Pancreatic injury in severe trauma: early diagnosis and therapy improve the outcome

BACKGROUND: Pancreatic injury is a dangerous complication in multiple injury, and experience with its diagnosis and treatment is usually limited. METHOD: Retrospective analysis of 3,840 patients admitted after multiple trauma from January 1, 1982, until May 31, 2000. RESULTS: A laparotomy was performed in 121 cases (3.15%) due to suspected intra-abdominal lesion. 32% of the patients (39/121) had a pancreatic lesion; 23% (9/39) had a rupture of the major pancreatic duct. Primary laparotomy was performed in 72% of the patients (28/39). Superficial lesions were treated by explorative laparotomy alone (n = 7), debridement and external drainage (n = 20), or necrosectomy and lavage (n = 3). Complex pancreatic lesions were treated by pancreatojejunostomies (n = 5), pancreatic left resections (n = 2), or exploration alone (n = 2). 8 of 39 patients died (20%), 4 intraoperatively. Of the surviving 35 patients, a pancreas-associated complication developed in 8 patients (23%): pancreatic abscesses (n = 4), traumatic pancreatitis (n = 3), pancreatic fistulas (n = 2), and pseudocysts (n = 2). CONCLUSIONS: Pancreatic injury is an infrequent but dangerous complication in severe trauma. Superficial lesions not affecting the major pancreatic duct can be managed by debridement and external drainage. If the major pancreatic duct is ruptured, organ-preserving, complex reconstructive procedures are necessary. When diagnosed timely and treated according to severity and overall situation, pancreatic injuries have an acceptable morbidity, but usually a high mortality.     

355例以腹部损伤为主的严重创伤救治分析

【摘要】〓目的〓探讨腹部损伤为主的严重创伤的诊断及救治措施。方法〓对1999年9月~2012年9月救治的355例以腹部损伤为主的严重创伤进行分析总结。结果〓本组急诊腹部手术319例/次,其中103例/次在一次麻醉下分组同台完成了两个以上部位的手术。重症监护病房(ICU)平均住院日28.6±10.8天。临床治愈237例(66.8%),致残78例(22.0%),死亡40例(11.2%)。结论〓病史和体格检查应同抢救治疗同步(如维持呼吸道通畅、止血措施,抗休克等);应积极采用诊断性腹腔穿刺、B超、CT等比较简洁和敏感的快速诊断方法;手术顺序应按受损器官的重要性和损伤的严重程度决定,尽可能在一次麻醉下分组同台处理不同部位的损伤;主动采用损伤控制性外科(DCS)策略,可有效降低死亡率。严重多发伤病人术后均应进入ICU监护和治疗。     

严重腹部创伤患者目标温度管理研究

目的探讨对严重腹部创伤患者实施目标温度管理的效果。方法将2016年收治的严重腹部创伤患者50例设为对照组,采用传统的体温护理方法;2017年收治的47例设为干预组,采用目标温度管理策略进行体温复苏管理。比较两组患者入院至损伤控制性手术前复苏时间,以及在2个时间点的体温、pH值及凝血功能相关指标。结果在损伤控制性手术前,干预组复苏时间、体温、血pH值、乳酸、凝血反应时间、凝血形成时间显著优于对照组(P0.05,P0.01)。两组凝固角、最大振幅、纤维蛋白溶解率及纤维蛋白溶解百分数比较,差异无统计学意义(均P0.05)。结论目标温度管理策略可明显改善创伤患者低体温的发生,预防酸中毒和凝血功能紊乱的发展,为患者行确定性手术赢得时间。     

合并腹部创伤的严重多发伤患者外周血MIP-1α的表达及意义

目的 探讨严重腹部创伤后炎症反应的分子机制。方法 损伤程度评分(injury severity score，ISS)≥16分的创伤患者28例，A组为无腹部创伤组共15例，B组为合并腹部创伤组共13例，健康对照组10例。用酶联免疫吸附法(ELISA)检测伤后不同时间外周血浆MIP-1α的表达水平，用Ficoll-Hypaque梯度离心法和粘附法分离纯化单核细胞，流式细胞术分析单核细胞CD86和CD64的表达情况。结果 A、B二组创伤患者外周血单核细胞CD64表达均明显增加，CD86表达明显降低，创伤患者血浆MIP-1α表达水平明显升高，于第1日最明显，B组异常表达持续时间更长，组间比较差异显著。结论 创伤后单核细胞功能的变化与创伤后不同功能单核细胞亚群比例的变化有关，合并腹部创伤的严重多发伤患者更易发生感染并发症。     

Pancreatic injury in children: good outcome of nonoperative treatment

Purpose

Treatment of blunt injury of the pancreas in children remains controversial. Some prefer nonoperative treatment, whereas others prefer operative management in selected cases. This report reviews the treatment of patients with blunt pancreatic trauma admitted to a level I pediatric trauma center in The Netherlands.

Methods

Medical records of all children less than 15 years with blunt pancreatic trauma admitted to the University Medical Center St Radboud in the period 1975 to 2003 were retrospectively analyzed.

Results

Thirty-four children were included, age 3 to 14 years. Most injuries were because of bicycle accidents (58%). On admission, amylase was raised in 90% of the patients. Five patients had pancreatic duct injuries identified by imaging (endoscopic retrograde cholangiopancreaticography was used once, magnetic resonance cholangiopancreaticography twice) or at surgery. Thirty-one children were initially managed nonoperatively. Pancreatic surgery was performed in 3 children (1 Roux-Y, 2 drainage only). Mean hospital stay was 29 days in the operative group and 24 days in the nonoperative group. Fluid collections developed in 2 operated patients. Both resolved spontaneously. In 14 of the 31 nonoperated patients, a pseudocyst developed. Only 6 of these needed secondary intervention. Of these, 3 were drained percutaneously. There was no mortality and no long-term morbidity in both groups.

Conclusions

Nonoperative management of pancreatic injury in children has good clinical outcome. Only 10% need secondary surgery. In 50%, pseudocysts develop of which half can be managed nonoperatively. The reliability of computed tomographic scan grading is of limited value to decide whether to operate primarily. There is little to gain with ERCP and stenting. The place of MRCP as a noninvasive diagnostic tool remains to be determined.     

Decompressive craniectomy in trauma patients with severe brain injury

Decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial. We conducted a retrospective review of prospectively collected data on all patients requiring surgery for TBI from 1995 through 2001 at Cedars-Sinai Medical Center. Patients were separated into two groups: Group A, craniectomy, and Group B, craniotomy. We had 120 patients; 24 (20%) had craniectomy and 96 (80%) had craniotomy. There were no significant differences in demographics or Injury Severity Scores. The craniectomy group had significantly more TBI as evidenced by more frequently collapsed basilar cisterns on CT scan (P = 0.0001). There was no significant difference in actuarial survival between the groups: 52.8 per cent in the craniectomy group and 79.2 per cent in the craniotomy group (P = 0.08). Calculated mortality for craniectomy was 37.5 per cent versus 18.8 per cent for craniotomy (P = NS). We found four preoperative findings to be significant predictors of mortality: 1) Glasgow Coma Scale score, 2) Injury Severity Score, 3) Simplified Acute Physiology Score, and 4) Acute Physiology and Chronic Health Evaluation II. The type of surgery was not found to be a significant predictor of death even when adjusted for severity of injury. Craniectomy may be helpful for patients with TBI associated with preoperative CT scan evidence of basilar cistern collapse. This is evidenced by similar survival rates between the two groups despite clinical evidence of greater TBI among craniectomy patients.     

Clinical course and outcome of severe head injury in Australia

The records of 159 severely head-injured patients (all in coma for longer than 6 hours) from Sydney, Australia, were studied. The clinical course, charted over a 2-week period, indicated that 60% of deaths occur by Day 3 and that 12% of patients remain in coma (Glagow Coma Scale (GCS) score less than 7) for more than 2 weeks. Overall, at long-term follow-up review more than 2 years after injury, 51% of patients were dead, 7% were severely disabled or vegetative, and 42% had a good to moderate recovery. Outcome of the patients in prolonged coma was assessed separately, with only one-third making a good or moderate recovery; two-thirds of the severely disabled patients came from this group. The high proportion of poor outcomes associated with prolonged coma suggests that this group of patients should be specifically targeted in research. One appropriate intervention with this group would be the restructuring and intensification of early rehabilitation. However, the GCS score lacks the precision needed for this type of study, and a better measure of recovery should be developed.     

腹部闭合性损伤伴严重多发伤的诊断和治疗

对47例腹部闭合性损伤伴严重多发伤的临床资料进行回顾性分析。47例均在入院48h内手术治疗，其中20例单纯行腹部手术，27例与胸心外科、骨外科、脑外科、泌尿外科联合手术。术前主要疾病确诊38例(80．8％)。治愈39例(83．0％)，死亡8例(17．0％)。作者认为对腹部闭合性损伤伴严重多发伤应快速准确地判断病情，严格掌握手术适应证，选择合适术式，及时手术，是挽救患者生命的关键。     

Surgical treatment of pancreatic injuries in severe abdominal trauma

In spite of its low incidence, pancreatic injuries hold important place in abdominal trauma because of diagnostic difficulties, severe potential complications, therapeutic challenges, and high mortality rates. These injuries are related with specific morbidity and are very often accompanied with injuries of other organs. This retrospective study included 31 patients treated at The Clinic for Emergency Surgery of Clinical Center of Serbia during the period of 2004-2009 with intraoperativelly confirmed diagnosis of pancreatic trauma. The most common mechanism of injury was blunt trauma (83.9%). Among available diagnostic methods, abdominal ultrasound was characterized with high incidence of false-negative findings (33.3%) while for CT it was at 16.6%. The type of surgical procedure was related to degree and severity of injury. Specific complications occurred in 22.6% of patients, while mortality rate was 25.8%. The creation of unambiguous algorithms for optimal treatment of patients with pancreatic trauma require multi-centric prospective studies.     

Diagnosis and treatment of patients with closed injury of abdominal cavity organs in combination with craniocerebral trauma

Results of diagnosis and treatment of 114 injured persons with closed abdominal trauma, combined with craniocerebral trauma were suggested. In 34 (29.8%) observations the injury of two or more organs of peritoneal cavity was diagnosed, the parenchymatous organs trauma--in 35 (30.7%) and the hole organs trauma--in 45 (39.5%). Cerebral concussion was established in 61 (53.5%) of injured persons, cerebral contusion--in 26 (22.8%), cerebral compression on the contusion background--in 16 (14%) and subdural hematoma--in 11 (9.7%). In all the injured persons the operative intervention was performed. In 32 (28%) the blood of their own was transfused. To reduce the endogenous intoxication severity there were performed the forced diuresis, hemosorption--in 10 (8.7%), the blood ultraviolet irradiation--in 41 (35.9%), intravenous laserotherapy--in 40 (35%). After the operation 14 (12.3%) of patients died. High mortality in combined cranioabdominal trauma is caused by the injury severity, the traumatic shock and mutual burden syndrome presence.     

中严重损伤诊治中的几点经验

腹部严重损伤发生后 ,病人全身脏器可能多处同时受到损害。在诊治时有的脏器损害所致的后果已充分表达 (如大出血休克及脏器内容外溢引起的继发性腹膜炎 ) ,但也有些脏器的损害的后果表达不够明显 ,这是由于解剖部位比较隐蔽或术者经验不足的缘故。在这类病人的抢救中 ,今就我们的有限经验结合实例 ,分属几种情况加以介绍并略加讨论以就正于同道。1　经验教训1 1　在大型抢救工作中 ,对如何组织发挥手术台上下全体人员的积极性、主动性 ,往往重视不够。负责人的特长与头脑保持清醒冷静是十分重要的。做到抢救工作有节奏地、有序地进行 ,以免…     

胸腹部损伤伴休克合并中重型颅脑损伤的诊断和治疗

本院自2001年10月至2005年4月，收治胸腹部损伤伴休克合并中重型颅脑损伤病例78例，现就其诊治体会分析如下。     

One-year outcome and course of recovery after severe traumatic brain injury

Goal  

To describe the outcome of patients with severe traumatic brain injury (TBI) 3, 6 and 12 months after trauma.     

Abbreviated laparotomy in severe abdominal trauma

On critically injured patient the decision to perform a damage control laparotomy is based on the volume of transfusion and shock. The aim of the surgery which is to obtain as fast as possible the best hemostasis to limit the peritoneal thermal loss and to perform as soon as possible physiologic restoration in the Intensive Care Unit.     

Blunt intraabdominal arterial injury in pediatric trauma patients: injury distribution and markers of outcome

Background

The epidemiology of pediatric blunt intraabdominal arterial injury is ill defined. We analyzed a multiinstitutional trauma database to better define injury patterns and predictors of outcome.

Methods

The American College of Surgeons National Trauma Database was evaluated for all patients younger than 16 years with blunt intraabdominal arterial injury from 2000 to 2004. Injury distribution, operative treatment, and variables associated with mortality were considered.

Results

One hundred twelve intraabdominal arterial injuries were identified in 103 pediatric blunt trauma patients. Single arterial injury (92.2%) occurred most frequently: renal (36.9%), mesenteric (24.3%), and iliac (23.3%). Associated injuries were present in 96.1% of patients (abdominal visceral, 75.7%; major extraabdominal skeletal/visceral, 77.7%). Arterial control was obtained operatively (n = 46, 44.7%) or by endovascular means (n = 6, 5.8%) in 52 patients. Overall mortality was 15.5%. Increased mortality was associated with multiple arterial injuries (P = .049), intraabdominal venous injury (P = .011), head injury (P = .05), Glasgow Coma Score less than 8 (P < .001), cardiac arrest (P < .001), profound base deficit (P = .007), and poor performance on multiple injured outcomes scoring systems (Revised Trauma Score [P < .001], Injury Severity Score [P = .001], and TRISS [P = .002]).

Conclusion

Blunt intraabdominal arterial injury in children usually affects a single vessel. Associated injuries appear to be nearly universal. The high mortality rate is influenced by serious associated injuries and is reflected by overall injury severity scores.