Pancreatic Trauma: Imaging Review and Management Update

Ayoob, Andres; Lee, James T.; Herr, Keith D.; LeBedis, Christina A.; Jain, Ashwin; Soto, Jorge A.; Lim, Jeehyun; Joshi, Gayatri; Graves, Joseph A.; Hoff, Carrie N.; Hanna, Tarek N.

doi:10.1148/rg.2021200077

Cited by 34 publications

(46 citation statements)

References 61 publications

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“…Due to the pancreas’s retroperitoneal location, isolated injury with abdominal trauma is quite rare [ 2 ]. Pancreatic injury is usually found with a combination of hepatic (47% of cases), gastric (42%), major vascular (41%), splenic (28%), renal (23%), and duodenal (19%) anatomic injury [ 3 , 4 ]. It is also important to note the specific type of trauma and the correlated anatomical manifestations seen on the pancreas.…”

Section: Discussionmentioning

confidence: 99%

An Unusual Case of Isolated Pancreatitis Secondary to Blunt Abdominal Trauma

Hamzoian¹,

Plasencia²,

Ekpa³

et al. 2022

Cureus

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Acute pancreatitis is an inflammatory condition affecting a large population and resulting in one of the most common causes of gastrointestinal hospitalizations in the United States. The pathogenesis resulting in pancreatic injury has multiple etiologies with gallstones and alcohol consumption contributing to a large majority of cases. Consequently, one uncommon cause of acute pancreatitis, direct abdominal trauma, often gets overlooked. This case describes a 20-year-old male with no past medical history or surgical interventions presenting to the hospital with two days worth of abdominal pain. Physical exam was negative for erythema, ecchymosis and lacerations but further questioning revealed a recent history of an altercation resulting in multiple blunt blows to the abdomen. CT abdomen with contrast was positive for an edematous appearing pancreatic tail with surrounding soft tissue stranding; no pancreatic fluid collections, normal gallbladder and no intrahepatic or extrahepatic biliary ductal dilation. Pancreatitis has a multitude of etiologies and practitioners should address the insulting event as well as the pathological sequelae to prevent reoccurrence of the condition. The importance of taking a full and thorough history should not be overlooked; this could lead to misdiagnosis and misjudgment of the underlying pathological process. We propose the notion that there is a significant number of patients diagnosed with idiopathic pancreatitis who may have more accurately been diagnosed with traumatic pancreatitis with a more thorough history. Additionally, due to the pancreas’s retroperitoneal location, isolated injury with abdominal trauma, such as in this patient, is quite rare. It is critical to differentiate the underlying cause of acute pancreatitis to further counsel patients about avoidance of precipitating factors. We would like to stress the importance of obtaining a thorough history and ruling out alternative causes of patient presentation as management differs greatly after treatment of the acute phase reaction. In patients with traumatic pancreatitis, physicians should establish that there were no residual abdominal injuries and advise patients to restrain from any activities that would result in any sequential abdominal trauma.

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Section: Discussionmentioning

confidence: 99%

An Unusual Case of Isolated Pancreatitis Secondary to Blunt Abdominal Trauma

Hamzoian¹,

Plasencia²,

Ekpa³

et al. 2022

Cureus

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“…Pancreatic trauma shows temporal evolution due to the onset of pancreatitis which leads to a self-amplifying sequence of events. PT should be suspected in all patients with high-velocity injuries and polytrauma [ 14 ]. PT should be ruled out in all patients with a history or clinical evidence of the upper abdominal impact of any form.…”

Section: Discussionmentioning

confidence: 99%

A Pragmatic Approach to Pancreatic Trauma: A Single-Center Experience From a Tertiary Care Center

Sankar¹,

Somasekar²,

Krishna³

et al. 2022

Cureus

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Introduction Pancreatic trauma is rare and is usually associated with adjacent organ and vascular injuries, which adds to the high morbidity and mortality. In the American Association for the Surgery of Trauma (AAST) pancreatic trauma (PT) grading system, the higher grades are a composite of less and more severe extents of injuries. We hereby present an observational study of PT with management based on an indigenous algorithmic approach. Our protocol incorporating both the extent of disruption of the main pancreatic duct (MPD) and its amenability to interventions (endoscopic, radiological, or surgical) is pragmatic. Methods Ours is a retrospective observational study of 28 consecutive cases of PT, done over a three-year period in an academic institution, by an expert Surgical Gastroenterology unit. All patients diagnosed with PT on a contrast abdominal CT scan were included. After stabilization, they were stratified and managed according to an indigenous protocol. The primary outcome measure was treatment success in terms of recovery. The secondary outcome measure was morbidity of any form. Results One patient with Grade 1 PT was operated on for associated hollow viscus injury. Two patients with AAST Grade 2 and two patients with AAST Grade 3 injury were managed successfully without surgery. Twelve of 21 patients with Grade 3 PT underwent Kimura’s splenic vessel preserving distal pancreatectomy. Distal pancreatectomy with splenectomy and central pancreatectomy with Roux-en-Y pancreaticojejunostomy (PJ) was done for 7/21 and 2/21 patients, respectively, with Grade 3 PT. Two with Grade 5 injury underwent trauma Whipple. The overall mortality and morbidity rates in our series were 15.7% and 64%, respectively. Conclusion The pathogenesis in PT is a dynamic process and shows temporal evolution. These patients require serial and periodical clinical and radiological monitoring, especially in those managed conservatively initially. PT can be low or high grade. Patients with isolated low-grade PT can be managed according to the standard step-up approach for acute pancreatitis. A carefully selected subgroup of patients with partial MPD disruption either in the head or body of the pancreas can be managed by endotherapy. Complete distal parenchymal transections require early surgery tailored to individual patients in the form of either splenic vessel preserving distal pancreatectomy (SPDP) or distal pancreatectomy with splenectomy (DP+S). Damage control surgery is the dictum in unstable patients with Grades 4 and 5 injuries not responding to resuscitative measures. A trauma Whipple can be done in a carefully selected subgroup of stable patients with proximal massive disruptions in an experienced hepato-pancreatico-biliary (HPB) unit.

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“…It therefore remains unclear if NOM strategies improve prognosis, especially in the context of other recent changes in the treatment. As a result, LAP is still a valid option [5,13,16,17,20,22]. Combined with previous experience, we hypothesized that initial PCD without open the retroperitoneum might improve the clinical outcomes of blunt high-grade pancreatic trauma compared with initail LAP in selected patients.…”

Section: Introductionmentioning

confidence: 99%

“…The management of pancreatic trauma depends on several factors, including the mechanism of injury (blunt vs penetrating trauma), AAST-OIS grade, hemodynamic status, and extent of concomitant organ injury [5,13]. Particularly worth mentioning is that the outcomes related to high-grade injuries have not improved over the past many years as we intended [14][15][16][17].…”

Section: Introductionmentioning

confidence: 99%

“…Percutaneous drainage (PCD), without open the retroperitoneum, can be used as the initial management for pancreatic trauma patients with stable hemodynamics and no diffuse peritonitis caused by hollow organ injury. [23,29] Subsequently, ERCP-guided stent placement was performed along the injured MPD for internal drainage [5,17,23,30,31]. NOM strategies combined with internal and external drainage is thought to be bene cial in the acute and delayed phase by inducing less surgical stress, thereby lowering the in ammatory cascade, especially in already critically ill patients with serious injury [25,31,32].…”

Section: Introductionmentioning

confidence: 99%

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

Chen

Wang

et al. 2022

Preprint

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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).

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Pancreatic Trauma: Imaging Review and Management Update

Cited by 34 publications

References 61 publications

An Unusual Case of Isolated Pancreatitis Secondary to Blunt Abdominal Trauma

An Unusual Case of Isolated Pancreatitis Secondary to Blunt Abdominal Trauma

A Pragmatic Approach to Pancreatic Trauma: A Single-Center Experience From a Tertiary Care Center

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

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