Blunt Pancreatic Trauma Research Articles

Management of Blunt Pancreatic Injuries in Children

Background: Most blunt abdominal injuries of solid organs in children can be managed nonoperatively. To date, however, there has been no general agreement regarding the application of nonoperative management to pancreatic injuries. Objective: We evaluated the course of patients who underwent blunt pancreatic trauma and were managed nonoperatively, in order to determine the efficacy and safety of this strategy. Patients and Methods: A retrospective study of 26 patients with blunt pancreatic injury admitted to the Department of Pediatric Surgery at the Soroka Medical Center between 1983 and 2002 was conducted. The data was collected from the Trauma Registry and the medical records. The results were analyzed using Fisher's exact test for comparison of proportions and Student's t-test for comparison of means. Level of confidence was defined at p < 0.05. Results: We identified 26 children with blunt panc reatic injuries. 19 patients sustained a minor injury, and seven had a major injury with transection of the main pancreatic duct. All 19 patients considered to have a minor injury, including three in whom pseudocysts were formed, responded well to nonoperative management. Five of the seven patients who sustained a major injury required an interventional procedure. Conclusion: Most pediatric patients with blunt pancreatic trauma, including those with pseudocyst formation, respond well to supportive nonoperative management. Symptomatic patients due to a large pseudocyst or a pancreatic abscess can be managed successfully by percutaneous computerized tomographic scan-guided drainage; however, some of these patients may require operative intervention.

The Endocrine and Pancreatic Unit at the University of Verona, Italy

The Endocrine and Pancreatic Unit at the University of Verona, Italy

Detecting Blunt Pancreatic Injuries

Pancreatic injury after blunt abdominal trauma is exceedingly uncommon, occurring in less than 5% of major abdominal injuries. When blunt pancreatic injury does occur, however, it is notoriously difficult to identify. The use of serum amylase has been advocated in the diagnosis of such injury, yet it is neither sensitive nor specific. Computed tomography has become widely accepted in the evaluation of hemodynamically stable patients after blunt abdominal trauma, although it is clearly not a sensitive modality for the detection of pancreatic injury. In fact, numerous examples of normal CT scans with missed pancreatic injury have been documented. However, careful attention to CT technique and awareness of the CT manifestations of pancreatic injury may facilitate the diagnosis of pancreatic injury. Additionally, important information about the pancreatic duct can be obtained with the use of MRI-pancreatography or endoscopic retrograde pancreatography. Accurate, timely identification of major pancreatic ductal injury is imperative because delay in diagnosis and associated vascular injuries are largely responsible for the high morbidity and mortality associated with blunt pancreatic trauma. Blunt pancreatic trauma can be managed successfully by means of both operative and selective approaches. ( J Gastrointest Surg 2002; 6:587–598.)

Blunt Pancreatic Trauma by a Wheelchair User Restraint System During a Traffic Accident

Traffic accidents are the most common cause of blunt pancreatic trauma, and most injuries occur in unrestrained drivers. Blunt pancreatic trauma in a passenger or a restrained driver is rare. In this report, we describe a case of blunt pancreatic trauma caused by a restraint system for wheelchair users during a traffic accident.

Blunt Pancreatic Trauma

Blunt Pancreatic Trauma

Blunt Pancreatic Trauma

Blunt Pancreatic Trauma

Selective management of pediatric pancreatic injuries

Background: Despite trauma being the most common cause of pediatric pancreatitis, the diagnosis and management is often difficult. Methods: The hospital course, diagnostic and surgical procedures, and complications for all children with traumatic pancreatitis evaluated at a Regional Level I Trauma Center were reviewed retrospectively. Results: Twelve of 3,500 children (0.35%, mean age, 8.7 ± 1.2 years) were reviewed. Intraoperative diagnosis was made in three after penetrating trauma. Nine children sustained blunt pancreatic trauma (BPT) with serial radiographic imaging confirming the diagnosis in seven. Serial serum amylase levels, when performed, were normal in two and elevated in six, but did not predict injury severity or need for further intervention. Endoscopic retrograde cholangiopancreatography was performed in three children and indicated the need for surgical intervention in two and prevented planned laparotomy in one. Two children underwent computed tomography-guided fluid drainage. Pseudocysts developed in five children. Mortality rate from penetrating injuries was 66% with no deaths from BPT. Conclusions: A combination of serial radiographic, laboratory, and ERCP findings will improve the diagnosis and management of BPT. Penetrating or main ductal injuries require surgical intervention, and fluid collections may require drainage, but, otherwise, most BPT can be managed nonoperatively with minimal morbidity and mortality.

Diagnosis and initial management of blunt pancreatic trauma: Guidelines from a multiinstitutional review: E.L. Bradley, P.R. Young, M.C. Chang, et al. Ann Surg 227:861–869, (June), 1998

Diagnosis and initial management of blunt pancreatic trauma: Guidelines from a multiinstitutional review: E.L. Bradley, P.R. Young, M.C. Chang, et al. Ann Surg 227:861–869, (June), 1998

Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review.

The authors' objective was to resolve the current controversies surrounding the diagnosis and management of blunt pancreatic trauma (BPT). The diagnosis of BPT is notoriously difficult: serum amylase has been claimed to be neither sensitive nor specific, and recent anecdotal reports have suggested a role for computed tomography. The therapy of BPT has been controversial, with some suggesting selective observation and others advocating immediate exploration to prevent a delay-induced escalation in morbidity and death. The authors conducted a retrospective chart review of documented BPT from six institutions, using a standardized binary data form composed of 187 items and 237 data fields. A significant correlation between pancreas-specific morbidity and injury to the main pancreatic duct (MPD) was noted. Patients requiring delayed surgical intervention after an unsuccessful period of observation demonstrated notably higher pancreas-specific mortality and morbidity rates, principally because of the incidence of unrecognized injuries to the MPD. Although detection of MPD injuries by computed tomography was no better than flipping a coin, endoscopic pancreatography was accurate in each of the five cases in which it was used. The principal cause of pancreas-specific morbidity after BPT is injury to the MPD. Parenchymal pancreatic injuries not involving the ductal system rarely result in pancreas-specific morbidity or death. Delay in recognizing MPD injury leads to increased mortality and morbidity rates. CT is unreliable in diagnosing MPD injury and should not be used to guide therapy. Initial selection of patients with isolated BPT for observation or surgery can be based on the determination of MPD integrity.

Diagnosis and Initial Management of Blunt Pancreatic Trauma: Guidelines From a Multiinstitutional Review

Diagnosis and Initial Management of Blunt Pancreatic Trauma: Guidelines From a Multiinstitutional Review

Blunt pancreatic trauma. Role of CT.

To define the evolution patterns of blunt pancreatic trauma, and to point out the CT features most significant for the diagnosis. Ten cases of pancreatic trauma, observed over a period of about 10 years, were analyzed in retrospect. The cases were divided into 3 groups according to the time that had elapsed between trauma and first CT: early phase (within 72 h: n=3/10); late phase (after 10 days: n=3/10); and following pancreatic drainage (n=4/10). In the early phase, one case showed a blood collection surrounding the pancreatic head and duodenum, and displacing the mesenteric vessels to the left. In the 2 other cases it was possible to demonstrate a tear in the pancreas at the neck, perpendicular to the main pancreatic axis. In the late phase in all 3 cases, one cystic lesion was present at the site of the tear, either surrounding the gland or embedded - more or less deeply - within the parenchyma. One of the lesions subsided spontaneously; the 2 others required surgery. In the postoperative phase, an external fistula was demonstrated in 2 cases following percutaneous drainage of pancreatic cysts; the fistula was fed by a cystic lesion in the pancreatic neck. In the 2 other cases a pseudocyst developed. Early demonstration of a parenchymal tear was difficult. At a later stage the diagnosis was easier owing to the demonstration of cystic lesions within the parenchyma at the site of the tear. The surgical drainage of this lesion does not usually lead to healing since an external fistula or a pseudocyst may develop.

Blunt Pancreatic Trauma

Blunt Pancreatic Trauma

Assessment of pancreatic duct damage following trauma: is endoscopic retrograde cholangiopancreatography the gold standard?

A 12-year-old girl was admitted as an emergency with blunt pancreatic trauma. Computed tomography (CT) showed an intact pancreas. She failed conservative treatment. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated division of the pancreatic duct at the neck of pancreas. At laparotomy, however, there was complete necrosis of the pancreatic head. She recovered well following enteric drainage of the body of pancreas. CT and ERCP are considered the optimal imaging for pancreatic trauma but the findings may be misleading.

Blunt pancreatic trauma with main pancreatic duct disruption managed successfully with total parenteral nutrition: Report of a case

Although surgery is the usual treatment of choice for pancreatic trauma with disruption of the main pancreatic duct, we report herein the case of a patient in whom blunt pancreatic trauma with disruption of the proximal main pancreatic duct was successfully managed by conservative treatment. An 18-year-old women presented with abdominal pain 22 days after being involved in a car accident in which her upper abdomen was thrust against the steering wheel. Computed tomography revealed a pancreatic pseudocyst and a prevertebral pancreatic fracture, and endoscopic retrograde pancreatography showed complete disruption of the main pancreatic duct at the neck. Considering that the patient had been clinically stable since the accident, we elected to continue with conservative management and placed her on total parenteral nutrition. Rapid recovery followed and 6 years later, the patient remains well without any exocrine or endocrine insufficiency despite atrophy of the distal pancreas. This experience indicates that selected cases of main pancreatic duct disruption following blunt trauma may be amenable to conservative management.

CT diagnosis of blunt pancreatic trauma: importance of detecting fluid between the pancreas and the splenic vein.

The purpose of this study was to determine the value of detecting fluid between the splenic vein and the pancreas on CT scans in the diagnosis of pancreatic injury after blunt abdominal trauma. We retrospectively reviewed the abdominal CT scans of 10 patients with surgical- or autopsy-proved pancreatic injury after blunt abdominal trauma. The finding of fluid interdigitating between the pancreas and the splenic vein was then studied along with the reported CT features of pancreatic injury. These included intraperitoneal fluid, fluid in the lesser sac, extraperitoneal fluid, pancreatic edema or hematoma, and thickening of the anterior renal fascia. The CT scans of all 10 patients reviewed showed abnormalities suggesting pancreatic injury. Only 40% of patients showed all of the findings reported in the literature. Fluid interdigitating between the splenic vein and the pancreatic parenchyma was seen on CT scans in 90%. Our experience suggests that fluid between the splenic vein and the pancreas is a helpful CT finding for the diagnosis of pancreatic injury after blunt abdominal trauma. This finding was easy to recognize and in the proper clinical setting directs attention to additional subtle findings of pancreatic injury.

Chronic Obstructive Pancreatitis as a Delayed Complication of Pancreatic Trauma

Increasing surgical experience with the immediate consequences of pancreatic injuries has resulted from parallel growth in the volume of motor vehicle accidents and societal violence. However, few surgeons are aware that complications may be considerably delayed following pancreatic trauma, occurring in some cases months to years after apparent recovery from the original injury. In four patients with blunt pancreatic trauma initially treated by non-operative means, stricture of the main pancreatic duct developed over a period of months as a result of progressive fibrosis at the site of ductal injury. Pancreatic duct hypertension was demonstrated to be present in the obstructed duct, and secondary changes of chronic pancreatitis developed in the obstructed segment of the gland (“upstream” chronic pancreatitis). Seven similar patients with delayed onset of chronic obstructive pancreatitis after pancreatic trauma were found in the literature. Symptoms related to these acquired ductal strictures are most commonly those of abdominal pain and recurrent episodes of acute pancreatitis. Recognition of post-traumatic chronic obstructive pancreatitis principally involves awareness that injuries to the pancreatic duct can produce remote complications. Pancreatoenteric drainage, or resection of the obstructed segment of pancreas, provides prompt and effective relief.

Blunt Pancreatic Trauma

Major ductal injury is a determining factor in the outcome after pancreatic trauma. The purpose of this study was to determine the value of early endoscopic retrograde pancreatography (ERP) in patients with blunt pancreatic trauma. We attempted ERP in nine patients. Indications were abnormal pancreatic findings on CT scanning in five patients, a suboptimal view on CT scanning in three patients, and a high index of suspicion in one patient. ERP was successful in eight patients. Two had major ductal injury treated operatively and were discharged without complications. In six, ERP showed a normal pancreatic duct. These patients were treated conservatively; five were eventually discharged, and one died of necrotizing pneumonia. Our results suggest that ERP is safe and accurate in the diagnosis of blunt pancreatic ductal injuries. If the pancreatic ductal system is intact, conservative management is appropriate, but if ERP shows major ductal injury, surgical intervention is indicated.

Blunt pancreatic injuries in children: The role of percutaneous external drainage in the treatment of pancreatic pseudocysts

During the past 10 years, 26 cases of blunt pancreatic trauma were diagnosed in our institution. In 42.3% (11/26) the accident was bicycle-related. Seventy-three percent of patients were seen within 48 hours of injury. The most frequent clinical presentations included abdominal pain, tenderness and vomiting. Diagnosis of pancreatic injury was suggested by hypermylasemia in most cases. Associated trauma was seen in seven patients (26.9%) and it was intraabdominal in four (15.3%). Computerized tomography (CT) scan is the single most useful radiologic investigation in evaluating pancreatic trauma. Ultrasound, although less accurate than CT scan in determining the severity of the initial injury, is useful in the evaluation and treatment of pancreatic pseudocysts. Pancreatic pseudocysts developed in ten patients. Spontaneous resolution occurred in five (50%). In three patients, percutaneous external drainage (PED) was successful in treating pancreatic pseudocysts without complications or recurrence at 11, 19, and 31 months. PED is a suitable form of treatment in selected cases of pancreatic pseudocysts. Results in children are better than in the adult population, probably due to the absence of primary pancreatic pathology. We believe that PED should be considered the primary therapeutic procedure for traumatic pancreatic collections prior to more invasive surgical treatment, when there is no evidence of pancreatic duct transection on CT scan.

Blunt Pancreatic Trauma and the Preoperative Diagnosis by CT

Blunt Pancreatic Trauma and the Preoperative Diagnosis by CT

Management of Blunt Pancreatic Trauma

Management of Blunt Pancreatic Trauma