An analysis of predictors of morbidity after stab wounds of the pancreas in 78 consecutive injuries

Introduction

Penetrating injuries of the pancreas may result in serious complications. This study assessed the factors influencing morbidity after stab wounds of the pancreas.

Methods

A retrospective univariate cohort analysis was carried out of 78 patients (74 men) with a median age of 26 years (range: 16–62 years) with stab wounds of the pancreas between 1982 and 2011.

Results

The median revised trauma score (RTS) was 7.8 (range: 2.0–7.8). Injuries involved the body (n=36), tail (n=24), head/uncinate process (n=16) and neck (n=2) of the pancreas. All 78 patients underwent a laparotomy. Sixty-five patients had AAST (American Association for the Surgery of Trauma) grade I or II pancreatic injuries and thirteen had grade III, IV or V injuries. Eight patients (10.3%) had an initial damage control operation. Sixty-nine patients (84.6%) had drainage of the pancreas only, six had a distal pancreatectomy and one had a pancreaticoduodenectomy.Most pancreas related complications occurred in patients with AAST grade III injuries; eight patients (10.2%) developed a pancreatic fistula. Four patients (5.1%) died. Grade of pancreatic injury (AAST grade I–II vs grade III–V injuries, p<0.001), RTS (odds ratio [OR]: 5.01, 95% confidence interval [CI]: 1.46–17.19, p<0.007), presence of shock on admission (OR: 3.31, 95% CI: 1.16–9.42, p=0.022), need for a blood transfusion (OR: 6.46, 95% CI: 2.40–17.40, p<0.001) and repeat laparotomy (p<0.001) had a significant influence on the development of general complications.

Conclusions

Although mortality was low after a pancreatic stab wound, morbidity was high. Increasing AAST grade of injury, high RTS, shock on admission to hospital, need for blood transfusion and repeat laparotomy were significant factors related to morbidity.     

Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate,but angioembolization helps

BACKGROUND: American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grades IV and V complex hepatic injuries are highly lethal. Our objectives were to review experience and identify predictors of outcome and to evaluate the role of angioembolization in decreasing mortality. METHODS: This was a retrospective 8-year study of all patients sustaining AAST-OIS grades IV and V hepatic injuries managed operatively. Statistical analysis was performed using univariate and multivariate logistic regression. The main outcome measure was survival. RESULTS: The study included 103 patients, with a mean Revised Trauma Score of 5.61 +/- 2.55 and a mean Injury Severity Score of 33 +/- 9.5. Mechanism of injury was penetrating in 80 (79%) and blunt in 23 (21%). Emergency department thoracotomy was performed in 21 (25%). AAST grade IV injuries occurred in 51 (47%) and grade V injuries occurred in 52 (53%). Mean estimated blood loss was 9,414 mL. Overall survival was 43%. Adjusted overall survival rate after emergency department thoracotomy patients were excluded was 58%. Results stratified to AAST-OIS injury grade were as follows: grade IV, 32 of 51 (63%); grade V, 12 of 52 (23%); grade IV versus grade V (p < 0.001) odds ratio, 2.06; 95% confidence interval, 2.72 (1.40-3.04). Logistic regression analysis identified as independent predictors of outcome Revised Trauma Score (adjusted p < 0.0002), angioembolization (adjusted p < 0.0177), direct approach to hepatic veins (adjusted p < 0.0096), and packing (adjusted p < 0.0013). CONCLUSION: Improvements in mortality can be achieved with an appropriate operative approach. Angioembolization as an adjunct procedure decreases mortality in AAST-OIS grades IV and V hepatic injuries.     

胰腺损伤148例诊治分析

目的 探讨胰腺损伤的早期诊断、手术方式和并发症防治.方法 回顾分析20年间收治的胰腺损伤病历资料,包括性别、年龄、伤因、AAST分级、术式和疗效、并发症和死因等,并作统计学处理.结果 全组148例,手术132例,包括修补或仅引流、远端胰切除、远端胰(或囊肿)空肠Roux-n-Y吻合或其他内引流、憩室化、Whipple手术和损伤控制外科方法等术式.术后并发症发生率27.83%.Ⅲ～Ⅴ级与Ⅰ～Ⅱ级伤的胰瘘发生率差异有统计学意义(P＜0.01).病死率11.49%,死因主要为合并伤大出血(76.47%);而胰腺损伤级别间差异无统计学意义(P＞0.05).结论 首先控制合并伤大出血是提高胰腺损伤生存率的关键;术式取决于主胰管是否损伤,清除失活组织、充分外、内引流是胰腺损伤治疗的核心;早期诊断和正确的术式将明显减少并发症.     

Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center

Introduction: We present our experience in the management of penetrating pancreatic injuries, focusing on factors related to complications and death.

Methods: Retrospective trauma registry-based analysis of 62 consecutive patients with penetrating pancreatic injuries during an 11-year period. Overall injury severity was assessed by the injury severity score (ISS) and the penetrating abdominal trauma index (PATI). Pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS). Complications were characterised using standardised definitions. Mortality was recorded as early (within 48 h after admission) and late (after 48 h).

Results: Thirty patients suffered gunshot wounds and 24 had grade I pancreatic injuries. Shotgun and gunshot wounds were more destructive than stab wounds (higher PATI, number of intraabdominal injuries and mortality). Seventeen patients died. Most deaths occurred within 1 h after admission due to massive bleeding and severe associated injuries. Only one death was potentially related to the pancreatic injury. Mortality rate also correlated with pancreatic injury grading. Sixty-one patients had associated intraabdominal injuries. Combined pancreaticoduodenal injuries were present in 13 patients, and five died. Simple drainage was the most common procedure performed. Pancreas-related complications were found in 12 out of 47 patients who survived more than 48 h; intraabdominal abscess (n=7) that was associated with colon injuries, and pancreatic fistula (n=5).

Conclusion: An approach based on injury grade and location is advised. Routine drainage is recommended; distal resection is indicated in the presence of main duct injury, and the management of severe injuries will be tailored according to the overall physiologic status, presence of associated injuries, and duodenal viability. Morbidity and mortality is mainly due to associated injuries.     

Evidence-based validation of the predictive value of the American Association for the Surgery of Trauma kidney injury scale

BACKGROUND: To evaluate the predictive value of the American Association for the Surgery of Trauma (AAST) kidney injury scale for the management of traumatic renal injuries. METHODS: From October 1995 through October 2004, 424 patients presented to our hospital with traumatic renal injury. RESULTS: Overall, 27.8% of patients had grade I injury, 26.4% had grade II injury, 19.3% had grade III injury, 18.2% had grade IV injury, and 8.3% had grade V injury. Patient age, Glasgow Coma Scale score, Revised Trauma Score, creatinine, blood urea nitrogen (BUN), white blood count, gender, substance abuse, shock, flank ecchymosis, abdominal pain, and mortality were not associated with AAST grade. Systolic blood pressure and hematocrit levels decreased with increasing AAST grades (p = 0.032 and p = 0.045, respectively). Volume transfused and length of hospitalization increased with AAST grades (p = 0.003 and p = 0.004, respectively). Patients with gunshot injury had higher AAST grades than those with blunt trauma (p < 0.001). Hypotension (14%), blood transfusion (47%), gross hematuria (65.9%), and flank pain (25%) were associated with higher AAST grades (p = 0.010, p < 0.001, p = 0.016, and p = 0.001, respectively). Ninety patients (21.2%) underwent renal exploration: 61% nephrectomies and 39% renorraphies. In multivariable analyses, type of injury, hematuria at presentation, and AAST scale predicted the risk of renal exploration (p < 0.001, p = 0.024, and p < 0.001, respectively), whereas type of injury and AAST scale were the sole predictors of nephrectomy (p < 0.001 and p < 0.001, respectively). CONCLUSIONS: We confirmed that the AAST injury severity scale is a powerful and valid tool for prediction of clinical outcome in patients with renal trauma.     

Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries

Background

This single-centre study evaluated the efficacy of damage control surgery and delayed pancreatoduodenectomy and reconstruction in patients who had combined severe pancreatic head and visceral venous injuries.

Methods

Prospectively recorded data of patients who underwent an initial damage control laparotomy and a subsequent pancreatoduodenectomy for severe pancreatic injuries were evaluated to assess optimal operative sequencing.

Results

During the 20-year study period, 312 patients were treated for pancreatic injuries of whom 14 underwent a pancreatoduodenectomy. Six (five men, one woman, median age 20, range 16–39 years) of the 14 patients were in extremis with exsanguinating venous bleeding and non-reconstructable AAST grade 5 pancreatoduodenal injuries and underwent a damage control laparotomy followed by delayed pancreatoduodenectomy and reconstruction when stable. During the initial DCS, the blood loss compared to the subsequent laparotomy and definitive procedure was 5456 ml, range 2318–7665 vs 1250 ml, range 850–3600 ml (p < 0.01). The mean total fluid administered in the operating room was 11,150 ml, range 8450–13,320 vs 6850 ml, range 3350–9020 ml (p < 0.01). The mean operating room time was 113 min, range 90–140 vs 335 min, range 260–395 min (p < 0.01). During the second laparotomy five patients had a pylorus-preserving pancreatoduodenectomy and one a standard Whipple resection. Four of the six patients survived. Two patients died in hospital, one of MOF and coagulopathy and the other of intra-abdominal sepsis and multi-organ failure. Median duration of intensive care was 6 days, (range 1–20 days) and median duration of hospital stay was 29 days, (range 1–94 days).

Conclusion

Damage control laparotomy and delayed secondary pancreatoduodenectomy is a live-saving procedure in the small cohort of patients who have dire pancreatic and vascular injuries. When used appropriately, the staged resection and reconstruction allows survival in a previously unsalvageable group of patients who have severe physiological derangement.

     

Determinants of outcome in pancreatic trauma

Pancreatic injury remains a major source of morbidity and mortality. A previous review of this injury from our department confirmed that the failure to recognize major ductal injuries was a key element in poor outcome of these patients. We evaluated a treatment protocol in 72 consecutive patients that categorized injuries into one of four grades: grade I, pancreatic contusion or minor hematoma with an intact capsule and no parenchymal injury; grade II, parenchymal injury without major ductal injury; grade III, parenchymal disruption with presumed ductal injury; and grade IV, severe crush injury. All grade I and most grade II injuries were treated by drainage alone; the grade III and IV injuries were treated by pancreatic resection. Fifty-seven patients survived longer than 24 hours. There were 23 grade I patients. There were only minimal pancreatic complications and no deaths in this group. Of 18 patients with parenchymal injuries (grade II), only one death occurred, which was due to an inaccurate estimation of the degree of injury and delay in proper treatment. Sixteen patients with grade III and IV injuries were treated by resection with only one death, although the complications rose with increasing severity of the pancreatic injury. The mortality rate from pancreatic causes was 3% (2/57), a reduction from that in a previous report from our institution (19%). Our present study confirms the use of a vigorous diagnostic approach to pancreatic injuries, stresses the value of recognition of major ductal injury, and supports the utility of a treatment protocol in which clinical decisions are based on the severity of the pancreatic injury encountered.     

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.     

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

Background

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

Study design

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

Results

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

Conclusions

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

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.     

胰十二指肠切除术后外科相关并发症的分析与处理

目的 探讨胰十二指肠切除术后外科相关并发症发生的原因与处理措施.方法 回顾性研究1995年1月至2010年4月共412例行胰十二指肠切除术患者的临床资料,男性232例,女性180例,分析其术后并发症发生的影响因素与治疗方法.结果 本组中共有153例患者出现并发症214例次,总发生率为37.1%.术后30 d内死亡19例,总病死率4.6%.统计学分析显示,胰腺钩突全切除与否(P=0.022)、胰肠吻合方式(P=0.005)、胰管直径(P=0.007)及残余胰腺质地(P=0.000)与胰瘘的发生具有相关性;未进行胰腺钩突全切除(P=0.002)、术中失血量≥600ml(P=0.000)及合并胰瘘者(P=0.000)术后出血发生率显著增高;保留幽门的胰十二指肠切除术组术后胃排空障碍的发生率显著高于传统胰十二指肠切除术组(P=0.000).多因素Logistic回归分析表明,胰管直径及胰腺质地是影响胰瘘发生的独立危险因素;未进行胰腺钩突全切除、术中失血量≥600ml及胰瘘为影响术后出血的独立危险因素;联合血管切除或腹膜后淋巴清扫的患者与未行血管切除或腹膜后淋巴清扫的患者相比,并发症发生率的差异无统计学意义(P＜0.05).结论 合并慢性胰腺炎及胰管扩张的患者可行胰肠端侧黏膜对黏膜吻合,而端端或端侧套入式吻合更适于胰管不扩张或胰腺质软者;完整切除钩突、术中仔细止血是预防术后出血的重要因素;胰瘘是并发术后出血的重要原因之一.联合肠系膜上静脉或门静脉切除及腹膜后淋巴结清扫不会增加术后并发症的发生率.     

139例胰十二指肠切除术后各种并发症的临床分析

目的：探讨胰十二指肠切除术(PD)后各种并发症的原因及其防治方法。方法：回顾性分析近3年间行胰十二指肠切除术139例患者的临床资料；其中根治性手术91例，同时有43例行联合血管的胰十二指肠切除术。结果：术后发生并发症38例(27.4%)，包括上消化道出血10例(7.2%)，腹腔内出血4例(2.9%)，胰漏6例(4.3%)，胆漏4例(2.9%)，腹腔内感染3例(2.2%)，肺部感染5例(3.6%)，胃肠吻合口功能障碍6例(4.3%)。本组手术后死亡4例，病死率2.9%。结论：出血、胰漏、胆漏和腹腔内感染等是PD术后主要并发症，术中仔细操作并采用合适的吻合方法，术后密切观察和及时积极的处理是减少PD术后并发症和病死率的关键。     

Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial

OBJECTIVE: To determine whether temporary occlusion of the main pancreatic duct with human fibrin glue decreases the incidence of intra-abdominal complications after pancreatoduodenectomy (PD) or distal pancreatectomy (DP). SUMMARY BACKGROUND DATA: To the authors' knowledge, there are no randomized studies comparing outcomes after pancreatic resection with or without main pancreatic duct occlusion by injection of fibrin glue. Of three nonrandomized studies, two reported no fistulas after intracanal injection and ductal occlusion with fibrin glue after PD with immediate pancreatodigestive anastomosis, while another study reported no protective effect of glue injection. METHODS: This prospective, randomized, single-blinded, multicenter study, conducted between January 1995 and January 1999, included 182 consecutive patients undergoing PD followed by immediate pancreatic anastomosis or DP, whether for benign or malignant tumor or for chronic pancreatitis. One hundred two underwent pancreatic resection followed by ductal occlusion with fibrin glue (made slowly resorbable by the addition of aprotinin); 80 underwent resection without ductal occlusion. The main end point was the number of patients with one or more of the following intra-abdominal complications: pancreatic or other digestive tract fistula, intra-abdominal collections (infected or not), acute pancreatitis, or intra-abdominal or digestive tract hemorrhage. Severity factors included postoperative mortality, repeat operations, and length of hospital stay. RESULTS: The two groups were similar in pre- and intraoperative characteristics except that there were significantly more patients in the ductal occlusion group who were receiving octreotide, who had reinforcement of their anastomosis by fibrin glue, and who had fibrotic pancreatic stumps. However, the rate of patients with one or more intra-abdominal complications, and notably with pancreatic fistula, did not differ significantly between the two groups. There was still no significant difference found after statistical adjustment for these patient characteristic discrepancies, confirming the inefficacy of fibrin glue. The rate of intra-abdominal complications was significantly higher in the presence of a normal, nonfibrotic pancreatic stump and main pancreatic duct diameter less than 3 mm, whereas reinforcement of the anastomosis with fibrin glue or use of octreotide did not influence outcome. In multivariate analysis, however, normal pancreatic parenchyma was the only independent risk factor for intra-abdominal complications. No significant differences were found in the severity of complications between the two groups. CONCLUSIONS: Ductal occlusion by intracanal injection of fibrin glue decreases neither the rate nor the severity of intra-abdominal complications after pancreatic resection.     

Does center or surgeon volume influence adoption of minimally invasive versus open pancreatoduodenectomy? A systematic review and meta-regression

BackgroundThere has been increasing uptake of minimally invasive pancreatoduodenectomy during the past decade, but it remains a highly specialized procedure as benefits over open pancreatoduodenectomy remain contentious. This study aimed to evaluate current evidence on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy in terms of impact of center volume on outcomes.MethodsA systematic review of articles on comparative cohort and registry studies on minimally invasive pancreatoduodenectomy versus open pancreatoduodenectomy published until 31st December 2019 were identified, and meta-analyses were performed. Primary endpoints were International Study Group on Pancreatic Fistula grade B/C postoperative pancreatic fistula and 30-day mortality.ResultsAfter screening 7,390 studies, 43 comparative cohort studies (8,755 patients) with moderate methodological quality and 3 original registry studies (43,735 patients) were included. For the cohort studies, the median annual hospital minimally invasive pancreatoduodenectomy volume was 10. No significant differences were found in grade B/C postoperative pancreatic fistula (odds ratio: 0.98, 95% confidence interval: 0.78–1.23) or 30-day mortality (odds ratio: 1.14, 95% confidence interval: 0.65–2.01) between minimally invasive pancreatoduodenectomy when compared with open. No publication biases were present and meta-regression identified no confounding for grade B/C postoperative pancreatic fistula, center volume or 30-day mortality. Minimally invasive pancreatoduodenectomy was only strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection, shorter length of stay, and significantly higher rates of R0 margin resections.ConclusionMinimally invasive pancreatoduodenectomy remains noninferior to open pancreatoduodenectomy for grade B/C postoperative pancreatic fistula but is strongly associated with significantly lower rates of postoperative pulmonary complications and surgical site infection. Minimally invasive pancreatoduodenectomy can be adopted safely with good outcomes irrespective of annual center resection volume.     

Penetrating pancreatic injuries. Analysis of 103 consecutive cases

The optimal management of penetrating pancreatic injuries continues to be a matter of debate and controversy. The present study analyzes 103 consecutive patients with these wounds treated at a level I Trauma Center in a 14-year period (1975-1988). Twenty-seven patients died within 48 hours from extensive associated trauma (Abdominal Trauma Index [ATI] 46.7). The majority of the remaining 76 patients were treated by debridement and drainage. Nineteen patients with grade III injuries had distal pancreatectomy. Six patients with extensive combined pancreatoduodenal injuries had pancreatoduodenectomy. Pancreatoenteric anastomoses or duodenal diversion procedures rarely were used. Pancreatic complications included major fistulas in four patients (5%) and pancreatic abscess in nine patients (11%). Only one of the fistulas required subsequent fistulojejunostomy. Intra-abdominal abscesses occurred in 18 patients (23.6%), mostly in patients with associated colon injury (P less than 0.001). It is concluded that a conservative approach to penetrating pancreatic injuries yields optimal results and that associated colon injury is an important predeterminant for abscess formation.     

Resultados en el tratamiento de traumatismos esplénicos utilizando un protocolo multidisciplinar en 110 pacientes consecutivos en un hospital de nivel II

IntroductionNon-operative treatment (NOM) of splenic trauma is the management of choice in hemodynamically stable patients. The aim of the present study was to assess the failure rate of NOM after implementation of a multidisciplinary protocol for splenic injuries compared to literature results.MethodsA retrospective study was performed over a 16-year period. Patient data and management of splenic trauma was recorded according to our hospital protocol: demographic data, blood pressure, respiratory rate, Glasgow Coma Scale(GCS), Revised Trauma Score(RTS), Injury Severity Score(ISS), injury grade according to the American Association for the Surgery of Trauma(AAST), failure of NOM, morbidity and mortality.ResultsOne hundred ten patients were included: 90(81.8%) men, 20(18.2%) women; mean age 37 years; 106(96.5%) cases were blunt and four(3.5%) penetrating by knife. The diagnosis was established by US/CT. AAST classification: 14(13%) grade I; 24(22%) grade II; 34(31%) grade III; 37(34%) grade IV. Emergency laparotomy was performed in 54 patients: 37 due to grade IV injuries, 17 due to hemodynamic instability. NOM was utilized in 56 patients, spleen-preserving surgery in 16, and splenectomy in 38. Ten patients had postoperative complications: seven in the splenectomy group, two in the spleen-preserving surgery group, and one in the NOM group. One patient died. Average hospital stay: 22.8 days- NOM 17.6 days, conservative surgery 29 days, splenectomy 22.4 days.ConclusionsAlthough we continue with a high hospital stay, the literature reports support our results. The implementation of the protocol by consensus contributed to the change towards NOM.     

Validation of AAST EGS Grade for Acute Pancreatitis

Background

The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods.

Methods

Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014–1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems.

Results

There were 297 patients with a mean (±SD) age of 55?±?17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay.

Conclusions

The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system.Level of Evidence: IVStudy Type: Single institutional retrospective review

     

Pancreatic fistula after pancreatic head resection

BACKGROUND: Pancreatic resections can be performed with great safety. However, the morbidity rate is reported to be 40-60 per cent with a high prevalence of pancreatic complications. The aim of this study was to analyse complications after pancreatic head resection, with particular attention to morbidity and pancreatic fistula. METHODS: From November 1993 to May 1999, perioperative and postoperative data from 331 consecutive patients undergoing pancreatic head resection were recorded prospectively. Data were analysed and grouped according to the procedure performed: classic Whipple resection, pylorus-preserving pancreatoduodenectomy (PPPD) or duodenum-preserving pancreatic head resection (DPPHR). RESULTS: Pancreatic head resection had a mortality rate of 2.1 per cent; the difference in mortality rate between the three groups (0.9-3.0 per cent) was not significant. Total and local morbidity rates were 38.4 and 28 per cent respectively. DPPHR had a lower morbidity, both local and systemic, than pancreatoduodenectomy. The prevalence of pancreatic fistula was 2.1 per cent in 331 patients, and was not dependent on the procedure or the aetiology of the disease. Reoperations were performed in 3.9 per cent of patients, predominantly for bleeding and non-pancreatic fistula. None of the patients with pancreatic fistula required reoperation or died in the postoperative course. CONCLUSION: A standardized technique and a continuing effort to improve perioperative management may be responsible for low mortality and surgical morbidity rates after pancreatic head resection. Pancreatic complications occur with Whipple, PPPD and DPPHR procedures with a similar prevalence. Pancreatic fistula no longer seems to be a major problem after pancreatic head resection and rarely necessitates surgical treatment.     

再手术在胰十二指肠切除术后并发症处理中的疗效评价

目的探讨再手术在胰十二指肠切除（PD）术后并发症处理中的疗效。方法回顾性分析1986年1月至2005年12月间我院施行的392例PD术后并发症及再手术的原因、诊断、处理方式及疗效。结果PD术后并发症133例（33．9％），死亡14例（3．6％）。其中22例再手术，再手术的死亡3例，再手术死亡率13．6％。结论导致PD术后再手术主要并发症有出血、胰瘘和切口裂开等。再手术是处理PD术后并发症的一个有效手段且不增加手术死亡率。     

保留十二指肠胰头勺式切除术治疗慢性胰腺炎合并胰管结石的前瞻性研究

目的探讨保留十二指肠的胰头勺式切除术治疗慢性胰腺炎合并Ⅰ、Ⅲ型胰管结石患者的疗效。方法前瞻性分析2008年6月至2013年6月湖南省人民医院收治的55例慢性胰腺炎合并Ⅰ、Ⅲ型胰管结石患者的临床资料,按随机数字表法将患者分为经典组27例（行胰十二指肠切除术）和勺式组28例（行保留十二指肠的胰头勺式切除术）。经典组患者中慢性胰腺炎合并Ⅰ型胰管结石18例,合并Ⅲ型胰管结石9例。勺式组患者中慢性胰腺炎合并Ⅰ型胰管结石16例,合并Ⅲ型胰管结石12例。经典组患者行传统胰十二指肠切除术,消化道重建采用Child吻合,胰肠吻合采用胰腺空肠端侧套入式吻合,放置胰管支撑管。胆肠吻合采用空肠与胆总管端侧连续吻合。勺式组患者行保留十二指肠的胰头勺式切除术,作Kocher切口,游离十二指肠,采用“四边法”向胰头方向切开胰管。距离十二指肠边缘1cm处切除胰管前方的胰腺组织,暴露胰头部的各分支胰管,取尽结石,沟通主胰管。对合并Ⅲ型胰管结石的患者,必要时可剖开胰体尾部的胰管取石。消化道重建采用胰勺面空肠Roux—en—Y吻合术。采用门诊随访,随访时间截至2013年12月。计量资料采用t检验和Mann—WhitneyU秩和检验,计数资料采用矿检验。结果术中经典组2例患者改行保留十二指肠的胰头勺式切除术,勺式组1例患者改行胰十二指肠切除术。经典组实际施行手术人数为26例,勺式组为29例。所有患者围手术期无死亡,腹痛、腹泻等消化道症状多在术后2周左右得以改善。经典组患者手术时间为（7．5±1．6）h,出血量为（460±88）mL,术后住院时问为（18．0±3．5）d,住院费用为（7．8±2．1）万元,并发症发生率为19．2％（5／26）。勺式组患者手术时间为（4．0±1．0）h,出血量为（120±36）mL,术后住院时间为（9．5±2．9）d,住院费用为（3．9±1．2）万元,并发症发生率为3．4％（1／29）。两组患者在手术时间、出血量、术后住院时间、住院费用及并发症发生率等方面比较,差异均有统计学意义（t=9．358,11．365,6．325,8．647,x2=3．976,P〈0．05）。53例患者获得随访,中位随访时间为33个月（6个月至5年）,随访期间无患者死亡。经典组患者中24例获得随访,其中2例患者术后仍有轻微腹痛,1例腹痛剧烈,诊断为胰肠吻合口处胰管开口狭窄,经再次手术切除部分胰体组织后缓解;19例合并糖尿病的患者中12例病情好转或血糖恢复正常。勺式组患者均获得随访,其中2例术后轻微腹痛,疼痛时间较为短暂,未行处理;22例合并糖尿病的患者中16例血糖恢复正常。结论对慢性胰腺炎并Ⅰ、Ⅲ型胰管结石的患者,保留十二指肠的胰头勺式切除术是较为理想的术式。