What is the role of endoscopic retrograde cholangiopancreatography in assessing traumatic rupture of the pancreatic in children?

Background and study aims: Trauma is one of the most common causes of morbidity and mortality in the pediatric population. The diagnosis of pancreatic injury is based on clinical presentation, laboratory and imaging findings, and endoscopic methods. CT scanning is considered the gold standard for diagnosing pancreatic trauma in children. Patients and methods: This retrospective study evaluates data from 25 pediatric patients admitted to the University Hospital Motol, Prague, with blunt pancreatic trauma between January 1999 and June 2013. Results: The exact grade of injury was determined by CT scans in 11 patients (47.8%). All 25 children underwent endoscopic retrograde cholangiopancreatography (ERCP). Distal pancreatic duct injury (grade III) was found in 13 patients (52%). Proximal pancreatic duct injury (grade IV) was found in four patients (16 %). Major contusion without duct injury (grade IIB) was found in six patients (24%). One patient experienced duodeno-gastric abruption not diagnosed on the CT scan. The diagnosis was made endoscopically during ERCP. Grade IIB pancreatic injury was found in this patient. One patient (4%) with pancreatic pseudocyst had a major contusion of pancreas without duct injury (grade IIA). Four patients (16%) with grade IIB, III and IV pancreatic injury were treated exclusively and nonoperatively with a pancreatic stent insertion and somatostatine. Two patients (8%) with a grade IIB injury were treated conservatively only with somatostatine without drainage. Eighteen (72 %) children underwent surgical intervention within 24 h after ERCP. Conclusion: ERCP is helpful when there is suspicion of pancreatic duct injury in order to exclude ductal leakage and the possibility of therapeutic intervention. ERCP can speed up diagnosis of higher grade of pancreatic injuries.     

Experience of two trauma-centers with pancreatic injuries requiring immediate surgery

BACKGROUND/AIMS: Pancreatic injury from blunt trauma is infrequent. The aim of the present study was to evaluate a simplified approach of management of pancreatic trauma injuries requiring immediate surgery consisting of either drainage in complex situation or pancreatectomy in the other cases. METHODOLOGY: From January 1986 to December 2006, 40 pancreatic traumas requiring immediate surgery were performed. Mechanism of trauma, clinical and laboratories findings were noted upon admission, classification of pancreatic injury according to Lucas' classification were considered. Fifteen (100%) drainages were performed for stage I (n=15), 60% splenopancreatectomies and 40% drainage was achieved for stage II (n=18), 3 Pancreaticoduonectomies and 2 exclusion of duodenum with drainage and 2 packing were performed for stage IV (n=7). RESULTS: There were 30 men and 10 women with mean age of 29+/-13 years (15-65). Thirty-eight patients had multiple trauma. Overall, mortality and global morbidity rate were 17% and 65% respectively, and the rates increased with Lucas' pancreatic trauma stage. CONCLUSIONS: Distal pancreatectomy is indicated for distal injuries with duct involvement, and complex procedures such as pancreaticoduodenectomy should be performed in hemodynamically stable patients.     

Pancreatic injury in children: review of 7 cases and the pertinent literature

Background/Aims: Treatment of blunt injury of the pancreas in children remains controversial. Some prefer non-surgical treatment, whereas others prefer surgical management in selected cases. This report reviews our management strategies of children with blunt pancreatic trauma and their outcomes. Methodology: Medical records of 7 children with traumatic pancreatic injury were retrospectively analyzed in our institutions. In addition, we reviewed the pertinent literature. Results: There were 2 males and 5 females with a median age of 7.6 years. Pancreatic injury was classified in 3 patients as grade I, in 2 patients as grade II, and in 2 patients as grade III (AAST). The two grade III children underwent ERCP preoperatively. ERCP showed injury to the main pancreatic duct in both of these patients, and emergency surgery was performed for both of them. These operative methods were spleen-preserving distal pancreatectomy and only drainage at the margin of the pancreas with non-resection, respectively. All 7 cases survived. Conclusions: ERCP is helpful for the diagnosis of suspected cases in pancreatic injury with grade III. In hemorrhagic shock state, appropriate surgical procedures with only drainage at the margin of the pancreas are useful for the treatment of pancreatic fistula in children.     

Abdominal CT scanning in pediatric blunt trauma

The use of the emergency IV contrast-enhanced abdominal computed tomography (CT) scanning was evaluated in 90 pediatric patients sustaining blunt abdominal trauma. Medical records, CT scans, and operative and postmortem reports, when applicable, were reviewed retrospectively. By identifying the organs of injury, CT scans of the abdomen, with IV contrast, proved to be useful to the surgeon in deciding whether to operate in the setting of blunt abdominal trauma. The failure rate for conservative, non-operative management (four of 33) in "positive" scans was low, and represented progression of known injuries, not the appearance of unexpected injuries. Similarly, the (unplanned) surgery rate in the "negative" scan cases was low (one of 57). Abdominal CT scans cannot be relied on to consistently diagnose gastrointestinal perforation or pancreatic injury.     

闭合性胰腺损伤21例的诊治分析

目的 探讨闭合性胰腺损伤的诊断治疗方法.方法 对近5年来收治并行手术治疗的21例闭合性胰腺损伤的临床资料进行回顾性分析.结果 21例患者中3例为单纯胰腺损伤,18例为合并腹腔内其他脏器损伤.根据胰腺损伤分级标准,Ⅰ、Ⅱ、Ⅲ、Ⅳ、Ⅴ级损伤的例数分别为4、7、5、3、2例,仅有9例患者术前通过CT获得诊断,11例术中探查确诊,1例第一次手术时漏诊.手术方式采用局部引流或清创缝合后引流8例,连同脾脏的胰体尾切除5例,保留脾脏的胰体尾切除3例,近侧断端封闭、远侧断端胰腺空肠吻合3例,十二指肠憩室化加局部引流1例,胰十二指肠切除1例.12例手术后完全治愈,5例术后并发胰瘘,2例形成假性囊肿,均经引流而治愈,死亡2例.结论 胰腺闭合性损伤术前误诊率高,应尽可能采用CT检查以明确诊断;术中需仔细探查,选择简单、有效的手术方式,保证引流通畅是治疗成功的关键.     

Fracture of the pancreas in two patients after a go-kart accident

Background

After blunt abdominal trauma, an isolated injury to the pancreatic duct is uncommon. Physical signs and laboratory parameters are often inaccurate, and missing this diagnosis can cause serious clinical problems.

Case outlines

Two young women (aged 18 and 20 years) are reported who sustained isolated trauma to the pancreatic duct in go-kart accidents. Each patient sustained a fracture of the pancreas.This injury was diagnosed only after a period of clinical observation with repeated laboratory parameters, ultrasound and CT scan. Pancreatic tissue was conserved by performing a pancreaticojejunostomy.

Discussion

After any episode of blunt abdominal trauma, isolated injury to the pancreatic duct should be considered. Serum analysis, ultrasonography and CT scanning can be helpful in early diagnosis. Preservation of pancreatic tissue can be achieved with a good clinical outcome.     

Management of pancreatic trauma: A pancreatic surgeon's point of view

BackgroundPancreatic trauma occurs in 0.2% of patients with blunt trauma and 1–12% of patients with penetrating trauma. Traumatic pancreatic injuries are characterised by high morbidity and mortality, which further increase with delayed diagnoses. The diagnosis of pancreatic trauma is challenging. Signs and symptoms can be non-specific or even absent.MethodsA critical review of studies reporting the management and outcomes of pancreatic trauma was performed.ResultsThe management of pancreatic trauma depends on the haemodynamic stability of the patient, the degree and location of parenchymal injury, the integrity of the main pancreatic duct, and the associated injuries to other organs. Nevertheless, the involvement of the main pancreatic duct is the most important predictive factor of the outcome. The majority of pancreatic traumas are managed by medical treatment (parenteral nutrition, antibiotic therapy and somatostatin analogues), haemostasis, debridement of devitalised tissue and closed external drainage. If a proximal duct injury is diagnosed, endoscopic transpapillary stent insertion can be a viable option, while surgical resection by pancreaticoduodenectomy is restricted to an extremely small number of selected cases. Injuries of the distal parenchyma or distal duct may be managed with distal pancreatectomy with spleen preservation. At the pancreatic neck, when pancreatic transection occurs without damage to the parenchyma, a parenchyma-sparing procedure is feasible.ConclusionThe management of pancreatic injuries is complex and often requires a multidisciplinary approach. Here, we propose a management algorithm that is based on parenchymal damage and the site of duct injury.     

Correlation of trauma scoring systems with abdominal septic complications in abdominal trauma.

INTRODUCTION: Anatomical trauma scoring systems can predict the occurrence of postoperative abdominal septic complications (ASC) after major abdominal trauma; however, this has not been validated in any Indian study. We attempted such an evaluation in patients attending a teaching hospital in central India. METHOD: A retrospective analysis of data from 169 patients who had undergone emergency laparotomy for penetrating or blunt abdominal injury between August 1996 and July 2001 was done. Every patient was scored using three trauma severity indices and the occurrence of ASC was identified. RESULTS: Patients who developed ASC had higher trauma severity scores than those who did not. Thirty-eight patients had isolated small bowel injury; trauma scores underestimated the occurrence of ASC in these patients. CONCLUSIONS: Trauma severity indices may serve as useful tools to predict the occurrence of postoperative ASC in patients with abdominal trauma, except in those with isolated small bowel injury. There is thus a need to modify the weight of small bowel injury in these scoring systems.     

The role of endoscopic retrograde pancreatography in the treatment of traumatic pancreatic duct injury.

BACKGROUND: The status of the main pancreatic duct (MPD) is the most important determinant of the morbidity and mortality associated with pancreatic trauma. Early diagnosis and optimal treatment are critical, especially when there is MPD injury. METHODS: Twenty-three patients with pancreatic trauma were studied prospectively with respect to clinical and laboratory findings, CT, and endoscopic retrograde pancreatography (ERP). Treatment modalities and clinical outcome were assessed in relation to ERP findings. RESULTS: The pancreatic duct was injured in 14 of 23 patients (11 MPD, 3 branch duct). Contrast leakage from the MPD into peritoneal cavity at ERP confirmed MPD injury in 8 patients, who underwent surgical exploration. Three patients with leakage from a branch duct into the pancreatic parenchyma recovered with conservative treatment. Three patients in whom ERP demonstrated contrast leakage from the MPD confined to the parenchyma underwent successful transpapillary stent insertion with complete resolution of the leak at 3-month follow-up. Patients who underwent ERP more than 72 hours after trauma had a significantly higher rate of pancreas-associated complications and a tendency to remain hospitalized longer than patients who underwent ERP earlier. CONCLUSION: Early ERP is one of the most useful methods for demonstrating MPD injury. ERP assists with treatment planning based on the degree of pancreatic duct injury.     

Management of blunt pancreatic injury by applying the principles of damage control surgery: experience at a single institution

Background/Aims: This study analyzes the outcomes of treatment for blunt pancreatic injuries by applying the principles of damage control surgery and discusses the management of those injuries. Methodology: Medical records of the patients who received surgical treatment for blunt pancreatic injury during the last 30 months were investigated retrospectively. Results: A total of 23 patients were confirmed to have pancreatic injury in laparotomy during the investigation period. Based on the final surgical findings, 3 patients were classified into grade I, 9 into grade II, 7 into grade III, 2 into grade IV, and 2 into grade V by the American Association for the Surgery of Trauma - Organ Injury Scale classification. Damage control surgery was performed for 17 patients (73.9%). As a result, 8 cases of pancreatic complication, such as fistula, pseudocyst or abscess, were observed in 6 patients (26.1%). Three patients died with a mortality rate of 13.0%. The causes of death were hemorrhage in other organs and multiple organ failure. Conclusions: For a good prognosis, the first operation time after injury should be decreased and surgical technique should be simplified by damage control surgery to reduce complications as well as to prevent exacerbation of the general condition in patients with major pancreatic injury.     

Prognosis and treatment of pancreaticoduodenal traumatic injuries: which factors are predictors of outcome?

Background/purpose

Abdominal trauma rarely causes injuries involving the duodenum and pancreas. Associated injuries occur in 46% of all pancreatic injuries. The morbidity and mortality of pancreaticoduodenal injuries remain high.

Methods

The present study is a retrospective review of our experience from 1989 to 2008 in the surgical treatment of traumatic pancreaticoduodenal injuries. Mortality, morbidity, prognostic factors, and the value of surgical techniques were analyzed.

Results

In our level I Trauma Center, between 1989 and 2008, 55 patients had a pancreaticoduodenal injury. In 68.5% of cases pancreatic injuries were found, 20.4% had duodenal injury, and 11.1% suffered combined pancreaticoduodenal injuries; 85.3% of the patients had blunt abdominal trauma, while 14.9% had penetrating injuries. We treated 78.1% of the patients with external drainage and/or simple suture; distal pancreatectomy was performed in 9% of cases and duodenal resection with anastomosis (3.7%) and diversion procedures (3.7%) were performed in an equal number of patients. Age, American Association for the Surgery of Trauma (AAST) grade, organ involved, hemodynamic status, intraoperative cardiac arrest, and operative time remained strongly predictive of mortality on multivariate analysis. The AAST grade represented, on multivariate analysis, the only independent prognostic factor predictive of overall morbidity. In the past decade we have used feeding jejunostomy more frequently, with a reduction of mortality and operating time, due also to a better approach from a dedicated trauma team.

Conclusions

Optimal management and better outcome of pancreaticoduodenal injuries seem to be associated with shorter operative time, and with simple and fast damage control surgery (DCS), in contrast to definitive surgical procedures.     

Evaluation of the abdomen in intoxicated patients: is computed tomography scan or peritoneal lavage always indicated?

STUDY OBJECTIVE: To investigate the necessity of intensive evaluation of the intoxicated patient with normal mentation for intra-abdominal injury after blunt torso trauma. DESIGN: Retrospective study; trauma registry and medical records. SETTING: Level I regional trauma center serving a population of 2.3 million. PARTICIPANTS: Adult victims of blunt trauma more than 17 years old, admitted between January 1, 1986, and December 31, 1989, with suspected blunt abdominal injury and serum ethanol of more than 100 mg/dL and Glasgow Coma Score of 15. INTERVENTION: All patients had serum ethanol levels measured in mg/dL and computed tomography (CT) scan of the abdomen and/or diagnostic peritoneal lavage (DPL). RESULTS: Criteria were met by 92 patients. Eighty-nine underwent CT scans, two had DPL, and one had both. Of 17 patients complaining of abdominal pain and/or tenderness on palpation, six (35.3%) had blood in the peritoneal cavity demonstrated by CT scan or DPL and underwent celiotomy. All 75 patients without abdominal pain or tenderness had negative CT scan or DPL, with no missed injury. CONCLUSION: In the intoxicated blunt trauma patient with normal mentation, the physical examination is a reliable indicator of abdominal injury. Elevated alcohol level, per se, should not be considered an absolute indication for DPL or abdominal CT.     

Contributions of peritoneal lavage enzyme determinations to the management of isolated hollow visceral abdominal injuries.

STUDY OBJECTIVE: To determine the role of lavage amylase (LAM) and lavage alkaline phosphatase (LAP) in the identification of intraperitoneal hollow visceral injuries. DESIGN: Retrospective. SETTING: Level I trauma center, city/county institution. TYPE OF PARTICIPANTS: Patients with hollow visceral organ injury following major blunt or penetrating trauma whose diagnostic peritoneal lavage was negative by lavage red blood cell and lavage white blood cell were negative. MEASUREMENTS AND MAIN RESULTS: Fifty-one patients with injury isolated to one or more hollow visceral structures underwent diagnostic peritoneal lavage; 28 were positive based on aspirate, lavage red blood cell count (greater than 100,000/mm3), or lavage white blood cell count (greater than 500/mm3). Of the remaining 23 patients, each of 11 with isolated small bowel injury had LAM greater than or equal to 20 IU/L and six of these had LAP levels greater than or equal to 3 IU/L. All six patients with colon injury and two of the patients with gallbladder injury had LAM less than 20 IU/L and LAP less than 3 IU/L. CONCLUSIONS: In patients with hollow visceral injury and otherwise normal diagnostic peritoneal lavage, elevation in LAM is highly specific for isolated small bowel injury. Lavage enzyme determinations appear unhelpful in the detection of colonic injury. We recommend routine enzyme determinations of lavage effluent as a marker for isolated small bowel injury.     

Retrospective Analysis of Duodenal Injuries: A Comprehensive Overview

Background/Aim:

Duodenal injury is an uncommon finding, accounting for about about 3 – 5% of abdominal trauma, mainly resulting from both penetrating and blunt trauma, and is associated with significant mortality (6 - 25%) and morbidity (30 - 60%).

Patients and Methods:

Retrospective analysis was performed in terms of presentation, management, morbidity and mortality on 14 patients of duodenal injuries out of a total of 172 patients of abdominal trauma attending Subharti Medical College.

Results:

Epigastric pain (100%) along with vomiting (100%) is the usual presentation of duodenal injuries in blunt abdominal trauma, especially to the upper abdomen. Computed tomography (CT) was diagnostic in all cases. Isolated duodenal injury is a rare finding and the second part is mostly affected.

Conclusion:

Duodenal injury should always be suspected in blunt upper abdominal trauma, especially in those presenting with epigastric pain and vomiting. Investigation by CT and early surgical intervention in these patients are valuable tools to reduce the morbidity and mortality.     

Computed tomography changing over time in type 1 pulmonary laceration

Pulmonary laceration has been accepted as a rare event of primary lung injury in blunt chest trauma. Four types of pulmonary laceration have been classified according to computed tomographic (CT) pattern, lung location, and injury mechanism. Type 1 pulmonary laceration represents the most common injury as a result of blunt chest trauma in young patients. I report the role of chest CT scan and conservative management for a young man diagnosed with type 1 pulmonary laceration after a fall from scaffolding.     

Pancreatic injuries in earthquake victims: What have we learnt?

ObjectiveTo analyze the clinical characteristic and management of patients with pancreatic injuries from the Wen-Chuan and Lu-Shan earthquakes.MethodsWe retrospectively reviewed 39,784 patients from the Wen-Chuan earthquake and 1489 from the Lu-Shan earthquake. The demographics, clinical data, treatment strategies, and outcomes of patients with pancreatic injuries were recorded and compared between survivors of the two earthquakes.ResultsPancreatic injury occurred only in a small proportion (0.2%) in patients with trauma on admission, and most (61%) patients had Grades I–II pancreatic injuries. Blunt trauma was the leading cause of pancreatic trauma. Most patients (95%) suffered multiple injuries, of which chest injuries (61%) were the most common. Elevated serum amylase levels were observed in 50 (86%) of 58 patients, and computed tomography (CT) identified pancreatic injuries in 32 (80%) of 40 patients. A significantly higher rate (p = 0.043) of pancreatic complication was present in patients with Grade III and IV injuries (38%) than in those with Grade I and II injuries (18%). Forty patients were initially treated by conservative management with 6 (15%) requiring delayed operations. Four (67%) pancreatic complications and 2 (33%) deaths occurred in patients with delayed operations.ConclusionsRepeated serum amylase analysis, CT, and laparoscopic exploration were reliable diagnostic modalities to diagnose pancreatic injury. Conservative management was safe in patients with Grade I and II injuries. Delayed operation, especially for Grade III patients, resulted in increased morbidity and mortality.     

Surgical treatment of liver trauma (analysis of 244 patients)

BACKGROUND/AIMS: The liver is the most common injured intraabdominal organ after trauma. This retrospective study was designed to analyze the results of the surgical treatment of 244 cases of liver trauma operated between 1973 and 2001. METHODOLOGY: Two hundred and seventeen of the cases were male and 27 were female. Mean age of the patients was 29.6. Blunt injuries were responsible for liver trauma in 53.6% of the patients. According to the American Association for the Surgery of Trauma classification we evaluated the patients to two groups. The first one was Group A, minor hepatic injuries, which consisted of grade I, grade II and grade III injuries, and the second one was Group B, major hepatic injuries, which consisted of grade IV, grade V and grade VI injuries. There were 238 cases in Group A and 6 cases in Group B. Primary suturing of the hepatic rupture was performed in 187 of 238 cases in group A. Liver injuries of the other 50 cases did not require suturing so that we drained the suprahepatic and infrahepatic spaces during laparotomy. The remaining case in group A had resectional debridement and hemostasis. On the other hand we performed regular or irregular hepatic resection in all group B patients. RESULTS: Overall mortality rate was 16.3%. The mortality rate was higher in group B than group A (66.6% and 15.1%, respectively). The mortality rate was also higher in the blunt abdominal trauma cases than penetrating injuries (25.9% and 5.3% consecutively). CONCLUSIONS: We concluded that the injury grade and the type of trauma influence the mortality rate. Careful clinical assessment and close radiological monitoring of the patients with minor hepatic injuries, may prevent unnecessary laparotomies.     

Surgical treatment of hepatic injury: morbidity and mortality analysis of 109 cases

BACKGROUND/AIMS: We aimed to determine the factors that affect morbidity and mortality in patients that underwent surgery for hepatic injury. METHODOLOGY: Records of 109 blunt or penetrating hepatic trauma patients that underwent surgery in the Third Surgical Clinic of Izmir Atattürk Training and Research Hospital between 1994 and 2004 were reviewed retrospectively. Evaluated parameters were: age, gender, cause of injury, diagnostic procedures, preoperative blood pressure (BP), hemoglobin (Hb) level, amount of intraabdominal blood, associated injuries, the number of involved hepatic segments and anatomic distribution, severity of injury, abdominal trauma index (ATI), amount of blood transfusions, type of surgery, hospital stay, and rates of morbidity and mortality. RESULTS: Median age of the patients was 29 years. The injury was penetrating in 53.2% of the patients and blunt in 46.8%. Abdominal blood was 500cc or less in 70 (64.2%) patients. Isolated hepatic injury was encountered in 29 (26.6%) cases. 22.9% of the patients had major injuries. Hemostasis was achieved by electrocautery, sponge-gel, primary suturing, hepatic resection or perihepatic packing. Morbidity and mortality rates were 40.4% and 14.6% respectively. CONCLUSIONS: Age, type of the injury, BP and Hb levels, amount of intraabdominal blood, degree of injury, ATI, and accompanying organ injuries significantly affect morbidity and/or mortality.     

Utility of lavage alkaline phosphatase in detection of isolated small intestinal injury

The ability of lavage alkaline phosphatase (LAP) to detect small intestinal injury was studied in 81 patients who underwent diagnostic peritoneal lavage following blunt and penetrating abdominal trauma. Patients with a grossly positive lavage were excluded. The LAP of five patients with small intestinal injury (79.0 +/- 41.7 IU/L) was significantly greater than in 76 cases without (1.2 +/- 0.4 IU/L; P less than .05). LAP greater than or equal to 3 was seen in six patients. Four had isolated small intestinal pathology, and one had combined small and large bowel injury. In three of these five, other lavage values were normal. One possible false positive occurred. The sensitivity of LAP greater than or equal to 3 (100%) exceeded that of usual lavage parameters in the detection of small intestinal injury. LAP may be a sensitive marker for small intestinal pathology in the immediate postinjury period.     

Non-operative management of isolated liver trauma

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.