Faculty Collaboration Database

An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain? J Trauma Acute Care Surg 2018 Sep;85(3):435-443

Date

05/23/2018

Pubmed ID

29787527

DOI

10.1097/TA.0000000000001987

Scopus ID

2-s2.0-85052738933 (requires institutional sign-in at Scopus site)   31 Citations

Abstract

INTRODUCTION: Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies.

METHODS: We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured.

RESULTS: We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9).

CONCLUSION: CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries.

LEVEL OF EVIDENCE: Epidemiologic/Diagnostic study, level III.

Author List

Byrge N, Heilbrun M, Winkler N, Sommers D, Evans H, Cattin LM, Scalea T, Stein DM, Neideen T, Walsh P, Sims CA, Brahmbhatt TS, Galante JM, Phan HH, Malhotra A, Stovall RT, Jurkovich GJ, Coimbra R, Berndtson AE, O'Callaghan TA, Gaspard SF, Schreiber MA, Cook MR, Demetriades D, Rivera O, Velmahos GC, Zhao T, Park PK, Machado-Aranda D, Ahmad S, Lewis J, Hoff WS, Suleiman G, Sperry J, Zolin S, Carrick MM, Mallory GR, Nunez J, Colonna A, Enniss T, Nirula R

Author

Todd A. Neideen MD Associate Professor in the Surgery department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Abdominal Injuries
Adult
Aged
Drainage
Female
Humans
Injury Severity Score
Male
Middle Aged
Pancreas
Pancreatectomy
Pancreatic Ducts
Pancreatic Fistula
Pancreatic Pseudocyst
Retrospective Studies
Surgical Stapling
Sutures
Tomography, X-Ray Computed
Wounds, Penetrating