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Krige JE, Jonas EG, Nicol AJ, Navsaria PH. Pancreaticoduodenectomy in high-grade pancreatic and duodenal trauma. Injury 2025; 56:112048. [PMID: 39608132 DOI: 10.1016/j.injury.2024.112048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2024] [Accepted: 11/17/2024] [Indexed: 11/30/2024]
Affiliation(s)
- Jake E Krige
- Surgical Gastroenterology Unit, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
| | - Eduard G Jonas
- Surgical Gastroenterology Unit, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
| | - Andrew J Nicol
- Trauma Centre, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
| | - Pradeep H Navsaria
- Trauma Centre, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
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Choron RL, Piplani C, Kuzinar J, Teichman AL, Bargoud C, Sciarretta JD, Smith RN, Hanos D, Afif IN, Beard JH, Dhillon NK, Zhang A, Ghneim M, Devasahayam R, Gunter O, Smith AA, Sun B, Cao CS, Reynolds JK, Hilt LA, Holena DN, Chang G, Jonikas M, Echeverria-Rosario K, Fung NS, Anderson A, Fitzgerald CA, Dumas RP, Levin JH, Trankiem CT, Yoon J, Blank J, Hazelton JP, McLaughlin CJ, Al-Aref R, Kirsch JM, Howard DS, Scantling DR, Dellonte K, Vella MA, Hopkins B, Shell C, Udekwu P, Wong EG, Joseph B, Lieberman H, Ramsey WA, Stewart CH, Alvarez C, Berne JD, Nahmias J, Puente I, Patton J, Rakitin I, Perea L, Pulido O, Ahmed H, Keating J, Kodadek LM, Wade J, Henry R, Schreiber M, Benjamin A, Khan A, Mann LK, Mentzer C, Mousafeiris V, Mulita F, Reid-Gruner S, Sais E, Foote CW, Palacio CH, Argandykov D, Kaafarani H, Bover Manderski MT, Moko L, Narayan M, Seamon M. Pancreaticoduodenectomy in trauma patients with grade IV-V duodenal or pancreatic injuries: a post hoc analysis of an EAST multicenter trial. Trauma Surg Acute Care Open 2024; 9:e001438. [PMID: 39717488 PMCID: PMC11664373 DOI: 10.1136/tsaco-2024-001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 11/04/2024] [Indexed: 12/25/2024] Open
Abstract
Introduction The utility of pancreaticoduodenectomy (PD) for high-grade traumatic injuries remains unclear and data surrounding its use are limited. We hypothesized that PD does not result in improved outcomes when compared with non-PD surgical management of grade IV-V pancreaticoduodenal injuries. Methods This is a retrospective, multicenter analysis from 35 level 1 trauma centers from January 2010 to December 2020. Included patients were ≥15 years of age with the American Association for the Surgery of Trauma grade IV-V duodenal and/or pancreatic injuries. The study compared operative repair strategy: PD versus non-PD. Results The sample (n=95) was young (26 years), male (82%), with predominantly penetrating injuries (76%). There was no difference in demographics, hemodynamics, or blood product requirement on presentation between PD (n=32) vs non-PD (n=63). Anatomically, PD patients had more grade V duodenal, grade V pancreatic, ampullary, and pancreatic ductal injuries compared with non-PD patients (all p<0.05). 43% of all grade V duodenal injuries and 40% of all grade V pancreatic injuries were still managed with non-PD. One-third of non-PD duodenal injuries were managed with primary repair alone. PD patients had more gastrointestinal (GI)-related complications, longer intensive care unit length of stay (LOS), and longer hospital LOS compared with non-PD (all p<0.05). There was no difference in mortality or readmission. Multivariable logistic regression analysis determined PD to be associated with a 3.8-fold greater odds of GI complication (p=0.010) compared with non-PD. In a subanalysis of patients without ampullary injuries (n=60), PD patients had more anastomotic leaks compared with the non-PD group (3 (30%) vs 2 (4%), p=0.028). Conclusion While PD patients did not have worse hemodynamics or blood product requirements on admission, they sustained more complex anatomic injuries and had more GI complications and longer LOS than non-PD patients. We suggest that the role of PD should be limited to cases of massive destruction of the pancreatic head and ampullary complex, given the likely procedure-related morbidity and adverse outcomes when compared with non-PD management. Level of evidence IV, Multicenter retrospective comparative study.
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Affiliation(s)
- Rachel Leah Choron
- Surgery, Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Charoo Piplani
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Julia Kuzinar
- Surgery, Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Amanda L Teichman
- Surgery, Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Christopher Bargoud
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | | | - Randi N Smith
- Trauma/Surgical Critical Care, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dustin Hanos
- Grady Memorial Hospital Corp, Atlanta, Georgia, USA
| | - Iman N Afif
- Temple University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Ashling Zhang
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mira Ghneim
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | | | - Oliver Gunter
- Trauma/Surgical Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alison A Smith
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Brandi Sun
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Chloe S Cao
- University of Kentucky, Lexington, Kentucky, USA
| | | | - Lauren A Hilt
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Grace Chang
- Surgery, Mount Sinai Hospital, Chicago, Illinois, USA
| | - Meghan Jonikas
- Department of Surgery, Mount Sinai Hospital, Chicago, Illinois, USA
| | | | - Nathaniel S Fung
- Riverside University Health System Medical Center, Moreno Valley, California, USA
| | - Aaron Anderson
- Indiana University Health Methodist Hospital, Indianapolis, Indiana, USA
| | | | | | - Jeremy H Levin
- Indiana University Health Methodist Hospital, Indianapolis, Indiana, USA
| | | | - JaeHee Yoon
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Jacqueline Blank
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | - Rami Al-Aref
- Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | | | | | | | | | - Michael A Vella
- Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Chloe Shell
- WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | - Pascal Udekwu
- Surgery, WakeMed Health and Hospitals, Raleigh, North Carolina, USA
| | | | - Bellal Joseph
- University of Arizona Medical Center - University Campus, Tucson, Arizona, USA
| | | | | | - Collin H Stewart
- University of Arizona Medical Center - University Campus, Tucson, Arizona, USA
| | - Claudia Alvarez
- University of California Irvine School of Medicine, Irvine, California, USA
| | - John D Berne
- Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | - Jeffry Nahmias
- University of California Irvine School of Medicine, Irvine, California, USA
| | - Ivan Puente
- Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | - Joe Patton
- Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | | | - Lindsey Perea
- Lancaster General Health, Lancaster, Pennsylvania, USA
| | - Odessa Pulido
- Lancaster General Health, Lancaster, Pennsylvania, USA
| | - Hashim Ahmed
- Surgery, Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, Texas, USA
| | | | - Lisa M Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale New Haven Hospital, New Haven, CT, USA
| | - Jason Wade
- Hartford Hospital, Hartford, Connecticut, USA
| | - Reynold Henry
- Oregon Health & Science University, Portland, Oregon, USA
| | - Martin Schreiber
- Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Abid Khan
- The University of Chicago Medicine, Chicago, Illinois, USA
| | - Laura K Mann
- Spartanburg Regional Medical Center, Spartanburg, South Carolina, USA
| | - Caleb Mentzer
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | | | | | - Shari Reid-Gruner
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Erica Sais
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | - Lilamarie Moko
- Surgery, Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Mayur Narayan
- Surgery, Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Mark Seamon
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Krige J, Jonas E, Nicol AJ, Navsaria PH. Resection and reconstruction in high-grade pancreatic head injuries. World J Gastrointest Surg 2024; 16:1467-1469. [PMID: 38817297 PMCID: PMC11135313 DOI: 10.4240/wjgs.v16.i5.1467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/03/2024] [Accepted: 04/18/2024] [Indexed: 05/23/2024] Open
Abstract
This study by Chui et al adds further important evidence in the treatment of high-grade pancreatic injuries and endorses the concept of the model of pancreatic trauma care designed to optimize treatment, minimize morbidity and enhance survival in patients with complex pancreatic injuries. Although the authors have demonstrated favorable outcomes based on their limited experience of 5 patients who underwent a pancreaticoduodenectomy (PD), including 2 patients who were "unstable" and did not have damage control surgery (DCS), we would caution against the general recommendations promoting index PD without DCS in "unstable" grade 5 pancreatic head injuries.
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Affiliation(s)
- Jake Krige
- HPB Surgery, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Eduard Jonas
- HPB Surgery, University of Cape Town Health Sciences Faculty, Cape Town 7925, Western Cape, South Africa
| | - Andrew John Nicol
- Trauma Center, Department of Surgery, Groote Schuur Hospital, Cape Town 7925, Western Cape, South Africa
| | - Pradeep Harkson Navsaria
- Department of Surgery, Trauma Center, Groote Schuur Hosp, Cape Town 7925, Western Cape, South Africa
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Krige JE, Jonas EG, Nicol AJ, Navsaria PH. Letter to the Editor: Management and Outcome of Blunt Pancreatic Trauma: A Retrospective Cohort Study. World J Surg 2023; 47:2940-2941. [PMID: 37505310 DOI: 10.1007/s00268-023-07120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Jake E Krige
- HPB Unit, Surgical Gastroenterology and Trauma Centre, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa.
| | - Eduard G Jonas
- HPB Unit, Surgical Gastroenterology and Trauma Centre, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
| | - Andrew J Nicol
- HPB Unit, Surgical Gastroenterology and Trauma Centre, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
| | - Pradeep H Navsaria
- HPB Unit, Surgical Gastroenterology and Trauma Centre, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
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Krige JEJ, Jonas EG, Nicol AJ, Navsaria PH. Expedient management of complex grade V pancreaticoduodenal injuries. Eur J Trauma Emerg Surg 2023; 49:2319-2320. [PMID: 37526709 DOI: 10.1007/s00068-023-02329-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 08/02/2023]
Affiliation(s)
- Jake E J Krige
- HPB Unit, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa.
| | - Eduard G Jonas
- HPB Unit, Department of Surgery, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
| | - Andrew J Nicol
- Surgical Gastroenterology and Trauma Centre, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
| | - Pradeep H Navsaria
- Surgical Gastroenterology and Trauma Centre, Groote Schuur Hospital and University of Cape Town Health Sciences Faculty, Observatory, Cape Town, 7925, South Africa
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Chui JN, Kotecha K, Gall TMH, Mittal A, Samra JS. Surgical management of high-grade pancreatic injuries: Insights from a high-volume pancreaticobiliary specialty unit. World J Gastrointest Surg 2023; 15:834-846. [PMID: 37342855 PMCID: PMC10277947 DOI: 10.4240/wjgs.v15.i5.834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/22/2023] [Accepted: 03/14/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND The management of high-grade pancreatic trauma is controversial. AIM To review our single-institution experience on the surgical management of blunt and penetrating pancreatic injuries. METHODS A retrospective review of records was performed on all patients undergoing surgical intervention for high-grade pancreatic injuries [American Association for the Surgery of Trauma (AAST) Grade III or greater] at the Royal North Shore Hospital in Sydney between January 2001 and December 2022. Morbidity and mortality outcomes were reviewed, and major diagnostic and operative challenges were identified. RESULTS Over a twenty-year period, 14 patients underwent pancreatic resection for high-grade injuries. Seven patients sustained AAST Grade III injuries and 7 were classified as Grades IV or V. Nine underwent distal pancreatectomy and 5 underwent pancreaticoduodenectomy (PD). Overall, there was a predominance of blunt aetiologies (11/14). Concomitant intra-abdominal injuries were observed in 11 patients and traumatic haemorrhage in 6 patients. Three patients developed clinically relevant pancreatic fistulas and there was one in-hospital mortality secondary to multi-organ failure. Among stable presentations, pancreatic ductal injuries were missed in two-thirds of cases (7/12) on initial computed tomography imaging and subsequently diagnosed on repeat imaging or endoscopic retrograde cholangiopancreatography. All patients who sustained complex pancreaticoduodenal trauma underwent PD without mortality. The management of pancreatic trauma is evolving. Our experience provides valuable and locally relevant insights into future management strategies. CONCLUSION We advocate that high-grade pancreatic trauma should be managed in high-volume hepato-pancreato-biliary specialty surgical units. Pancreatic resections including PD may be indicated and safely performed with appropriate specialist surgical, gastroenterology, and interventional radiology support in tertiary centres.
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Affiliation(s)
- Juanita Noeline Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, NSW, Australia
| | - Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
| | - Tamara MH Gall
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, NSW, Australia
- Department of Surgery, University of Notre Dame, Sydney 2006, NSW, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney 2006, NSW, Australia
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Bolaji T, Ratnasekera A, Ferrada P. Management of the complex duodenal injury. Am J Surg 2023; 225:639-644. [PMID: 36588016 DOI: 10.1016/j.amjsurg.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Complex duodenal trauma is a rare injury with an incidence of 1-4.7% of all abdominal trauma. Historically, varied approaches have been used in the management of these complex injuries and the prevention of complications. This is a review of the current management methodology of complex duodenal injury. METHODS A review of the medical literature to include the past and current management of duodenal trauma was performed. Google scholar (1970-2022) and PubMed (1970-2022) were searched using the keywords: complex duodenal trauma, surgical management, and duodenal complications. DISCUSSION Complex duodenal trauma can be classified using the AAST grading scale as those encompassing grades III-V. Multiple studies and review articles characterize the difficulty in managing complex duodenal injuries. The tenets of operative management of duodenal trauma include the decision for damage control, resection of non-viable tissue, restoring gastrointestinal continuity, diversion of gastrointestinal contents, bile and pancreatic enzymes, allowing the repair to heal, and providing feeding access. The variety of both historic and current approaches attempt to address these tenets. The incidence of complications are as high as 65% with the most common complications including abscess formation, suture line dehiscence and fistula formation. The overall mortality ranges from 5 to 30%. CONCLUSIONS Many different approaches and strategies have been proposed to repair complex duodenal injuries, all of which address important tenets of its management. The risk of complications remains high, therefore, it is vital to have a thoughtful and multidisciplinary approach when treating these injuries.
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Affiliation(s)
- Toba Bolaji
- ChristianaCare, 4755 OgletownStanton Rd, Newark, DE, 19718, United States.
| | | | - Paula Ferrada
- Inova Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, United States
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Feliciano DV. 2022 Excelsior Surgical Society/Edward D Churchill Lecture: Extraordinary Evolution of Surgery for Abdominal Trauma. J Am Coll Surg 2023; 236:439-448. [PMID: 36730657 DOI: 10.1097/xcs.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- David V Feliciano
- From the Shock Trauma Center/Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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Feng J, Zhang HY, Yan L, Zhu ZM, Liang B, Wang PF, Zhao XQ, Chen YL. Feasibility and safety of “bridging” pancreaticogastrostomy for pancreatic trauma in Landrace pigs. World J Gastrointest Surg 2021; 13:419-428. [PMID: 34122732 PMCID: PMC8167843 DOI: 10.4240/wjgs.v13.i5.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/20/2021] [Accepted: 04/26/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In recent years, we created and employed a new anastomosis method, “bridging” pancreaticogastrostomy, to treat patients with extremely severe pancreatic injury. This surgery has advantages such as short length of surgery, low secondary trauma, rapid construction of shunts for pancreatic fluid, preventing second surgeries, and achieving good treatment outcomes in clinical practice. However, due to the limited number of clinical cases, there is a lack of strong evidence to support the feasibility and safety of this surgical procedure. Therefore, we carried out animal experiments to examine this procedure, which is reported here.
AIM To examine the feasibility and safety of a new rapid method of pancreaticogastrostomy, “bridging” pancreaticogastrostomy.
METHODS Ten Landrace pigs were randomized into the experimental and control groups, with five pigs in each group. “Bridging” pancreaticogastrostomy was performed in the experimental group, while routine mucosa-to-mucosa pancreaticogastrostomy was performed in the control group. After surgery, the general condition, amylase levels in drainage fluid on Days 1, 3, 5, and 7, fasting and 2-h postprandial blood glucose 6 mo after surgery, fasting, 2-h postprandial peripheral blood insulin, and portal vein blood insulin 6 mo after surgery were assessed. Resurgery was carried out at 1 and 6 mo after the former one to examine the condition of the abdominal cavity and firmness and tightness of the pancreaticogastric anastomosis and pancreas.
RESULTS After surgery, the general condition of the animals was good. One in the control group did not gain weight 6 mo after surgery, whereas significant weight gain was present in the others. There were significant differences on Days 1 and 3 after surgery between the two groups but no differences on Days 5 and 7. There were no differences in fasting and 2-h postprandial blood glucose and fasting and 2-h insulin values of postprandial peripheral blood and portal vein blood 6 mo after surgery between the two groups. One month after surgery, the sinus tract orifice/anastomosis was patent in the two groups. Six months after surgery, the sinus tract orifice/anastomosis was sealed, and pancreases in both groups presented with chronic pancreatitis.
CONCLUSION “Bridging” pancreaticogastrostomy is a feasible and safe a means of damage control surgery during the early stage of pancreatic injury.
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Affiliation(s)
- Jian Feng
- Department of Hepatopancreatobiliary Surgery, Peking University Shougang Hospital, Beijing 100144, China
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Hang-Yu Zhang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Li Yan
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Zi-Man Zhu
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Bin Liang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Peng-Fei Wang
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiang-Qian Zhao
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Yong-Liang Chen
- Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
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Biffl WL, Zhao FZ, Morse B, McNutt M, Lees J, Byerly S, Weaver J, Callcut R, Ball CG, Nahmias J, West M, Jurkovich GJ, Todd SR, Bala M, Spalding C, Kornblith L, Castelo M, Schaffer KB, Moore EE. A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries. J Trauma Acute Care Surg 2021; 90:776-786. [PMID: 33797499 DOI: 10.1097/ta.0000000000003080] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. METHODS Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate. RESULTS Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. CONCLUSION Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice. LEVEL OF EVIDENCE Retrospective diagnostic/therapeutic study, level III.
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Affiliation(s)
- Walter L Biffl
- From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO
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Paulino J, Vigia E, Cunha M, Amorim E. Two-stage pancreatic head resection after previous damage control surgery in trauma: two rare case reports. BMC Surg 2020; 20:98. [PMID: 32397989 PMCID: PMC7216496 DOI: 10.1186/s12893-020-00763-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background This study describes the successful treatment of two clinical settings of grade V pancreaticoduodenal blunt trauma only possible due to the prompt collaboration of a peripheral trauma hospital and a central hepatobiliary and pancreatic unit. Case presentation We reviewed the clinical records of two male patients aged 17 and 47 years old who underwent a two-stage pancreaticoduodenectomy after a previous Damage-Control Surgery (DCS). Both patients were transferred to our Hepatobiliopancreatic Unit 2 days after immediate DCS with haemostasis, debridement, duodenostomy, gastroenterostomy, external drainage and laparostomy. One day after, they both underwent a two-stage Whipple’s procedure with external cannulation of the main bile duct and the main pancreatic duct with seized calibre silicone drains through the skin. The reconstructive phase was performed two weeks later. The first patient had an uneventful post-operative course and was discharged on post-operative day 8. The second patient developed a high debt biliary fistula on post-operative day 5 being submitted to a relaparotomy with extensive peritoneal lavage. After conservative measures the fistula underwent a progressive closure in 15 days, and the patient was discharged at post-operative day 50 without any limitations. Conclusions Pancreaticoduodenectomy is a life-saving operation in selected grade V pancreaticoduodenal trauma lesions. DCS is a salvage approach, often performed in peripheral hospitals, making an early referral to an hepatobiliopancreatic centre mandatory to achieve survival in these severely injured patients. A two-staged Whipple’s operation for severe duodenal / pancreatic trauma can be performed safely and may represent a life-saving option under these very unusual circumstances.
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Affiliation(s)
- Jorge Paulino
- Centro Hepatobiliopancreático e de Transplantação, Centro Hospitalar Universitário de Lisboa Central, Hospital Curry Cabral, Universidade Nova de Lisboa, Lisboa, Portugal.
| | - Emanuel Vigia
- Centro Hepatobiliopancreático e de Transplantação, Centro Hospitalar Universitário de Lisboa Central, Hospital Curry Cabral, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Miguel Cunha
- Department of Surgery, Centro Hospitalar Universitário do Algarve - Unidade de Portimão, Portimão, Portugal
| | - Edgar Amorim
- Department of Surgery, Centro Hospitalar Universitário do Algarve - Unidade de Portimão, Portimão, Portugal
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Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y, Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14:56. [PMID: 31867050 PMCID: PMC6907251 DOI: 10.1186/s13017-019-0278-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022] Open
Abstract
Duodeno-pancreatic and extrahepatic biliary tree injuries are rare in both adult and pediatric trauma patients, and due to their anatomical location, associated injuries are very common. Mortality is primarily related to associated injuries, but morbidity remains high even in isolated injuries. Optimal management of duodeno-bilio-pancreatic injuries is dictated primarily by hemodynamic stability, clinical presentation, and grade of injury. Endoscopic and percutaneous interventions have increased the ability to non-operatively manage these injuries. Late diagnosis and treatment are both associated to increased morbidity and mortality. Sequelae of late presentations of pancreatic injury and complications of severe pancreatic trauma are also increasingly addressed endoscopically and with interventional radiology procedures. However, for moderate and severe extrahepatic biliary and severe duodeno-pancreatic injuries, immediate operative intervention is preferred as associated injuries are frequent and commonly present with hemodynamic instability or peritonitis. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) duodenal, pancreatic, and extrahepatic biliary tree trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Leslie Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital, La Jolla, CA USA
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Imitiaz Wani
- Department of Surgery, DHS Hospitals, Srinagar, Kashmir India
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta Canada
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Gustavo Pereira Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Carlos Ordonez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Emmanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Maria Grazia Sibilla
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Yosuke Matsumura
- Department of Emergency and Critical Care Medicine, Chiba University Hospital, Chiba, Japan
| | - Peter T. Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mazyr, Belarus
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics and Gynecology, University of Buea, Buea, Cameroon
| | - Rao Ivatury
- General and Trauma Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Francesco Favi
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Fernando Machado
- General and Emergency Surgery Department, Montevideo Hospital, Montevideo, Uruguay
| | - Junichi Matsumoto
- Department of Emergency and Critical Care Medicine, Saint-Marianna University School of Medicine, Kawasaki, Japan
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes, UGA-Université Grenoble Alpes, Grenoble, France
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
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Brillantino A, Andreano M, Lanza M, D'Ambrosio V, Fusco F, Antropoli M, Lucia A, Zito ES, Forner A, Ambrosino F, Monte G, Cricrì AM, Robustelli U, De Masi A, Calce R, Ciardiello G, Renzi A, Castriconi M. Advantages of Damage Control Strategy With Abdominal Negative Pressure and Instillation in Patients With Diffuse Peritonitis From Perforated Diverticular Disease. Surg Innov 2019; 26:656-661. [PMID: 31221028 DOI: 10.1177/1553350619857561] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients' conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann's procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann's procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.
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Mwita C, Negesa R, Boeck M, Wandera A. Open abdomen management and outcomes: two case reports from western Kenya and a review of literature from Africa. Pan Afr Med J 2019; 32:33. [PMID: 31143338 PMCID: PMC6522152 DOI: 10.11604/pamj.2019.32.33.17859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 01/09/2019] [Indexed: 01/06/2023] Open
Abstract
The open abdomen (OA) is clinically indicated for attenuating the effects of select intra-abdominal insults that may lead to high intra-abdominal pressure with fascial closure. Despite the high incidence of conditions warranting OA in Africa, there are few reports on its use and outcomes. A retrospective chart review was performed for two patients managed with an OA at the Moi Teaching and Referral Hospital. For comparison, a literature review on related studies from Africa was performed. One patient had an anastomotic leak, while the other had a perforated gastric ulcer. A Bogotá bag was used for temporary abdominal content containment. There was no mortality in our series and fascial closure was achieved in one patient. Upon review of studies from Africa, overall mortality stood at 44%, while 25% of surviving patients underwent fascial closure. The use of OA in Africa is associated with high mortality and low rates of fascial closure. Our limited experience shows this technique is a viable treatment option in an attempt to bridge a patient to abdominal closure during critical illness.
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Affiliation(s)
- Clifford Mwita
- Department of Surgery and Anesthesiology, Moi University School of Medicine, Eldoret, Kenya.,Afya Research Africa, Nairobi, Kenya
| | - Ruth Negesa
- Department of Surgery and Anesthesiology, Moi University School of Medicine, Eldoret, Kenya
| | - Marissa Boeck
- Department of Surgery, New York-Presbyterian Hospital/Columbia, New York, United State of America
| | - Andrew Wandera
- Department of Surgery and Anesthesiology, Moi University School of Medicine, Eldoret, Kenya
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Søreide K, Weiser TG, Parks RW. Clinical update on management of pancreatic trauma. HPB (Oxford) 2018; 20:1099-1108. [PMID: 30005994 DOI: 10.1016/j.hpb.2018.05.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma. METHODS Systematic literature review until May 2018. RESULTS Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries. CONCLUSION Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.
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Affiliation(s)
- Kjetil Søreide
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Clinical Medicine, University of Bergen, Norway; Department of Gastrointestinal Surgery, Stavanger University Hospital, Norway.
| | - Thomas G Weiser
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Stanford University Department of Surgery, Section of Trauma and Critical Care, Stanford, CA, USA
| | - Rowan W Parks
- Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK
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Abstract
PURPOSE To examine surgical outcomes of children with pancreaticoduodenal injuries at a Quaternary Level I pediatric trauma center. METHODS We queried a prospectively maintained trauma database of a level one pediatric trauma center for all cases of pancreatic and/or duodenal injury from 2002 to 2017. Analysis was conducted using JMP 13.1.0. RESULTS 170 children presented with pancreatic and/or duodenal injury. 13 (7.7%) suffered a combined injury and this group forms the basis for this report with mean ISS of 22.8 (± 15.1), RTS2 of 6.4(± 2.1), and median age of 6.6 (1.3-13.5) years. Child abuse (31%) and bicycle injuries (23%) were the most common mechanisms. 8/13 (61.5%) required operative intervention. Higher AAST pancreatic and duodenal injury grade (2.9 vs. 1.2, p = 0.05 and 3.6 vs. 1.4, p = < 0.01), lower RTS2 (7.84 vs. 5.49, p < 0.01), and lower GCS (9.6 vs. 15, p = 0.03) predicted operative intervention. 6/8 (75%) undergoing surgery survived to discharge with only (2/6) survivors suffering postoperative complications. Both mortalities were secondary to severe traumatic brain injury. CONCLUSION Surgical management of complex pancreaticoduodenal injury is an uncommon traumatic event that is associated with high injury severity, but survival occurs in most scenarios.
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Managing grade 5 pancreatic injuries-Think smart, act smart, and call in the pancreatic cavalry early. J Trauma Acute Care Surg 2017; 82:1187-1188. [PMID: 28520690 DOI: 10.1097/ta.0000000000001459] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kilen P, Greenbaum A, Miskimins R, Rojo M, Preda R, Howdieshell T, Lu S, West S. General surgeon management of complex hepatopancreatobiliary trauma at a level I trauma center. J Surg Res 2017; 217:226-231. [PMID: 28602224 DOI: 10.1016/j.jss.2017.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/20/2017] [Accepted: 05/03/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of general surgeons (GS) taking trauma call on patient outcomes has been debated. Complex hepatopancreatobiliary (HPB) injuries present a particular challenge and often require specialized care. We predicted no difference in the initial management or outcomes of complex HPB trauma between GS and trauma/critical care (TCC) specialists. MATERIALS AND METHODS A retrospective review of patients who underwent operative intervention for complex HPB trauma from 2008 to 2015 at an ACS-verified level I trauma center was performed. Chart review was used to obtain variables pertaining to demographics, clinical presentation, operative management, and outcomes. Patients were grouped according to whether their index operation was performed by a GS or TCC provider and compared. RESULTS 180 patients met inclusion criteria. The GS (n = 43) and TCC (n = 137) cohorts had comparable patient demographics and clinical presentations. Most injuries were hepatic (73.3% GS versus 72.6% TCC) and TCC treated more pancreas injuries (15.3% versus GS 13.3%; P = 0.914). No significant differences were found in HPB-directed interventions at the initial operation (41.9% GS versus 56.2% TCC; P = 0.100), damage control laparotomy with temporary abdominal closure (69.8% versus 69.3%; P = 0.861), LOS, septic complications or 30-day mortality (13.9% versus 10.2%; P = 0.497). TCC were more likely to place an intraabdominal drain than GS (52.6% versus 34.9%; P = 0.043). CONCLUSIONS We found no significant differences between GS and TCC specialists in initial operative management or clinical outcomes of complex HPB trauma. The frequent and proper use of damage control laparotomy likely contribute to these findings.
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Affiliation(s)
- Peter Kilen
- School of Medicine, University of New Mexico Health Sciences Center, School of Medicine, Albuquerque, New Mexico
| | - Alissa Greenbaum
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Richard Miskimins
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Manuel Rojo
- School of Medicine, University of New Mexico Health Sciences Center, School of Medicine, Albuquerque, New Mexico
| | - Razvan Preda
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Thomas Howdieshell
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Stephen Lu
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Sonlee West
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico.
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21
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Treating complex pancreatic injuries. Trauma and pancreatic surgeons working together is the modern management paradigm. J Visc Surg 2017; 154:143. [PMID: 28427788 DOI: 10.1016/j.jviscsurg.2017.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Krige JE, Spence RT, Navsaria PH, Nicol AJ. Development and validation of a pancreatic injury mortality score (PIMS) based on 473 consecutive patients treated at a level 1 trauma center. Pancreatology 2017; 17:592-598. [PMID: 28596059 DOI: 10.1016/j.pan.2017.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/13/2017] [Accepted: 04/15/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study sought to develop a pancreatic injury mortality score (PIMS) to identify patients at greatest risk of in-hospital mortality after a major pancreatic injury. METHODS The study used data from a prospective database of 473 patients treated for pancreatic injuries between January 1990 and December 2015. Two thirds of the patients were assigned to the derivation cohort and one third to the validation cohort. Clinical correlates of in-hospital death were identified and considered in stepwise logistic regression analyses that identified the factors included in the risk index. RESULTS Five variables, age >55, shock on admission, a vascular injury, number of associated injuries and American Association for the Study of Trauma (AAST) pancreatic injury scale correlated with in-hospital death and were used to calculate PIMS. The final score ROC in the derivation dataset was 0.84 (95% CI 0.79-0.89) and in the validation dataset was 0.91 (95% CI 0.84-0.97), which were comparable (p = 0.1). Finally, cut-off scores were used to generate three risk groups and the rate of mortality within the low (PIMS 0-4), medium (PIMS 5-9), and high risk (PIMS 10-20) groups were not significantly different. The scoring system was tested in a validation cohort and showed good calibration and discrimination for in-hospital mortality. CONCLUSIONS We have derived and validated the PIMS, a novel organ-specific risk prediction score calculated from five variables for in-hospital mortality following major pancreatic trauma. PIMS is simple, quick and easily understandable, increases clinical risk prediction for patients with complex pancreatic and can be used as a benchmark for survival.
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Affiliation(s)
- Jake E Krige
- Department of Surgery, Groote Schuur Hospital, Observatory, Cape Town, South Africa; University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Observatory, Cape Town, South Africa.
| | - Richard T Spence
- Department of Surgery, Groote Schuur Hospital, Observatory, Cape Town, South Africa; Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Pradeep H Navsaria
- Department of Surgery, Groote Schuur Hospital, Observatory, Cape Town, South Africa; Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Andrew J Nicol
- Department of Surgery, Groote Schuur Hospital, Observatory, Cape Town, South Africa; Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
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Krige JE, Thomson SR. Pancreatoduodenectomy for trauma: applying novel reconstruction techniques. SURGICAL TECHNIQUES DEVELOPMENT 2016. [DOI: 10.4081/std.2016.6293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This single center study evaluated the technical modifications and outcome of reconstruction after pancreaticoduodenectomy for trauma. Prospectively recorded data including reconstructive techniques used in patients who underwent a pancreatoduodenectomy (PD) for trauma were analyzed. Twenty patients underwent a PD. Six had an initial damage control procedure. Thirteen had a pylorus-preserving PD and 7 a standard Whipple resection because injury to the pylorus precluded a pylorus-preserving resection. Twelve patients had a pancreatojejunostomy and 8 a pancreatogastrostomy, 3 of whom had a duodenojejunal hepaticojejunal sequence of anastomoses to allow endoscopic biliary stent retrieval. Three patients died postoperatively of multi-organ failure. All 17 survivors had postoperative complications: 5 patients developed pancreatic fistula, 2 had gastric outlet obstruction, 2 had bile leaks, 2 had duodenal anastomotic leaks, all of which resolved with conservative treatment. Pancreatic and biliary reconstructions performed under adverse conditions after a trauma PD required a variety of technical modifications. The pylorus does not have to be sacrificed and posterior gastric implantation is a safe option for an edematous pancreas.
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