Management of blunt major pancreatic injury

BACKGROUND: Major duct injury is the principal determinant of outcome for patients with pancreatic trauma, and there are a number of therapeutic choices available specific to the location of the insult. We report a series of blunt major pancreatic injury cases, with a review of the different procedures used and a discussion of the results. METHODS: A total of 48 cases of blunt major pancreatic injury treated during a 10-year period at one trauma center were reviewed retrospectively. Diagnosis and assessment of injury severity were based on imaging studies and proved by surgical findings. Charts were reviewed to establish the mechanism of injury, surgical indications and imaging studies, management strategy, and outcome. RESULTS: Of the 32 grade III patients, 19 underwent distal pancreatectomy with splenectomy, 8 had pancreatectomy with preservation of the spleen, and 2 received a pancreatic duct stent, with the remaining 3 individuals undergoing nonsurgical treatment, pancreaticojejunostomy, and drainage alone, respectively. The grade III complication rate was 60.6%. Of the 14 grade IV patients, 4 underwent drainage alone because of the severity of the associated injuries, 4 underwent pancreaticojejunostomy, 3 had distal pancreatectomy with splenectomy, and 1 underwent distal pancreatectomy. The two remaining patients received a pancreatic duct stent. The grade IV complication rate was 53.8%. The Whipple procedure was performed for two grade V patients; one died subsequently. For all 48 patients, intraabdominal abscess was the most common morbidity (n = 11) followed, in order of prevalence, by major duct stricture (n = 4), pancreatitis (n = 2), pseudocyst (n = 2), pancreatic fistula (n = 1), and biliary fistula (n = 1). All stented cases developed complications, with one dying and three experiencing major duct stricture. CONCLUSION: The complication rate for our cases of blunt major pancreatic injury was high (62.2%), especially when treatment was delayed more than 24 hours; the same result was also noted for cases transferred from other institutions. Distal pancreatectomy with spleen preservation had a lower complication rate (22.2%) compared with other procedures and is suggested for grade III and grade IV injuries. Magnetic resonance pancreatography was unreliable early after injury but was effective in the chronic stage. Although pancreatic duct stenting can be used to treat posttraumatic pancreatic fistula and pseudocyst, the major duct stricture in the chronic stage of recovery and the risk of sepsis in the acute stage must be overcome.     

Pancreatic transection from blunt abdominal trauma: early versus delayed diagnosis and surgical management

BACKGROUND AND AIMS: Pancreatic trauma is relatively uncommon, but carries high morbidity and mortality rates, especially when diagnosis is delayed or inappropriate surgery is attempted. PATIENT MATERIAL: The clinical course and surgical management of 14 patients with distal pancreatic transection or severe laceration with or without main pancreatic duct (MPD) injury caused by blunt abdominal trauma were analyzed in a university teaching hospital. The average age of the 14 patients (12 male, 2 female) was 28.9 years (range 5-56). Six patients had isolated pancreatic trauma, and intra-abdominal and extra-abdominal (mean 0.8) injuries associated with pancreatic transection were seen in the other 8 patients. RESULTS: Nine patients were diagnosed and operated on within the first 24 h. Eight of them underwent transection of the gland with MPD injury; distal pancreatectomy with splenectomy was performed in 3 and without splenectomy in 2, distal pancreatogastrostomy in 1, and - due to associated duodenal laceration and/or contusion of the pancreatic head - pylorus-preserving pancreatoduodenectomy in 2. In 1 case (grade II laceration) only external drainage was necessary. All the patients with early, correctly diagnosed parenchymal and ductal injury survived. Only 1 patient required reoperation due to haemorrhage after pancreatoduodenectomy. The other 5 cases were referred elsewhere after initial treatment, and all of them underwent some kind of external drainage. Three had undetected MPD injury, and in the other 2 cases the parenchymal lesions were either underestimated or missed. All of these cases required subsequent resection (1), internal drainage due to fistula (2), or drainage of developed abscess (2). Three of them had severe septic and pulmonary complications; 1 patient with MPD injury was lost to follow-up. CONCLUSION: Patients requiring delayed surgical intervention after an unsuccessful period of observation or a subsequent operation due to undetected MPD injury demonstrated a higher rate of pancreas-specific mortality and morbidity.     

Resection versus drainage in the management of patients with AAST-OIS grade IV blunt pancreatic injury: A single trauma centre experience

IntroductionWe aimed to compare outcomes of pancreatic resection with that of peripancreatic drainage for American Association for the Surgery of Trauma–Organ Injury Scale (AAST-OIS) grade IV blunt pancreatic injury in order to determine the optimal treatment method.Materials and methodsNineteen surgical patients with AAST-OIS grade IV blunt pancreatic injury between 1994 and 2016 were retrospectively studied.ResultsAmong the 19 patients, 14 were men and 5 were women (median age: 33 years). Twelve patients underwent pancreatic resection (spleen-sacrificing distal pancreatectomy, n = 6; spleen-preserving distal pancreatectomy, n = 3; and central pancreatectomy with Roux-en-Y anastomosis, n = 3), and seven underwent peripancreatic drainage. After comparing these two groups, no significant differences were found in terms of gender, shock at triage, laboratory data, injury severity score, associated injury, length of hospital stay, and complication. The only significant difference was that in the drainage group, the duration from injury to surgery was longer than that from injury to resection (median, 48 hours vs. 24 hours; P = 0.036). In the drainage group, three patients required reoperation, and another three required further pancreatic duct stent therapy.ConclusionsIn the surgery of the grade IV blunt pancreatic injury, pancreatic resection is warranted in early, conclusive MPD injury; if surgery is delayed or MPD injury has not been clearly assessed, peripancreatic drainage is an alternative method. However, peripancreatic drainage alone is not adequate and further pancreatic duct stent or reoperation is required. Further studies should be conducted to confirm our conclusions.     

Blunt pancreatic trauma in children

Purpose

To report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies.

Methods

Ten children admitted over the last 10 years with pancreatic blunt trauma were included in the present series.

Results

The average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8?C14 days and no complications during the 1-year follow-up period.

Conclusion

The present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.     

Long-term results of endoscopic stent in the management of blunt major pancreatic duct injury

Background Pancreatic stents can be used to treat a variety of acute and chronic pancreatic lesions. Sporadic successful trials in trauma patients have been reported. To our knowledge, however, a series with long-term follow-up has not previously been reported. We treated six patients in a 6-year period and report the long-term results. Methods From February 1999 to February 2005, six blunt-trauma patients with major pancreatic duct disruption were treated with pancreatic duct stent at a single trauma center. Assessment of injury severity and diagnosis were based on abdominal computed tomography (CT) and proved by endoscopic retrograde pancreatography (ERP), with chart review used to establish mechanism of injury, timing of ERP, and stent placement, as well as the long-term outcome. Results Three of the six injuries were classified AAST grade III and three were grade IV; the interval to ERP with stent placement ranged from 8 hours to 22 days after the injury. One patient developed sepsis and died. One patient’s stent could be removed early (52 days post-stenting) with mild ductal stricture, whereas the other four were complicated by severe ductal stricture that required repeated and prolonged stenting treatment. Removal of the stents was only possible in three of these four cases (at 12, 19, and 39 months, respectively), with stent dislodgment in the pancreatic duct occurring in another. Conclusions Stent therapy may avoid surgery in the acute trauma stage, and may be preserved as another choice for acute grade IV pancreatic injury. However, variant outcome and long-term ductal stricture reveal that the role of pancreatic duct stent is uncertain and may not be suitable for acute grade III pancreatic injury. However, it needs more clinical data to define the value in the acute blunt pancreatic duct injury.     

Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: preliminary findings

BACKGROUND: The purpose of this study was to determine the utility of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of pancreatic duct trauma and pancreas-specific complications. METHODS: Ten hemodynamically stable patients with clinically suspected pancreatic injury related to blunt abdominal trauma (n = 8), penetrating trauma (n = 1), or iatrogenic trauma (n = 1) underwent MRCP. Two abdominal radiologists conducted a review of the MRCPs to assess for the presence or absence of pancreatic duct trauma and pancreas-specific complications such as pseudocysts. The MRCP findings were correlated with endoscopic retrograde cholangiopancreatograms (n = 2), surgical findings (n = 1), computed tomographic scans (n = 10), and with clinical, biochemical or imaging follow-up (n = 10). RESULTS: Diagnostic quality MRCPs were obtained in each of the 10 patients. A mean imaging time of 5 minutes was required to perform the MRCPs. Pancreatic duct injuries were detected in four patients; pseudocysts were detected in three of these four patients. The pancreatic duct injuries in three patients were acute or subacute. In one of the three patients, disruption of a side branch of the pancreatic duct diagnosed with MRCP was not detected with endoscopic retrograde cholangiopancreatography but was confirmed surgically. In the fourth patient, the pancreatic duct injury was chronic; MRCP revealed a posttraumatic stricture in this patient who had sustained blunt abdominal trauma 17 years previously. In the remaining six patients, pancreatic duct trauma was excluded with MRCP. The information derived from the MRCPs was used to guide clinical decision-making in all 10 patients. CONCLUSIONS: MRCP enables noninvasive detection and exclusion of pancreatic duct trauma and pancreas-specific complications and provides information that may be used to guide management decisions.     

Management of blunt pancreatic trauma in children

Purpose  Blunt abdominal trauma is the major cause of abdominal injury in children. Because of the retroperitoneal location, insidious signs and symptoms and the lack of sensitivity with common imaging modalities often lead to difficulties in making an accurate diagnosis. The most common complication is the formation of a pancreatic fistula, pancreatitis and a pancreatic pseudocyst, which usually manifests within 3 or 4 weeks after injury. Methods  The case records of seven children (4 male, 3 female) treated for blunt pancreatic injury in the department of pediatric surgery, University Hospital, Split were reviewed. Results  The treatment modalities were selected according to the grade of the pancreatic injury, hemodynamic status and associated injuries. Because all of the patients were classified as grade I or II according to the American Association for the Surgery of Trauma (AAST) classification, a conservative treatment was selected for all seven patients. In four patients the conservative treatment resulted in the total regression of the clinical, biochemical and radiological signs within four weeks (AAST grade I). In the other three patients, pancreatic pseudocysts arose within 3 or 4 weeks after the injury (AAST grade II). Conclusions  The status of the main pancreatic duct and the location of the pancreatic injury constitute the basis of the AAST scoring system. This scale should be used as a guide to selecting a surgical or conservative strategy. Based on these data, two factors appear to be the most important determinants of the treatment strategy for children with pancreatic injury: the grade of the pancreatic injury, which is determined according to the status of the main pancreatic duct and the clinical status of the patient.     

Outcomes after resection versus non-resection management of penetrating grade III and IV pancreatic injury: A trauma quality improvement (TQIP) databank analysis

BackgroundHigh-grade traumatic pancreatic injuries are associated with significant morbidity and mortality. Non-resection management is associated with fewer complications in pediatric patients. The present study evaluates outcomes following resection versus non-resection management of severe pancreatic injury caused by penetrating trauma.MethodsA retrospective study of the Trauma Quality Improvement Program (TQIP) database was performed from 1/2010 to 12/2014. Patients with AAST Organ Injury Scale pancreatic grade III and IV injuries caused by penetrating trauma were included in the study. Demographics, vital signs on admission, Abbreviated Injury Scale per body region, Injury Severity Score, transfusion and therapeutic modality were obtained. Mortality, length of stay (LOS), pseudocyst, pancreatitis, sepsis, thromboembolism, renal failure, ARDS and unplanned ICU admission or re-operation were stratified according to injury grade and treatment modality. Patients were stratified into those who did/did not undergo pancreatic resection.ResultsA total of 4,098 patients had a pancreatic injury of which 15.9% (n = 653) had a grade III and 6.7% (n = 274) a grade IV pancreatic injury. There were no differences in patient demographics or overall injury severity between the resected and non-resected cohorts within each pancreatic injury grade. Forty-two percent of grade III and 38.0% of grade IV injuries underwent pancreatic resection. The total LOS was longer in the resection arm irrespective of pancreatic injury severity. There was no significant difference in morbidity between cohorts. Similarly, mortality was not significantly different between the two management approaches for grade III: 15.1% (95% CI 11.0–19.9) vs. 18.4% (95% CI 14.6–22.6), p = 0.32 and grade IV: 24.0% (95% CI: 16.2–33.4) vs. 27.1% (95% CI: 20.5–34.4), p = 0.68.ConclusionResection for treatment of grade III and IV pancreatic injury is not associated with a significant decrease in mortality but is associated with an increase in hospital LOS.     

Conservative Management of Major Blunt Renal Trauma with Extravasation: A Viable Option?

Abstract Objectives:   To evaluate our experience in the management of patients with major blunt renal trauma treated at a major urban trauma center during the last ten years. Patients and Methods:   The medical records of 72 patients with major blunt renal lacerations treated from 1998 to 2008 were reviewed retrospectively. Patients were broken down into two groups based on whether they were managed conservatively (group 1) or surgically (group 2). Each group was compared with respect to the initial evaluation, computerized tomography findings, associated injuries, hospital stay, transfusion requirements, nephrectomy rate, complications and follow-up imaging. Results:   There were 57 patients with grade IV and 15 patients with grade V renal injuries. Of these, 51 (70.8%) patients were managed conservatively (48 with grade IV and 3 with grade V) and 21 (29.2%) patients were managed surgically (9 with grade IV and 12 with grade V). Patients in group 1 had significantly lower transfusion requirements (3.1 vs. 7.5 units, p < 0.0001), shorter hospital stays (11.8 vs. 15.9 days p < 0.003) and fewer complications (21.6 vs. 76.1%, p < 0.001). No death was observed in group 1, while three in group 2 died of major associated injuries. All surviving patients had significant resolution of the extravasation before hospital discharge. Conclusions:   Our data supports the conservative management of grade IV blunt renal parenchymal injuries in the absence of hemodynamic instability of renal origin. Even select patients with grade V parenchymal injuries can undergo a trial of conservative management.     

Injuries associated with pediatric liver trauma

Injury remains the leading cause of childhood mortality for children younger than 14 years of age, with the liver being particularly susceptible to blunt trauma in children. This study reviews the authors' institutions' experience with pediatric liver injuries in an attempt to establish current patterns of injury, management and outcomes. A single-center, retrospective review was conducted of 105 consecutive pediatric patients who presented with a traumatic liver injury from January 1996 through February 2004. Average patient age was 13.1+/-4.9 years and 58 per cent were male. Perihospital mortality was 8.6 per cent, with 67 per cent of mortality being attributed to head injury. The majority of patients were managed nonoperatively (81%). Liver injury was most often grade II (35%) by CT scan. Liver injury grade did not affect survival, but did affect injury management, with grade I and grade IV liver injuries more likely to be managed surgically (P < 0.001). Grade I liver injuries were associated with concomitant spleen injuries, whereas grade IV injuries were associated with pancreatic injuries. Surgical management was associated with a higher injury severity score (P = 0.005), higher mortality (P = 0.01), and with other associated injuries as well. Children experiencing blunt abdominal trauma are at risk of significant morbidity and mortality; however, these risks stem more likely from associated injuries than injury to the liver proper. Clinicians should maintain a high index of suspicion for potentially catastrophic associated injuries to the pancreas with high-grade liver injury.     

Management of pancreatic trauma

Between 1974 and 1984, 25 patients with pancreatic trauma were seen at three Regina hospitals. Eighteen had blunt injuries and 7 penetrating injuries. The mean injury severity score was 37 and the mean age 24.5 years. Management was nonoperative in six patients. Of the 19 treated surgically, 14 underwent laparotomy and drainage, 2 laparotomy without drainage and 3 pancreatic resection. Complications related to pancreatic injury occurred in 11 patients. One patient died. The results of this series suggest that the majority of patients with pancreatic injuries can be treated by laparotomy and drainage with a low mortality, but the complication rate is high. In select patients, visualization of the pancreatic duct may allow the surgeon to perform definitive surgical management at the initial procedure.     

Pancreatic trauma in children

BACKGROUND: Pancreatic trauma is rare in children, and management strategies are diverse and controversial. The aim of this study was to report the outcome of a consecutive series of children with pancreatic injury seen at a single regional centre over a decade. METHODS: All children under 14 years of age referred with pancreatic injury between January 1995 and June 2004 were reviewed retrospectively. RESULTS: Nine children (six boys) aged 3-13 years sustained pancreatic injuries: one grade I (minor contusion), two grade II (major contusion without duct injury or tissue loss), five grade III (distal transection and duct injury) and one grade IV (proximal transection). Grade I and II injuries were successfully managed without surgery. The five children with grade III injuries were initially treated without operation, but each developed a large symptomatic pseudocyst that failed to resolve with percutaneous drainage. Four underwent a spleen-sparing distal pancreatectomy and one boy with a transected pancreatic neck was treated by Roux-en-Y jejunostomy drainage. A 6-year-old boy who sustained severe pancreatobiliary trauma (grade IV) was treated by Roux-en-Y drainage. All children made a full recovery. CONCLUSION: The management of pancreatic injuries in children should be individualized depending on the site of injury, timing of referral, presence of associated injuries and institutional expertise.     

闭合性胰腺损伤的诊断和治疗：附32例报告

目的：探讨闭合性胰腺损伤的早期诊断和治疗方法。
方法：回顾性分析收治的闭合性胰腺损伤32例的临床资料。
结果：CT诊断符合率为79.3%。非手术治疗4例,其中I级3例,II级1例。 手术治疗28例,I级5例和II级7例行胰周清创外引流术;6例Ⅲ级胰腺损伤中,行远端胰腺切除术和脾切除术4例,行保脾远端胰腺切除术2例;5例Ⅳ级胰腺损伤中,行胰腺空肠Roux-en-Y吻合术4例,行远端胰腺切除术和脾切除术1例;5例Ⅴ级胰腺损伤中,行十二指肠憩室化手术1例,2例胰头严重毁损伤行胰十二指肠切除术,2例由于复合伤情较重,首先应用损伤控制手术,于受伤后48 h再次行彻底性手术。全组死亡3例,死亡原因主要为多器官功能衰竭,余25例中术后发生并发症19例（76.0%）,包括胰瘘、胰腺假性囊肿等,均经治疗而愈。
结论：无明确主胰管损伤、临床情况稳定时,胰腺损伤可先行非手术治疗。手术治疗适于重度闭合性胰腺损伤,根据胰腺损伤的程度选择合理的手术方式可提高治愈率,降低病死率。     

Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes

Background

Nonoperative management (NOM) is an accepted treatment of pediatric solid organ injuries and is typically successful. Blunt pancreatic trauma tends to require operative intervention more frequently. We sought to identify predictors of failure of NOM and compare the outcome of operative management against NOM.

Methods

A retrospective analysis was performed from January 1993 to December 2002 of all children with blunt pancreatic injuries from the trauma registries of 7 designated level 1 pediatric trauma centers. Failure of NOM was defined as the need for intraabdominal operative intervention. Injuries were graded I to V, and ductal injury was defined as grades III to V. Parameters included mechanism of injury, injury severity score (ISS), organ grade, Glasgow Coma Scale score, and outcome. Data were analyzed by Fisher exact test and Mann-Whitney U test, with mean values ± SD and significance of P < .05.

Results

Pancreatic injuries were present in 173 (9.2%) of 1823 patients. Of these, 43 (26.0% [43/173]) required an operation. Valid morbidity data was obtained in 118 of 173 patients. ISS was significantly higher in all patients treated operatively. Patients with an injury of grade III to V failed NOM more frequently than all patients with pancreatic injury (P =.0169). Length of stay was longer, and the incidence of pseudocysts, drainage procedures, and pancreatitis was higher in NOM patients, although not significant.

Conclusions

Patients with pancreatic injuries had a NOM failure rate of 26.0%. ISS and injury grades III to V were predictors of NOM failure. Patients with pancreatic ductal injury require more aggressive management.     

胰腺外伤单中心136例诊治报告

目的 总结单中心10年胰腺外伤治疗经验。方法 回顾性分析2008年1月至2017年12月中国人民解放军南京总医院普通外科收治的136例胰腺外伤病人的临床资料,根据美国创伤外科协会（AAST）标准进行胰腺外伤分级,随访观察并发症发生情况及预后。结果 闭合伤131例,开放伤5例。腹部CT检查（64.0%）是胰腺外伤最主要的诊断方式。37例（27.2%）非手术治疗中,13例Ⅲ级或Ⅳ级胰腺外伤病人经保守治疗获得成功;99例（72.8%）病人行手术治疗。整体并发症发生率为49.3%,主要并发症包括腹腔内并发症［腹腔脓肿（27.9%）、胰瘘（25.0%）、肠瘘（14.7%）、腹腔出血（12.5%）、胰腺假性囊肿（5.9%）、创伤性胰腺炎（5.88%）］和全身并发症［肺部感染（11.8%）、休克（7.4%）、急性呼吸窘迫综合征（5.9%）、肾功能不全（5.2%）、多器官功能障碍综合征（6.6%）］。病死率为8.1%（11/136）,胰腺坏死、胰瘘及感染所致的多器官功能衰竭是最主要的死亡原因。结论 大部分轻度胰腺外伤可行保守治疗,内镜下主胰管支架植入可应用于血流动力学稳定的Ⅲ、Ⅳ级胰腺外伤病人,手术引流适用于合并腹部其他器官损伤的低级别胰腺外伤。高级别胰腺外伤应遵循损伤控制外科理念,选择合理的手术方式。根据胰腺外伤的严重程度和全身情况,个体化选择治疗方案,加入多学科综合治疗协作组模式有助于降低病死率。     

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??Management of pancreatic trauma: A report of 136 cases DING Wei-wei??WANG Kai??LIU Bao-chen??et al. Research Institute of General Surgery??Jinling Hospital??Medical School of Nanjing University??Nanjing 210002??China
Corresponding author??LI Jie-shou??E-mail: lijieshounj@163.com
Abstract Objective To summarize experience of management of pancreatic trauma. Methods A retrospective review was performed of all patients with pancreatic injury admitted to Nanjing General Hospital over a 10-year period between January 2008 and December 2017. Traumatic injuries of the pancreas were graded according to the American Association for the Surgery of Trauma (AAST) score. Complications and outcomes were also collected. Results A total of 136 patients diagnosed with pancreatic trauma were included. Mechanism of injury included 131 of blunt trauma and 5 of penetrating trauma. Initial diagnosis was made by computed tomography in 87 patients (64.0%)??and CT scan was proposed as the first-line diagnosis method. Thirty-seven patients (27.2%) were managed non-operatively while 99 patients (72.8%) received surgical intervention. Overall complication rate was 49.3%. The most common intra-abdominal complication was intra-abdominal abscess (27.9%)??and pulmonary infection was considered as the most common systemic complication. In-hospital mortality was 8.1% (11/136)??of which MODS caused by pancreatic necrosis??pancreatic fistula and abdominal sepsis were the main cause of death. Conclusion Low-grade pancreatic injuries could be managed with NOM (non-operative management) successfully. Pancreatic duct stent placement procedure could be applied to those patients with hemodynamically stable. Surgical drainage was suitable for low-grade pancreatic injury patients with associated intra-abdomen injury. Damage control surgery was recommended for high grade pancreatic injuries. Individualized treatment options for pancreatic trauma according to AAST grade and location of injury were recommended. An individual-centered??multidisciplinary approach was recommended in the management of pancreatic trauma??which significantly reduces mortality.     

Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review.

OBJECTIVE: The authors' objective was to resolve the current controversies surrounding the diagnosis and management of blunt pancreatic trauma (BPT). SUMMARY BACKGROUND DATA: The diagnosis of BPT is notoriously difficult: serum amylase has been claimed to be neither sensitive nor specific, and recent anecdotal reports have suggested a role for computed tomography. The therapy of BPT has been controversial, with some suggesting selective observation and others advocating immediate exploration to prevent a delay-induced escalation in morbidity and death. METHODS: The authors conducted a retrospective chart review of documented BPT from six institutions, using a standardized binary data form composed of 187 items and 237 data fields. RESULTS: A significant correlation between pancreas-specific morbidity and injury to the main pancreatic duct (MPD) was noted. Patients requiring delayed surgical intervention after an unsuccessful period of observation demonstrated notably higher pancreas-specific mortality and morbidity rates, principally because of the incidence of unrecognized injuries to the MPD. Although detection of MPD injuries by computed tomography was no better than flipping a coin, endoscopic pancreatography was accurate in each of the five cases in which it was used. CONCLUSIONS: The principal cause of pancreas-specific morbidity after BPT is injury to the MPD. Parenchymal pancreatic injuries not involving the ductal system rarely result in pancreas-specific morbidity or death. Delay in recognizing MPD injury leads to increased mortality and morbidity rates. CT is unreliable in diagnosing MPD injury and should not be used to guide therapy. Initial selection of patients with isolated BPT for observation or surgery can be based on the determination of MPD integrity.     

Healing of Blunt Liver Injury After Non-Operative Management: Role of Ultrasonography Follow-Up

Abstract Background:   Non-operative management of patients with blunt liver trauma has become the standard of care. Usually after initial computed tomography (CT) evaluation and a short-term intra-hospital instrumental and clinical monitoring, no other imaging assessment is routinely requested. A restriction of physical activities for a few (unfixed number of) months is the most common recommendation. A few studies investigated the re-establishment of normal hepatic parenchymal architecture, but there is no evidence of the correct length of time for a certain resumption to normal life. To understand the progression of traumatic liver damage and the time course of healing, and to indicate the correct spontaneous recovery time, a long-term sonographic followup was done. Methods:   Forty-four patients with blunt non-operatively managed hepatic injury were selected by a retrospective review of a prospectively collected database. At admission, in accordance with the American Association for the Surgery of Trauma (AAST), all lesions were evaluated by CT and graded by the Organ Injury Scale (OIS). The progression of liver repair was followed by ultrasonographic (US) controls on days 3, 5, 10, 15, 30, and 60, and monthly up to a complete clinical recovery and sonographic disappearance of lesions. Results:   One OIS grade I, 20 grade II, 13 grade III, eight grade IV, and two grade V hepatic injuries were included in the study. Forty patients were monitored until liver normalization by 218 US examinations. The median time for liver repair in OIS grades II, III, IV, and V was 30, 63, 62, and 118 days, respectively, and 75% of the patients recovered in 60, 80, and 98 days in the II, III, and IV classes, respectively. Conclusion:   In our experience, a long time variability for spontaneous liver repair after blunt trauma and non-operative treatment was found, but a parenchymal US normalization was evidenced in a median time shorter than that usually reported in the literature.     

Nonoperative management of blunt pancreatic injury in childhood

PURPOSE: Nonoperative management for blunt pancreatic injury in children was performed between 1977 and 1998. The efficiency and safety of nonoperative management was examined. METHODS: Pancreatic injury was diagnosed in 20 children. The surgical indication was determined by hemodynamic instability and the management of associated injuries. Children without surgical indications were treated initially by nonoperative management. RESULTS: Nineteen of 20 children were treated initially nonoperatively, and 18 of the 19 survived. Surgical exploration was performed in only 1 child with perforation of the duodenum and bile duct. One child died of complications of total parenteral nutrition. Ultrasound scan and computed tomography scan showed pancreatic contusion in 9, laceration in 6, and injury of the main pancreatic duct (MPD) in 5. Pseudocysts were detected in 10 (5 laceration and 5 MPD injury). Pseudocysts smaller than 10 cm disappeared after nonoperative management, and those larger than 10 cm required operative management. Rupture of pseudocysts occurred in 2 children by rotating the upper torso. CONCLUSIONS: Nonoperative management of pancreatic injuries is effective in children, although careful management is required to avoid complications. Pseudocysts smaller than 10 cm were treated successfully by nonoperative management, and those larger than 10 cm required surgical management.     

Complex Hepatic Injuries: an Audit from a Tertiary Center

Abstract Background:  Nonoperative management is being increasingly employed in the management of blunt hepatic injuries. Patients and Methods:  We analyzed patients with complex hepatic injuries over a period of 10 years (1996–2006). Results:  Two hundred and ten patients with blunt hepatic injury were admitted and 103 patients had complex liver injuries. The predominant mode of injury was road traffic accidents in 91.2%. The grade distribution of liver injuries was grade III (72.8%), grade IV (23.3%) and grade V (4.9%). Twenty-four patients (23.3%) underwent surgery for persistent hemodynamic instability, persistent fall in hemoglobin level, bile leaks and intra-abdominal collection with sepsis. Associated intra-abdominal injuries were present in 19.4%, and 58.4% had associated extra-abdominal injuries. The operative procedures included hepatectomy (1), suture hepatorraphy (12), T-tube drainage for bile duct injuries (5), perihepatic sponge and gel foam packing (9), liver abscess drainage (3), and resection and debridement of liver tissue in six patients. The mortality and morbidity in this series was 10.7 and 56.4%, respectively. Multiorgan failure was present in 5, single organ failure in 37, sepsis in 24, biliary complications in 16 and intra-abdominal collection in 17 patients. Endoscopic management for bile leaks was performed in five patients, image-guided pig-tail drainage for abscesses in 11 patients, while angioembolization was done in two patients for right hepatic artery bleed. The mortality was not significantly different in surgical and nonoperative groups but operated patients had significantly higher morbidity. Conclusions:  Complex liver injuries can be managed successfully with conservative treatment in majority, with low mortality and acceptable morbidity. Surgery is reserved for selected indications.