Evaluation of a diagnostic protocol using screening diagnostic peritoneal lavage with selective use of abdominal computed tomography in blunt abdominal trauma.

BACKGROUND: The optimal method of evaluating blunt abdominal trauma remains controversial. A combination of a sensitive screening test, diagnostic peritoneal lavage (DPL), and a specific test, abdominal computed tomography (CT), may be a safe, efficient approach to adult blunt abdominal trauma. METHODS: A prospective cohort study compared a protocol using screening DPL followed by selective use of abdominal CT (DPL/abdominal CT) and the use of abdominal CT alone in the evaluation of hemodynamically stable, adult blunt trauma patients. RESULTS: One hundred sixty-seven adult blunt trauma patients were initially evaluated by DPL (n = 71) or abdominal CT (n = 96). Emergency department evaluation required less time in the DPL/abdominal CT group than in the abdominal CT alone group (41 minutes vs. 2.5 hours; p < 0.001). There were no missed injuries in the DPL/abdominal CT group versus seven missed injuries in the abdominal CT group (p = 0.02). There were no nontherapeutic celiotomies in either study group. CONCLUSION: Screening DPL, followed by abdominal CT if positive, is a safe, efficient method of evaluating adult blunt abdominal trauma that reduces the time required to evaluate the abdomen, does not result in increased nontherapeutic celiotomies, results in fewer missed injuries, and reduces the overall use of abdominal CT.     

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.     

Mesenteric injury after blunt abdominal trauma.

OBJECTIVE: To present our experience of mesenteric injuries after blunt abdominal trauma. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 31 patients with mesenteric injuries out of 333 who required operations for blunt abdominal trauma between March 1978 and March 1998. 21 were diagnosed within 6 hours (median 160 min, early group) and in 10 the diagnosis was delayed (median 21 hours, range 15 hours-7 days, delayed group). INTERVENTIONS: Emergency laparotomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and hospital stay. RESULTS: There were no deaths. The diagnosis was confirmed by diagnostic peritoneal lavage in 17/21 patients in the early group whereas 7/10 in the delayed group were diagnosed by clinical examination alone. Most of the injuries (n = 23) were caused by road traffic accidents. 30 patients had injured the small bowel mesentery and 4 the large bowel mesentery. 25 of the 31 patients had associated injuries. There were no complications in the early group, compared with 6 wound infections and 1 case of small bowel obstruction in the delayed group (p < 0.0001). Median hospital stay in the early group was 11 days (range 3-24) compared with 23 days (range 10-61) in the delayed group (p = 0.004). CONCLUSION: Because delay in diagnosis is significantly associated with morbidity and duration of hospital stay we recommend that all patients admitted with blunt abdominal trauma should have a diagnostic peritoneal lavage as soon as possible     

Detecting blunt pancreatic injuries

Pancreatic injury after blunt abdominal trauma is exceedingly uncommon, occurring in less than 5 % of major abdominal injuries. When blunt pancreatic injury does occur, however, it is notoriously difficult to identify. The use of serum amylase has been advocated in the diagnosis of such injury, yet it is neither sensitive nor specific. Computed tomography has become widely accepted in the evaluation of hemodynamically stable patients after blunt abdominal trauma, although it is clearly not a sensitive modality for the detection of pancreatic injury. In fact, numerous examples of normal CT scans with missed pancreatic injury have been documented. However, careful attention to CT technique and awareness of the CT manifestations of pancreatic injury may facilitate the diagnosis of pancreatic injury. Additionally, important information about the pancreatic duct can be obtained with the use of MRI-pancreatography or endoscopic retrograde pancreatography. Accurate, timely identification of major pancreatic ductal injury is imperative because delay in diagnosis and associated vascular injuries are largely responsible for the high morbidity and mortality associated with blunt pancreatic trauma. Blunt pancreatic trauma can be managed successfully by means of both operative and selective approaches.     

Management of major pancreatic duct injuries in children.

BACKGROUND: The operative versus nonoperative management of major pancreatic ductal injuries in children remains controversial. The computed tomographic (CT) scan may not be accurate for determination of location and type of injury. We report our experience with ductal injury including the recent use of acute endoscopic retrograde cholangiopancreatography (ERCP) for definitive imaging, and an endoscopically placed stent as definitive treatment. This has not been reported in children. METHODS: In review of 14,245 admissions to a regional pediatric trauma center over a 14-year period, 18 patients with major ductal injuries from blunt trauma were noted. Records were reviewed for mechanism of injury, method of diagnosis, management, and outcome. RESULTS: There were 10 girls and 8 boys, ranging in age from 2 months to 13 years. The most common mechanisms of injury were motor vehicle and bicycle crashes. Admission CT scan in 16 children was suggestive of injury in 11, and missed the injury in 5. Distal pancreatectomy was carried out in eight patients with distal duct injuries: one died of central nervous system injury. Nonoperative management in three proximal duct injuries suggested by initial CT scan and in three missed distal duct injuries resulted in pseudocyst formation in five survivors; one patient died of central nervous system injuries. Two children with minimal abdominal pain, normal initial serum amylase, and no initial imaging developed pseudocysts. Two of seven pseudocysts spontaneously resolved and five were treated by delayed cystogastrostomy. Two recent children with suggestive CT scans were definitively diagnosed by acute ERCP and treated by endoscopic stenting. Clinical and chemical improvement was rapid and complete and the stents were removed. Follow-up ERCP, CT scan, and serum amylase levels are normal 1 year after injury. CONCLUSION: Pancreatic ductal injuries are rare in pediatric blunt trauma. CT scanning is suggestive but not accurate for the diagnosis of type and location of injury. Acute ERCP is safe and accurate in children, and may allow for definitive treatment of ductal injury by stenting in selected patients. If stenting is not possible, or fails, distal injuries are best treated by distal pancreatectomy; proximal injuries may be managed nonoperatively, allowing for the formation and uneventful drainage of a pseudocyst.     

Non-operative management of blunt abdominal injuries

Over the past three decades, non-operative management has been shown to be an effective therapeutic option in hemodynamically stable patients. We retrospectively reviewed the last 7 years of our experience with the non-operative management of blunt abdominal traumas. From January 1998 to July 2005, 123 patients with blunt abdominal traumas and injuries to the spleen, liver and pancreas were admitted to our hospital. Fifty-eight of them (47.2%) were submitted to non-operative management; 5 (8.6%) presented associated splenic and hepatic injuries. We performed non-operative treatment for 27 splenic injuries (33.7% of all splenic injuries), 32 hepatic injuries (62.7% of all hepatic injuries) and 3 pancreatic injuries (75% of all pancreatic injuries). There was no mortality and no complications. We submitted one haemodynamically stable patient who presented a grade V hepatic injury and "contrast pooling" at abdominal CT scan to angiography and transarterial embolisation; this patient was successfully managed non-operatively. The overall success rate of non-operative management was 98.5%. The only non-operative management failure was a patient with both splenic and hepatic injuries. The success rate for injuries to the spleen was 96.3%, to the liver 96.9% and to the pancreas 100%. We conclude that hemodynamically stable patients suffering intra-abdominal injury can be safely managed non-operatively.     

Nonoperative management of blunt splenic trauma: a multicenter experience

The experience of six referral trauma centers with 832 blunt splenic injuries was reviewed to determine the indications, methods, and outcome of nonoperative management. During this 5-year period, 112 splenic injuries were intentionally managed by observation. There were 40 (36%) patients less than 16 years old and 72 adults. The diagnosis was established by computed tomography in 89 (79%) patients, nuclear scan in 23 (21%), ultrasound in four (4%), and arteriography in two (2%). There were 28 Class I, 51 Class II, 31 Class III, two Class IV, and no Class V splenic injuries. Nonoperative management was unsuccessful in one (2%) child and 12 (17%) adults (p less than 0.05). Failure was due to ongoing hemorrhage in 12 patients and delayed recognition of pancreatic injury in one patient. Of the 12 patients ultimately requiring laparotomy for control of hemorrhage, seven (58%) were successfully treated with splenic salvage techniques. Overall mortality was 3%; none of the four deaths was due to splenic or associated abdominal injury. This contemporary multicenter experience suggests that patients with Class I, II, or III splenic injuries after blunt trauma are candidates for nonoperative management if there is: 1) no hemodynamic instability after initial fluid resuscitation; 2) no serious associated abdominal organ injury; and 3) no extra-abdominal condition which precludes assessment of the abdomen. Strict adherence to these principles yielded initial nonoperative success in 98% of children and 83% of adults. Application of standard splenic salvage techniques to treat the patients with persistent hemorrhage resulted in ultimate splenic preservation in 100% of children and 93% of adults.     

Injuries of the gastrointestinal tract from blunt trauma in children: a 12-year experience at a designated pediatric trauma center

INTRODUCTION: Nonoperative management of solid organ injury from blunt trauma in children has focused concern on potential delays in diagnosis of hollow viscus injury with resultant increases in morbidity, mortality, and cost. This study of a large pediatric trauma database will review the issues of difficulty and/or delay in diagnosis as it relates specifically to definitive treatment and outcome. METHODS: We surveyed 11,592 consecutive admissions to a designated pediatric trauma center from 1985 to 1997 to identify children with documented injury of the gastrointestinal (GI) tract from blunt trauma. The records were extensively analyzed specifically in regard to mechanism of injury, type and site of injury, time to diagnosis, operative treatment, complications, and final outcome. RESULTS: The 79 children identified, 4 months to 17 years old, included 27 females and 52 males. Mechanism of injury included 15 restrained and 7 unrestrained passengers, 15 pedestrians, 15 child abuse victims, 10 bike handlebar intrusions, 8 discrete blows to the abdomen, 4 bike versus auto, 3 falls, and 2 crush injuries. There were 51 perforations, 6 avulsions, and 22 lesser injuries including contusions. Injury of the small bowel was most common, 44 cases, followed by the duodenum, 18 cases, colon, 17 cases, and stomach, 6 cases. In 45 children, diagnosis was made quickly by a combination of obvious clinical findings, plain x-ray and/or initial computed tomographic findings mandating urgent operative intervention. Diagnosis was delayed beyond 4 hours in 34 children, beyond 24 hours in 17 children and was made by persistent clinical suspicion, aided by delayed computed tomographic findings of bowel wall edema or unexplained fluid. The six deaths were caused by severe head injury. Complications included two delayed abscesses and two cases of intestinal obstruction. All 73 survivors left the hospital with normal bowel function. CONCLUSIONS: Injury to the GI tract from blunt trauma in children is uncommon (<1%). The majority of GI tract injuries (60%) are caused by a discrete point of energy transfer such as a seatbelt (19%), a handle bar (13%), or a blow from abuse (19%), or other blows and is unique to this population. Although diagnosis may be difficult and often delayed, this did not result in excessive morbidity or mortality. Safe and effective treatment of GI tract injuries is compatible with nonoperative management of most other injuries associated with blunt abdominal trauma in children, while reducing the risk of nontherapeutic laparotomy.     

Leukocytosis and free fluid are important indicators of isolated intestinal injury after blunt trauma

BACKGROUND: The detection of isolated intestinal injuries after blunt trauma can be difficult because of subtle signs and symptoms, often leading to delayed diagnosis. We hypothesized that specific clinical indicators could be identified to assist in the diagnosis of these injuries. METHODS: Medical records of all patients with such injuries from 1988 to 1996 were reviewed. The patients were stratified into those operated on within 6 hours of presentation (apparent injury) and those operated on after 6 hours (occult injury), and the data were compared. RESULTS: Forty-six patients with isolated intestinal injuries were identified. There were no differences in the rate of peritonitis or free fluid on abdominal computed tomography, blood loss, intraoperative findings, or morbidity and mortality between groups. Leukocytosis (sensitivity, 84.8%; specificity, 55.2%; p = 0.01) and free fluid on computed tomography were frequently present, however, and their significance was underappreciated in the occult injury group. CONCLUSION: After blunt abdominal trauma in patients without obvious indications for invasive evaluation of the abdomen (e.g., peritoneal lavage, laparoscopy, laparotomy), leukocytosis can indicate an intestinal injury. Additionally, unexplained free fluid on abdominal computed tomography must be aggressively evaluated.     

Associated injuries in blunt solid organ trauma: implications for missed injury in nonoperative management

BACKGROUND: During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or spleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and spleen injuries, and missed injuries were reviewed in patients undergoing NOM. METHODS: Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsuspected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or spleen injury. RESULTS: Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or spleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. CONCLUSION: Damage to the pancreas and bowel is significantly associated with liver as opposed to spleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with spleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We speculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the spleen accounts for the greater rate of associated injuries to the pancreas/small bowel.     

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.     

The complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma

To determine the roles of diagnostic peritoneal lavage (DPL) and abdominal computed tomography (CT) in the evaluation of blunt abdominal trauma, we compared our results in the eras before and after the advent of abdominal CT. In the pre-CT era 1977 to 1980 (group 1; 365 patients), DPL was the diagnostic procedure of choice. In the CT era 1983 to 1986 (group 2; 282 patients), DPL was used for unstable, polytraumatized patients, and CT was reserved for stable patients. The rate of delayed recognition of documented visceral injury (7%) was similar for groups 1 and 2. Celiotomy was nontherapeutic in 21 (14%) patients in group 1 and in 5 (5%) in group 2 (p less than 0.02). Despite immediate availability of abdominal CT, clinical examination alone or in combination with DPL was the diagnostic procedure of choice in 41% of those with blunt abdominal trauma in group 2. The complementary use of abdominal CT and DPL in those with blunt abdominal trauma decreased the rate of nontherapeutic celiotomy, did not result in a significant increase in missed injuries, and allowed identification of candidates for nonoperative management of solid organ injury.     

Towards a non-operative strategy for severe blunt pancreatic injury—Case report

BackgroundPancreatic injury remains uncommon and the majority occurs in association with injury of other organs. For years, surgery has been advised for those with evidence of pancreatic duct damage. However, a lot of changes were seen in the management of blunt abdominal trauma, with strong support for non-operative management of solid organ injuries. There is strong evidence from paediatric patients that those with severe pancreatic contusion and ductal injury can be managed conservatively.Patients and methodWe present our cases of severe blunt pancreatic injury with ductal damage that were successfully managed non-operatively. We reviewed the literature to find evidence to support this management strategy.ResultOur case report and the literature showed that majority of pancreatic ductal injury have been successfully managed non-operatively without increased morbidity or mortality.ConclusionNon-operative management of blunt pancreatic injury with ductal damage allows the formation of a pseudocyst for delayed drainage safely. This strategy of “induced pseudocyst” is particularly applicable to cases that present late and those with concomitant injuries of other organs. The majority of pseudocysts will subside by themselves. The use of embolization may decrease the need for urgent operation and timely percutaneous drainage may help relieve early symptoms.     

胰腺损伤的诊治策略探讨

目的探讨胰腺损伤的诊断及治疗对策。方法回顾性分析45例胰腺损伤病例资料。结果17例闭合性胰腺损伤和6例开放性胰腺损伤属于腹部多脏器伤,表现腹腔出血、腹膜炎。5例腹部单纯性胰腺钝伤呈现肠梗阻3例、腹部肿决1例、胰腺炎1例。17例医源性胰腺损伤出现胰腺出血、胰瘘。胰腺损伤术前早期诊断困难,术中依据胰腺损伤的严重程度,采取不同的处理方法。治愈43例,死亡2例。结论手术探查可确诊开放性胰腺损伤和有腹部症状、CT可疑的闭合性胰腺损伤。医源性胰腺损伤重在预防。根据病人全身情况和胰腺损伤分级决定合适的术式是降低死亡率、减少并发症的关键。     

Use of abdominal ultrasonography to assess pediatric splenic trauma. Potential pitfalls in the diagnosis.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of abdominal ultrasonography (US) for screening and grading pediatric splenic injury. SUMMARY BACKGROUND DATA: The use of abdominal US has increased rapidly as a method of evaluating organ damage after blunt abdominal trauma. Despite US's increasing use, little is known about its accuracy in children with splenic injury. METHODS: Children (N = 32) suffering blunt abdominal trauma who were diagnosed with splenic injury by computerized tomography (CT) scan prospectively were enlisted in this study. Degree of splenic injury was evaluated by both CT and US. The ultrasounds were evaluated by an initial reading as well as by a radiologist who was blinded as to the results of the CT. RESULTS: Twelve (38%) of the 32 splenic injuries found on CT were missed completely on the initial reading of the US. When the ultrasounds were graded in a blinded fashion, 10 (31%) of the splenic lacerations were missed and 17 (53%) were downgraded. Seven (22%) of the 32 splenic fractures were not associated with any free intraperitoneal fluid on the CT scan. CONCLUSIONS: This study has shown that US has a low level of sensitivity (62% to 78%) in detecting splenic injury and downgrades the degree of injury in the majority of cases. Reliance on free intraperitoneal fluid may be inaccurate because not all patients with splenic injury have free intra-abdominal fluid. Based on these findings, US may be of limited use in the initial assessment, management, and follow-up of pediatric splenic trauma.     

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.     

Traumatisme de la rate : facteurs prédictifs d’échec du traitement non-opératoire

Introduction

Non-operative management of blunt splenic injury in adults has been applied with increasing frequency. However, predictive criteria for successful non-operative management are still a matter of debate.

Methods

we retrospectively reviewed all cases of blunt splenic injury in adult patients from 1997 to 2006.

Results

Of 190 patients with blunt splenic trauma (median age: 33 years, range 16-98), 43.7% (n=83) underwent emergency surgical intervention (Group I), and 56.3% (n=105) of patients were admitted for conservative treatment of splenic trauma. Conservative treatment was successful in 76.6% (n=82) (Group II), while 23.4% (n=25) of patients required a laparotomy (Group III). Ultimately, 43.2% of patients were successfully managed non-operatively, and 56.9% underwent laparotomy. Mechanism of injury was not significantly different among three groups. Group I patients presented significantly more frequently with hypovolemic shock (p<0.01), associated injuries (p<0.01), and high grade of splenic injury (p<0.01). All patients with active bleeding as evidenced by extravasation on CT scan, underwent exploratory laparotomy. Failure of non-operative management increased significantly with splenic trauma grade (grade I (0%), grade II (22.6%), grade III (27.6%) and grade IV (40%), (p<0.01) and with quantity of hemoperitoneum (10.4% of patients with small, 22.2% of patient with moderate, and 47.8% with large hemoperitoneum). The median interval for conservative treatment failure was 3 days (range: 1-15).Splenic injuries were operatively controlled by splenectomy (91.6%) and splenorrhaphy (8.4%).

Conclusion

Suitability of adult patients with blunt splenic injury for non-operative management may be predicted at initial presentation, based on hemodynamic status and associated injuries. The quantity of hemoperitoneum and magnitude of splenic injury are predictive factors for failure of conservative treatment. Early definition of these factors may help identify those patients likely to be successfully treated without laparotomy.     

Isolated free intra-abdominal fluid on CT in blunt trauma: The continued diagnostic dilemma

Purpose: The clinical significance of isolated free fluid (FF) without solid organ injury on computed tomography (CT) continues to pose significant dilemma in the management of patients with blunt abdominal trauma (BAT). Methods: We reviewed the incidence of FF and the clinical outcome amongst patients with blunt abdominal trauma in a metropolitan trauma service in South Africa. We performed a retrospective study of 121 consecutive CT scans over a period of 12 months to determine the incidence of isolated FF and the clinical outcome of patients managed in a large metropolitan trauma service. Results: Of the 121 CTs, FF was identified in 36 patients (30%). Seven patients (6%) had isolated FF. Of the 29 patients who had free fluid and associated organ injuries, 33 organ injuries were identified. 86% (25/29) of all 29 patients had a single organ injury and 14% had multiple organ injuries. There were 26 solid organ injuries and 7 hollow organ injuries. The 33 organs injured were: spleen, 12; liver, 8; kidney, 5;pancreas, 2; small bowel, 4; duodenum, 1. Six (21%) patients required operative management for small bowel perforations in 4 cases and pancreatic tail injury in 2 cases. All 7 patients with isolated FF were initially observed, and 3 (43%) were eventually subjected to operative intervention. They were found to have an intra-peritoneal bladder rupture in 1 case, a non-expanding zone 3 haematoma in 1 case, and a negative laparotomy in 1 case. Four (57%) patients were successfully managed without surgical interventions. Conclusions: Isolated FF is uncommon and the clinical significance remains unclear. Provided that reliable serial physical examination can be performed by experienced surgeons, an initial non-operative approach should be considered.     

A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury.

Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid organ injuries. The purpose of this study was to utilize a large statewide, population-based data set to perform a time-series analysis of the practice of physicians caring for blunt solid organ injury of the abdomen. The study was designed to assess the changing frequency and the outcomes of operative and nonoperative treatments for blunt hepatic and splenic injuries. METHODS: Data were obtained from the state hospital discharge data base, which tracks information on all hospitalized patients from each of the 157 hospitals in the state of North Carolina. All trauma patients who had sustained injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis. RESULTS: During the 5 years of the study, 210,256 trauma patients were admitted to the state's hospitals (42,051 +/- 7802 per year). The frequency of nonoperative interventions for hepatic and splenic injuries increased over the period studied. The frequency of nonoperative management of hepatic injuries increased from 55% in 1988 to 79% in 1992 in patients with hepatic injuries and from 34% to 46% in patients with splenic injuries. The rate of nonoperative management of hepatic injuries increased from 54% to 64% in nontrauma centers compared with an increase from 56% to 74% in trauma centers (p = 0.01). In patients with splenic injuries, the rate of nonoperative management increased from 35% to 44% in nontrauma centers compared with an increase from 33% to 49% in trauma centers (p < 0.05). The rate of nonoperative management was associated with the organ injury severity, ranging from 90% for minor injuries to 19%-40% for severe injuries. Finally, in an attempt to compare blood use in operatively and nonoperatively treated patients, the total charges for blood were compared in the two groups. When compared, based on organ injury severity, the total blood used, as measured by charges, was lower for nonoperatively treated patients. CONCLUSIONS: This large, statewide, population-based time-series analysis shows that the management of blunt injury of solid abdominal organs has changed over time. The incidence of nonoperative management for both hepatic and splenic injuries has increased. The study indicates that the rates of nonoperative management vary in relation to the severity of the organ injury. The rates increase in nonoperative management were greater in trauma centers than in nontrauma centers. These findings are consistent with the hypothesis that this newer approach to the care of blunt injury of solid abdominal organs is being led by the state's trauma centers.