Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers

Abstract

BACKGROUND Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers. METHODS This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity. RESULTS Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21–43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury. CONCLUSION Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system. LEVEL OF EVIDENCE Therapeutic/care management, level V; Prognostic and epidemiological, level IV.

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 .…”

“…5 When major duct disruptions (lacerations or transections) are treated ineffectively, there is a subsequent high risk of early complications (tissue necrosis, hemorrhage and/ or sepsis), sustained pancreatic duct leak requiring intervention(s) (surgical, endoscopic, radiologic), and long-term decreases in patient quality of life (pain, repeated interventions). [2][3][4] Although minor pancreatic duct trauma typically follows a less complicated course that is defined by time-limited sealing of these lower volume leaks (and therefore resolution of the leak itself), release of pancreatic enzymes remains a clinically important problem in subsets of these patients as well. 5 Benign small duct injury outcomes assume synchronous integrity and continuity of the main duct.…”

“…Pancreas trauma remains a challenging disease that frequently requires multidisciplinary care and prolonged patient follow-up 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 2–5 .…”

“…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] ]. …”