopically.

Outcomes of hemodynamically stable patients with pancreatic injury after blunt abdominal trauma

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.

Endoscopic retrograde cholangiopancreatography in patients with pancreatic trauma

BACKGROUND

: Pancreatic injury occurs in from 3% to 12% of patients with abdominal trauma. In many instances, a lack of impressive findings in the first 24 hours leads to a delay in diagnosis. Because pancreatic duct disruption is the major cause of traumatic pancreatitis, we evaluated our experience with endoscopic retrograde cholangiopancreatography (ERCP) in patients suspected of having of having pancreatic injury.

METHODS

: We reviewed the medical records of 26 patients evaluated perioperatively by ERCP for suspected pancreatic duct injury. The examinations were performed in the endoscopy suite or radiography special procedures or operating rooms under direct fluoroscopic control using fiberoptic or videooptic duodenoscopes.

RESULTS

: Seventeen men and nine women with a mean age of 32.8 +/- 2.2 years suffered severe abdominal trauma. ERCP was performed in these patients a mean of 19 +/- 11.3 days after trauma. Seven patients underwent ERCP just before or at laparotomy. Eight of 26 (31%) patients were found to have intact pancreatic and bile ducts, whereas 18 (69%) patients had substantial findings unsuspected by pre-ERCP imaging. Nine of these 18 patients with documented ductal injury underwent endoscopic treatment alone without further surgical intervention, including pancreatic sphincterotomies and/or pancreatic ductal stenting.

CONCLUSIONS

: ERCP is feasible and strongly indicated in the care of many patients with pancreatic trauma. Patient care and overall surgical and hospital needs may be substantially impacted by the use of both diagnostic and therapeutic endoscopic retrograde colongiopancreatography.

Pancreatic trauma: diagnostic and therapeutic strategies

The management of pancreatic trauma provides trauma surgeons with diagnostic and therapeutic challenges. The two most important facts that must be established are the location of the injury in relation to the superior mesenteric artery and vein and the status of the main pancreatic duct. If a pancreatic injury is discovered at the time of exploration and no main ductal injury is found, debridement and wide drainage are adequate therapy regardless of the location of the injury. If the status of the duct cannot be confidently determined and the injury lies to the left of the vessels, a single attempt at cholecystocholangiography should be performed. If this is unsuccessful, distal pancreatectomy with splenectomy with no further attempts at ductal imaging are our treatments of choice. Splenic salvage may be considered in the pediatric population. If the injury lies to the right of the vessels and the status of the duct is not able to be diagnosed with thorough exploration, we recommend endoscopic retrograde cholangiopancreatography (ERCP), either intraoperatively or on an urgent basis postoperatively, with wide closed suction drainage prior to closure of the abdomen. If the ERCP shows intact pancreatic and common bile ducts, expectant management is warranted. If the duct is injured, the patient is returned to the operating room for debridement of the injury, oversewing of the proximal pancreatic duct, and a distal pancreaticojejunostomy. Use of ERCP to stent this injury type has been reported but has yet to be rigorously studied. If the ampulla is destroyed or the pancreatic head is devascularized, pancreaticoduodenectomy is required either at the original surgery or after patient stabilization if damage control laparotomy is necessary. If a stable trauma patient has findings on a computed tomography suggestive of an isolated pancreatic injury, we still recommend laparotomy using the previously mentioned algorithm. All patients with pancreatic injury should have feeding access placed intraoperatively beyond the ligament of Treitz, with our choice being a nasal-jejunal feeding tube. Postoperative pancreatic fistulae should be managed with adequate closed suction drainage, octreotide, and observation for a period of at least 4 to 8 weeks prior to contemplation of surgical intervention.

Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas

BACKGROUND

In the treatment of patients with pancreatic injury, the focus of attention is usually on main ductal injuries.

METHODS

To develop a classification system for pancreatic ductal injuries, we retrospectively analyzed blunt pancreatic injuries in 40 patients. We assessed the relationships between findings on pancreatography (36 endoscopic retrograde procedures and 4 transduodenal procedures), the treatment modality, and the clinical course.

RESULTS

Patients with class 1 injuries (radiographically normal ducts, n = 13) could be treated nonsurgically without major complications. Patients with class 2 injuries (branch injuries, n = 7), in whom contrast medium from ductal branches did not leak from the pancreatic parenchyma (class 2a, n = 3), could be treated nonsurgically. Patients with leaks into the retroperitoneal space (class 2b, n = 4) required at least a drainage laparotomy. Patients with class 3 injuries (main duct injuries, n = 20), including two patients in whom conservative treatment resulted in severe complications, required laparotomy.

CONCLUSION

This classification system for pancreatic ductal injuries may facilitate the selection of appropriate therapeutic modalities for patients with blunt pancreatic injury.

Pancreatectomia distal no trauma: estudo multicêntrico

No período de cinco anos, 87 doentes com trauma pancreático foram tratados por pancreatectomia corpo-caudal em cinco serviços de emergência. A idade variou de 7 a 64 anos (média de 28), sendo que 73 (84%) eram do sexo masculino. O principal mecanismo de trauma foi o ferimento penetrante em 72,5%, com ferimentos por projéteis de arma de fogo em 3/4 dos casos. Lesões associadas ocorreram em 96% dos doentes. A extensão da ressecção pancreática correspondeu de 30% a 70%, em 62% dos casos. O baço foi preservado em 45,6% dos 57 doentes que se apresentaram sem lesão esplênica. A taxa de complicações foi de 40,2%, sendo a fístula pancreática e a pancreatite pós-operatória as mais freqüentes. A mortalidade total foi de 12 doentes (13,7%). As conclusões deste estudo foram as seguintes: a) há relação nas taxas de morbidade com o mecanismo de lesão; b) a morbidade é mais freqüente em doentes com trauma fechado; c) não há diferença na incidência de complicações com o método de fechamento do pâncreas remanescente nem com a extensão da ressecção; d) não há relação da mortalidade com o mecanismo de trauma; e) há uma tendência no aumento da taxa de mortalidade no trauma fechado com presença de lesões associadas.

Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations

OBJECTIVE

The objective of this study was to elucidate the significance and limitations of serum amylase levels in the diagnosis of blunt injury to the pancreas.

SUMMARY BACKGROUND DATA

Several recently published reports of analyses of patients with blunt abdominal trauma have indicated that determination of the serum amylase level on admission seemed to be of little value in the diagnosis of acute injury to the pancreas. Few previous reports have described clearly the significance and the limitations of the serum amylase level in diagnosing injury to the pancreas.

METHODS

Retrospective analysis of 73 patients with blunt injury to the pancreas during 16-year period from February 1980 to January 1996 was performed. The factors analyzed in the current study included age, gender, time elapsed from injury to admission, hypotension on admission, type of injury to the pancreas, intra-abdominal- and intracranial-associated injuries, and death.

RESULTS

The serum amylase level was found to be abnormal in all patients admitted more than 3 hours after trauma. Various comparisons between patients with elevated (n = 61, 83.6%) and nonelevated (n = 12, 16.4%) serum amylase levels showed the statistical significance solely of the time elapsed from injury to admission (7 +/- 1.5 hours vs. 1.3 +/- 0.2 hour, p < 0.001). The major factor that influences the serum amylase level on admission appeared to be the time elapsed from injury to admission. Determination of the serum amylase level is not diagnostic within 3 hours or fewer after trauma, irrespective of the type of injury.

CONCLUSIONS

To avoid failure in the detection of pancreatic injury, the authors advocate determination of serum amylase levels more than 3 hours after trauma.