Open or Not Open the Retroperitoneum: A Pandora’s Box for High-grade Pancreatic Trauma?

Background: The management strategy associated with the optimal clinical outcomes for patients with pancreatic trauma remains ambiguous. We sought to determine whether transitioning from initial laparotomy (LAP) to the nonoperative management strategy based on initial percutaneous drainage (PCD) without opening the retroperitoneum would improve clinical outcomes in patients with blunt high-grade pancreatic trauma.Methods: We conducted a retrospective cohort study of pancreatic trauma at a single tertiary referral center. Blunt high-grade pancreatic trauma patients with stable hemodynamics and no diffuse peritonitis were enrolled consecutively in the study. The primary outcome measure was the incidence of severe complications (Clavien-Dindo classification ≥ Ⅲb) for patients who underwent initial LAP vs PCD. To study effect modification by different initial strategies and to adjust for confounding, modified Poisson regression and sensitivity analysis based on propensity score matching and weighting were performed to estimate adjusted relative risks (aRR) and 95% confidence intervals (CIs).Results: Among 119 patients with blunt grade Ⅲ/Ⅳ pancreatic trauma (107 male [89.9%] and 12 female [10.1%]; mean age, 35.7 [SD, 12.7] years), 29 underwent initial PCD and 90 underwent initial LAP (January 2009 through October 2021). Compared with initial LAP, patients underwent initial PCD were significantly lower risk of severe complicates (9/29 [31.0%] vs 65/90 [72.2%]; aRR, 0.52 [95% CI, 0.30-0.90]). Consistent results are also observed in sensitivity analysis models. The relative risk of severe complications for the PCD group in propensity score matching model was 0.53 (95% CI, 0.28-0.99; P = 0.035), 0.37 (95% CI, 0.18-0.75; P = 0.006) in inverse probability of treatment weighting model, and 0.55 (95% CI, 0.31-0.99; P = 0.046) in overlap weighting model. In addition, the mean number of reinterventions per patient was 1.8 in the PCD group and 2.6 in the LAP group (P = 0.067). Conclusions: For blunt high-grade pancreatic trauma patients with stable hemodynamics and no diffuse peritonitis, initial PCD strategy without open the retroperitoneum has a significantly lower rate of severe complications and does not increase reinterventions compared with initial LAP. Further randomized controlled trials are warranted to validate these results.Trial Registration: ClinicalTrials.gov Identifier: NCT03681041(Sept. 21 2018).

Management of Pancreatic Trauma In Urban India: A Multicenter Study

Background: Pancreatic trauma occurs in 0.2-2% of patients with blunt trauma and 1–12% of patients with penetrating trauma. The mortality and morbidity rates range from 9-34% and 30-60% respectively. We aimed to review the management of pancreatic trauma in a multicenter database from India.Methods: We analyzed all patients who suffered a pancreatic injury and who were included in the multicenter prospective observational study ‘Towards Improved Trauma Care Outcomes (TITCO)’.Results: Of the 16047 trauma cases, 1134 (7.1%) patients suffered abdominal trauma. Of all those with abdominal trauma 55 patients (4.9%) had injury to the pancreas. 28 patients (50.9%) with pancreatic trauma were managed conservatively. 27 patients (49.1%) underwent surgical exploration in the form of laparotomies. 11 procedures were undertaken for pancreas. A total of 45 (82%) patients had associated injuries along with pancreatic injury. Thorax (19) (including injuries to lung, pleura and ribs), liver (17), bowel (14) and spleen (13) were the most common associated injuries.Conclusion: Conservative management was as common as operative management in patients with pancreatic injuries. Most (80%) grade III/IV underwent operative treatment. Many patients (82%) had associated injuries. Level of evidence: III

Management of Pancreatic Trauma in Urban India: A Multicenter Study

BackgroundPancreatic trauma occurs in 0.2-2% of patients with blunt trauma and 1–12% of patients with penetrating trauma. The mortality and morbidity rates range from 9-34% and 30-60% respectively. We aimed to review the management of pancreatic trauma in a multicenter database from India.MethodsWe analyzed all patients who suffered a pancreatic injury and who were included in the multicenter prospective observational study ‘Towards Improved Trauma Care Outcomes (TITCO)’.ResultsOf the 16047 trauma cases, 1134 (7.1%) patients suffered abdominal trauma. Of all those with abdominal trauma 55 patients (4.9%) had injury to the pancreas. 28 patients (50.9%) with pancreatic trauma were managed conservatively. 27 patients (49.1%) underwent surgical exploration in the form of laparotomies. 11 procedures were undertaken for pancreas. A total of 45 (82%) patients had associated injuries along with pancreatic injury. Thorax (19) (including injuries to lung, pleura and ribs), liver (17), bowel (14) and spleen (13) were the most common associated injuries.ConclusionConservative management was as common as operative management in patients with pancreatic injuries. Most (80%) grade III/IV underwent operative treatment. Many patients (82%) had associated injuries. Level of evidence: III

General Surgery Resident Operative Experiences in Solid Organ Injury: An Examination of Case Logs

Background Non-operative management (NOM) of traumatic solid organ injury (SOI) has become commonplace. This paradigm shift, along with reduced resident work hours, has significantly impacted surgical residents’ operative trauma experiences. We examined ongoing changes in residents’ operative SOI experience since duty hour restriction implementation, and assessed whether missed operative experiences were gained elsewhere in the resident experience. Methods We examined data from American College of Graduate Medical Education case log reports from 2003 to 2018. We collected mean case volumes in the categories of non-operative trauma, trauma laparotomy, and splenic, hepatic, and pancreatic trauma operations; case volumes for comparable non-traumatic solid organ operations were also collected. Solid organ injury operative volumes were compared against non-traumatic cases, and change over time was analyzed. Results Over the study period, both trauma laparotomies and non-operative traumas increased significantly ( P < .001). In contrast, operative volumes for splenic, hepatic, and pancreatic trauma all significantly decreased ( P < .001; P = .014; P < .001, respectively). Non-traumatic spleen cases also significantly decreased ( P < .001), but liver cases and distal pancreatectomies increased ( P < .001; P = .017). Pancreaticoduodenectomies increased, albeit not to a significant degree ( P = .052). Conclusions Continuing increases in NOM of SOI correlate with declining resident experience with operative solid organ trauma. These decreases can adversely affect residents’ technical skills and decision-making, although trends in specific non-traumatic areas may help to mitigate such losses. Further work should determine the impact of these trends on resident competence and autonomy.

Современные технологии диагностики и лечения травм поджелудочной железы

Pancreatic trauma is rare from 0.2% to 12% of abdominal injuries, but presents a complex clinical problem due to the erased initial symptoms and the absence of specific clinical signs, which lead to late diagnosis and delay surgical treatment. The symptoms of pancreatic trauma are nonspecific and often masked by trauma to other organs. In this regard, this article separately considers the issues of radiation diagnostics (ultrasound examination, multispiral computed tomography, magnetic resonance cholangiopancreatography, retrograde cholangiopancreatography, laparoscopy) and the choice of tactics for the treatment of рancreatic trauma.

1418 Non-Operative Versus Operative Management for Blunt Pancreatic Trauma in Adults: A Systematic Review of The Literature

Aim Pancreatic injury, a rare consequence of blunt abdominal trauma, is associated with significant morbidity and mortality when the appropriate management is delayed. Due to the rarity of the injury, there is currently a lack of evidence to establish a treatment pathway for adults. The aim of this review was to compare outcomes following non-operative and operative management of adults who suffered blunt pancreatic trauma injuries. Method An electronic literature search was performed from 2008 to 2020. Studies pertaining to adults sustaining blunt pancreatic injuries, of all grades (I-V) of severity, according to the American Association for the Surgery of Trauma, were included. The primary outcome was mortality, whilst secondary outcomes were components of pancreas specific morbidity. 1501 studies were initially identified and screened, and 11 studies were included in the review. Results Qualitative analysis showed an increase risk of mortality with increased severity of injury, and in the operative group compared to non-operative group. All patients who were haemodynamically unstable underwent immediate operative management, whereas the management strategy for patients with haemodynamic stability differed between the studies and depended on either the grade of injury, presence of other organ injury, or failure of initial management strategy. Conclusions This systematic review largely reaffirmed accepted practice in determining operative versus non-operative treatment for blunt pancreatic injury. Larger institutional analyses are required to add strength to the evidence supporting non-operative management for grade III or IV injuries with appropriate monitoring and subsequent intervention if required.