Does drainage or resection predict subsequent interventions and long-term quality of life in patients with Grade IV pancreatic injuries: A population-based analysis

Abstract

BACKGROUND:Clinical equipoise remains significant for the treatment of Grade IV pancreatic injuries in stable patients (i.e., drainage vs. resection). The literature is poor in regards to experience, confirmed main pancreatic ductal injury, nuanced multidisciplinary treatment, and long-term patient quality of life (QOL). The primary aim was to evaluate the management and outcomes (including long-term QOL) associated with Grade IV pancreatic injuries. METHODS:All severely injured adult patients with pancreatic trauma were evaluated (Grade IV injuries compared). Concordance of perioperative imaging, intraoperative exploration, and pathological reporting with a main pancreatic ductal injury was required.Patients with resection of Grade IV injuries were compared with drainage alone. Long-term QOL was evaluated (Standard Short Form-36). RESULTS:Of 475 pancreatic injuries, 36(8%) were confirmed as Grade IV. Twenty-four (67%) underwent a pancreatic resection (29% pancreatoduodenectomy; 71% extended distal pancreatectomy [EDP]). Patient, injury and procedure demographics were similar between resection and drainage groups (p > 0.05). Pancreas-specific complications in the drainage group included 92% pancreatic leaks, 8% pseudocyst, and 8% walled-off pancreatic necrosis. Among patients with controlled pancreatic fistulas beyond 90 days, 67% required subsequent pancreatic operations (fistulo-jejunostomy or EDP). Among patients whose fistulas closed, 75% suffered from recurrent pancreatitis (67% eventually undergoing a Frey or EDP). All patients in the resection group had fistula closure by 64 days after injury. The median number of pancreas-related health care encounters following discharge was higher in the drainage group (9 vs. 5; p = 0.012). Long-term (median follow-up = 9 years) total QOL, mental and physical health scores were higher in the initial resection group (p = 0.031, 0.022 and 0.017 respectively). CONCLUSION:The immediate, intermediate and long-term experiences for patients who sustain Grade IV pancreatic injuries indicate that resection is the preferred option, when possible. The majority of drainage patients will require additional, delayed pancreas-targeted surgical interventions and report poorer long-term QOL.

Getting going: Incorporating ultrasound into an HPB practice

“…It must also be remembered that in the context of today's real-time ultrasound capability, mentors from around the globe are often available to engage in urgent intraoperative consultations via virtual platforms (ie, smart phone). Although this has been best exemplified in cases of resuscitating severely injured patients [ 17 ] as well as diagnosing high-grade pancreas injuries [ 18 , 19 ], the time-of-day realities of scheduled elective HPB cases make this possibility easily accessible. Perhaps even more helpful in a support capacity is ensuring a good working relationship with the institutional interventional radiology colleagues.…”

Time to update the American Association for the Surgery of Trauma pancreas injury grading lexicon?

“…This includes not only the patency of the duct but also its alignment. More specifically, injury to the main pancreatic duct results in the leakage of significant volumes of pancreatic enzymes into the surrounding tissues 3–5 . This injury-related morphology is fundamentally different from lower-grade injuries to the pancreatic parenchyma that disrupt only minor ducts 5 .…”

“…As these lacerations increase in size, the risk of a main duct injury (i.e., high grade injury) increases substantially 6 . The confirmed loss of main duct integrity (i.e., grades III, IV, and V) generally mandates pancreas-directed interventions, including resectional treatment 2,4 …”

“…2,3 Individual patient courses following pancreatic injury are dependent on multiple factors such as synchronous injuries, preexisting medical comorbidities, physiologic presentation, and associated upper abdominal vascular trauma. [2][3][4][5] Although the AAST pancreas injury grading scale offers clinicians and researchers a common language, it remains limited by a lack of granularity, as well as inadequate distinction between blunt and penetrating mechanisms (i.e., contusions vs. lacerations). The grading scale is also deficient in regard to effectively communicating the specific location of the injury within the gland itself.…”

Hepatobiliary and pancreatic hemorrhage: Technical tools and tricks

“… Ongoing hemorrhage from hepatobiliary and pancreatic injuries continues to daunt even the most experienced surgeon. Despite the widespread centralization of elective hepatopancreatobiliary (HPB) surgery to high-volume centers, HPB trauma remains relatively common and requires a rapid and thoughtful approach [ [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] ]. …”