Main Pancreatic Duct Injury Research Articles

Management of Blunt Pancreatic Trauma in Children: A Persistent Controversy-Case Report and Comprehensive Literature Review.

Blunt pancreatic injury (BPI) is relatively uncommon in children, and is associated with relatively high morbidity and mortality, especially if diagnosis is delayed. The aim of this report is to review the literature regarding controversial questions in the early diagnosis and management of pediatric BPI. A representative case of blunt pancreatic trauma in a six-year-old girl with delayed diagnosis and intraoperative and postoperative complications was described. A systematic search of databases and the grey literature in Scopus and Web of Science using relevant keywords was conducted. A total of 26 relevant articles published in last 5 years were found in PubMed. Although early CT performance is considered part of initial pancreatic trauma workup, the sensitivity of CT for detecting main pancreatic duct injuries in children is relatively low. MRCP and ERCP (if available) are useful for assessing ductal injury and should be performed when the status of the pancreatic duct is unclear on the CT. Most patients with low-grade pancreatic damage may be treated conservatively. Although surgery involving distal pancreatectomy remains the preferred approach for most children with high-grade pancreatic injury, there is growing evidence to suggest that non-operative management (NOM) is safe and effective. Most pancreatic pseudo cysts following NOM had relatively mild complications, and most resolved spontaneously. For those children who do require surgery, a conservative operative approach with the least risk is advocated. In conclusion, the optimal management for pediatric pancreatic trauma is controversial. Further clinical trials are required to generate clinical practice guidelines on pancreatic trauma in a child population.

The role of main pancreatic duct stent in the enucleation of benign/borderline pancreatic head tumors: a cohort study.

This study aimed to reveal the role of preoperative main pancreatic duct (MPD) stent placement in reducing the intraoperative main pancreatic duct injury rate and the incidence of postoperative pancreatic leakage following pancreatic tumor enucleation. A retrospective cohort analysis was performed for all patients with benign/borderline pancreatic head tumors who were treated with enucleation. The patients were divided into two groups (standard vs. stent) depending on whether they underwent main pancreatic duct stent placement prior to surgery. Thirty-three patients were finally included in the analytical cohort. Compared with the standard group, patients in the stent group had a shorter distance between tumors and main pancreatic duct (p=0.01) and presented with larger tumors (p<0.01). The rates of POPF (grade B&C) were 39.1% (9/23) and 20% (2/10) in the standard and stent groups, respectively (p<0.01). Major postoperative complications occurred more frequently in the standard group than in the stent group (14 versus 2; p<0.01). No significant differences in mortality, in-hospital stay or medical cost were observed between the two groups (p>0.05). MPD stent placement prior to surgery may facilitate pancreatic tumor enucleation, minimize MPD injury and decrease the occurrence of postoperative fistula.

ISOLATED PANCREATIC INJURIES: A CASE SERIES

Context: Pancreatic injuries constitutes a set of rare abdominal solid organ injuries. Isolated pancreatic injuries are even more rare injuries and are often missed in initial clinical and radiological evaluation . such injuries present late and denitive guidelines to manage such injuries are lacking, considering rarity of such injuries. Unpredictable course involves traumatic pancreatitis, pancreatic necrosis, peripancreatic collections, infective complications and extra abdominal complication The aim of this study is to present clinical details and management outcomes of such casesAims: at our institute This study is a retrospective analytical study In this retrospective study medicalSettings and Design: Methods and Material: records of all the admissions were collected from trauma registry from may 2016 to april 2022 at Thanjavur medical college. All these records were screened for patients with isolated pancreatic injuries All continuous variables were analyzed with descriptive statisticsStatistical analysis used: and their mean, median, mode, range and frequencies were calculated. All categorical data are analyzed with frequencies. Comparison of data is done using: all nominal data is analyzed with parametric tests (Chi-square test, unpaired t test) and non-nominal data is analyzed with non- parametric tests (Fischer's exact test and Mann-whitney U test). In our study a total of 22 cases were included. Mean age being 33.91yearsResults: among which 81.8% were males. 72.7% of the patients suffered road trafc accidents. 77.3% of the patients had BMI less than 25. Main pancreatic duct (MPD) involvement was noticed in 22.7% patients. median levels of serum amylase levels were 390U/L. 22.7% patients underwent operative management were as rest were managed non-operatively. Two patients died due to severe pancreatitis. Isolated pancreatic injuries inConclusions: patients where surgery is otherwise not indicated due to other causes needs management tailored to the clinical needs of the patient. Diagnostic ambiguity is best resolved by combining computed tomography (CT) and Magnetic resonance cholangiopancreatography (MRCP). Patients with distal MPD injury are usually operated when presented early and pancreatic stenting is considered when proximal ductal injury is noticed. In selected cases conservative approach is not a contraindication, even in patients with MPD injury, considering high stula and peripancreatic collection rates in distal pancreatectomy.

Definition of a hospital volume threshold to optimize outcomes after drainage of pancreatic fluid collections with lumen-apposing metal stents: a nationwide cohort study

There is increasing interest in expanding the use of lumen-apposing metal stents (LAMSs) in patients with pancreatic fluid collections (PFCs). The aim of this study was to determine whether there is a hospital volume threshold for which patient outcomes could be optimized. Data from a large multicenter series of patients with PFCs treated with LAMSs were retrieved. Rate of adverse events (AEs) was the primary outcome. Multivariable models with restricted cubic splines were used to identify a hospital volume threshold by plotting hospital volume against the log odds ratio (OR) of AE rate. Propensity score matching was applied to obtain 2 well-balanced groups according to hospital volume, and univariate/multivariate logistic regression analysis was performed to identify significant predictors of AEs. Overall, 516 patients were included. Increasing hospital volume was associated with a reduced AE rate (P= .03), and the likelihood of experiencing an AE declined as hospital volume increased up to 15 cases. After propensity score matching, 175 patients in the high-volume (>15 cases) and 132 in the low-volume hospital group were compared. Overall, 41 AEs were observed (13.3%), of which 14 (8%) and 27 (20.4%) occurred at high-volume and low-volume centers, respectively (P= .001). Severe and fatal events were observed more frequently in low-volume centers (6% vs 1.7% and 2.2% vs 0%, respectively; P= .05). In multivariate analysis, main pancreatic duct injury (OR, 2.62; 95% confidence interval [CI], 1.26-4.67; P= .02), presence of abnormal vessels (OR, 2.93; 95% CI, 1.41-5.02; P= .006), and institutional experience (OR, 2.95; 95% CI, 1.48-5.90; P= .002) were significant predictors of AEs. With 15 procedures representing the minimum number of cases associated with the lowest risk for postprocedural AEs, hospital volume is associated with improved outcomes. (Clinical trial registration number: NCT03903523.).

Endoscopic ultrasound-guided pancreatic drainage for treating a traumatic main pancreatic duct injury in a child

Abstract A 10-year-old Japanese boy presented the day after a bicycle handlebar injury with mild abdominal pain. Computed tomography (CT) confirmed pancreatic transection and possible main pancreatic duct (MPD) injury because of a fluid collection around the pancreas. Conservative management (fasting, antibiotics, total parental nutrition, protease inhibitor) was initially successful, but an oral challenge with plain water on day 23 caused a relapse. CT identified a pancreatic pseudocyst. Endoscopic trans-papillary drainage was attempted but failed because the MPD was completely obstructed. Endoscopic ultrasound (EUS)-guided drainage of the pseudocyst with a lumen apposing metal stent (LAMS) was performed on day 29 via the stomach. On day 36, EUS-guided pancreatic drainage (EUS-PD) with a 5Fr plastic stent was performed via the stomach with rapid improvement in symptoms and elevated enzyme levels. Repeat oral challenge on day 39 was successful, the LAMS was removed on day 59 without recurrence. He was discharged well on day 69 and remains asymptomatic 20 months after treatment. Our case highlights the potential of minimally invasive endoscopic procedures as options for the non-surgical management of complete MPD disruption in a child. However, further research to develop dedicated pediatric endoscopic devices is required.

Current status and management of pancreatic trauma with main pancreatic duct injury: A multicenter nationwide survey in Japan.

BackgroundPancreatic trauma is reportedly associated with high morbidity and mortality. Main pancreatic duct (MPD) injury is critical for treatment.MethodsAs a study project of the Japanese Society for Abdominal Emergency Medicine (JSAEM), we collected the data of 163 patients with pancreatic trauma who were diagnosed and treated at JSAEM board‐certified hospitals from 2006 to 2016. Clinical backgrounds, diagnostic approaches, management strategies, and outcomes were evaluated.ResultsSixty‐four patients (39%) were diagnosed as having pancreatic trauma with MPD injury that resulted in 3% mortality. Blunt trauma and isolated pancreatic injury were independent factors predicting MPD injury. Nine of 11 patients with MPD injury who were initially treated nonoperatively had serious clinical sequelae and five (45%) required surgery as a secondary treatment. Among all cases, the detectability of MPD injury of endoscopic retrograde pancreatography (ERP) was superior to that of other imaging modalities (CT or MRI), with higher sensitivity and specificity (sensitivity = 0.96; specificity = 1.0).ConclusionsAcceptable outcomes were observed in pancreatic trauma patients with MPD injury. Nonoperative management should be carefully selected for MPD injury. ERP is recommended to be performed in patients with suspected MPD injury and stable hemodynamics.

Non–operative managementで軽快した膵体部主膵管損傷の1例(A case of nonoperative management of main pancreatic duct injury in the pancreatic body)

要旨症例は16歳の男性。サッカーの試合中に相手選手との接触により受傷した。CTで膵損傷と診断し経過観察。その後，症状の増悪はみられなかったが，第4病日のCTで膵周囲の液体貯留が左腎下極を越えて広がっており，MRCPを行ったところ膵体部に主膵管損傷を認めた。損傷部を越えてENPDチューブが留置可能であったため保存治療の方針とし，その後，画像所見，症状ともに改善がみられた。第25病日に，膵体部の嚢胞は残存していたが，長期留置による合併症を懸念し，ENPDチューブは抜去とした。抜去後，一時的に嚢胞の拡大を認めたが，その後自然に縮小傾向となり，第188病日には消失した。膵体部主膵管損傷に対するnon–operative managementは，膵頭部損傷と比較し手術療法に対する有用性の判断が難しい。今回我々は，膵体部主膵管損傷に対しNOMを行い有効であった症例を経験したので報告する。

The bridge stenting-based internal drainage in pancreatic trauma patients with main pancreatic duct injury.

Pancreatic trauma is associated with high mortality and morbidity, especially in main pancreatic duct (MPD) injuries. Here, we introduce a novel technique via the placement of bridge stenting-based internal drainage (BSID) along the injured MPD to restore pancreatic tissue integrity. Twelve patients with MPD injury underwent unobstructed BSID as physical support for healing. Six patients with peripheral organ injuries underwent operative end-to-end anastomosis of the MPD by using a polyurethane central venous catheter for the BSID, and the other six patients with isolated proximal MPD rupture received BSID via endoscopic pancreatic stent placement. The BSID technique was successfully performed in all pancreatic trauma patients without the need for a second open surgery. With this simplified BSID-based operation, a short procedure duration (242.7 ± 38.71min in the surgical group and 100.2 ± 16.24min in the endoscopic group) and a short hospital stay (13.0 ± 7.05days) were achieved. However, a few complications (41.67%) still occurred, including pancreatitis, fistula, abscess, pseudocyst, cholangitis, and haemorrhage. Except for the deceased case, all postoperative courses were marked by decreases in the peripancreatic fluid collection, blood amylase recovery, and normal endocrine function. The BSID approach is a feasible surgical approach for the treatment of MPD injury and can be used endoscopically in isolated MPD injuries for its safety and convenience.

Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma

IntroductionPancreatic trauma (PT) involving the main pancreatic duct is rare, but represents a challenging clinical problem with relevant morbidity and mortality. It is generally classified according to the American Association for the Surgery of Trauma (AAST) and often presents as concomitant injury in blunt or penetrating abdominal trauma. Diagnosis may be delayed because of a lack of clinical or radiological manifestation. Treatment options for main pancreatic duct injuries comprise highly complex surgical procedures. Patients and MethodsWe retrospectively analyzed clinical data from 12 patients who underwent surgery in two tertiary centers in Germany during 2003–2016 for grade III-V PT with affection of the main pancreatic duct, according to the AAST classification. ResultsThe median age was 23 (range: 7-44) years. In nine patients blunt abdominal trauma was the reason for PT, whereas penetrating trauma only occurred in three patients. MRI outperformed classical trauma CT imaging with regard to detection of duct involvement. Complex procedures as i.e. an emergency pancreatic head resection, distal pancreatectomy or parenchyma sparing pancreatogastrostomy were performed. Compared to elective pancreatic surgery the complication rate in the emergency setting was higher. Yet, parenchyma-sparing procedures demonstrated safety. ConclusionsOften extension of diagnostics including MRI and/or ERP at an early stage is necessary to guide clinical decision-making. If, due to main duct injuries, surgical therapy for PT is required, we suggest consideration of an organ preservative pancreatogastrostomy in grade III/IV trauma of the pancreatic body or tail.

Grade IV traumatic pancreatic injury with primary duodenum malignant lymphoma following pancreatoduodenectomy: a case report

BackgroundTraumatic pancreatic injury with a main pancreatic duct injury has a high incidence of mortality and requires a prompt and appropriate treatment. However, the best approach, and treatment options, which may be limited, remains controversial especially for the elderly patients. Herein, we present a case of traumatic pancreatic injury in an elderly patient for whom pancreatoduodenectomy was safe and effective.Case presentationAn 87-year-old man was diagnosed with a traumatic pancreatic injury with a main pancreatic duct injury. In addition, the horizontal segment of the duodenum was largely eradicated. There were no comorbidities, and his vital signs were stable. A pancreatoduodenectomy was performed. The postoperative course was uneventful, and he was discharged. Pathological examination revealed a primary follicular lymphoma of the duodenum.ConclusionsThis case demonstrated that pancreatoduodenectomy could be performed safely for a severe pancreatic injury in an elderly patient. However, special attention should be paid to select the optimal surgical procedure. Further, this was a rare case, as initially a primary follicular lymphoma of the duodenum was suspected as a duodenal injury coexisting with a traumatic pancreatic injury because of the increased duodenal thickness.

Endoscopic Retrograde Cholangiopancreaticography in Children: A Single-center Experience From Northern India

To evaluate spectrum, efficacy and safety of Endoscopic retrograde cholangiopancreatography (ERCP) in pediatric population. Retrospective case record review of pediatric patients (age ≤15 y) undergoing ERCP between January 2011 to June 2015 at a tertiary care referral hospital in New Delhi, India. The Indications for ERCP, cannulation success rate, procedure success rate and complications were recorded. The mean (SD) age of the participants were 11.5 (3) years. 164 ERCP procedures were done in 126 patients (67 males). All procedures were done under conscious sedation. The common indications for ERCP were choledocholithiasis (50, 30.5%), chronic calcific pancreatitis (38,23.2%), main pancreatic duct injury with leak (21,12.8%), and bile leak (12,7.3%). The cannulation success rate was 90.4% (114 out of 126), while procedural success rate was 86% (141 out of 164). Overall 8 complications were encountered; all were successfully managed conservatively. ERCP in children can be successfully performed at centers with such expertise.

主膵管断裂を伴った外傷性膵損傷に対してnon–operative managementにて救命し得た3例(Three successful cases of non–operative management for traumatic pancreatic damage with main pancreatic ductal rupture)

要旨 手術適応と考えられてきた主膵管損傷を伴うIIIb型（日本外傷学会分類）膵損傷に対して，非手術療法（non–operative management: NOM）にて治癒した3症例について検討した。診断はERCP（endoscopic retrograde cholangiopancreatography）時，主膵管からの造影剤の漏出により行った。診断と同時に，オクトレオチド酢酸塩（Sandostatin®），抗菌薬，メシル酸ガベキサートの投与を開始した。オクトレオチド酢酸塩にて膵外分泌を抑制することで，腹腔内の炎症拡大を抑えることができたと推測する。また急性膵炎の病態に対し，抗菌薬およびメシル酸ガベキサートの投与を行った。加えて，急性期以降に形成された膵仮性嚢胞に対し経十二指腸乳頭的，経皮的，経胃的などの膵液ドレナージ処置を行った。難渋したが，いずれの症例も軽快退院することができた。3症例を通して，急性期の膵液ドレナージおよび急性期以降の膵仮性嚢胞ドレナージの2段階ドレナージを主体としたNOMにより，本来手術を要すると考えられている主膵管断裂を伴った外傷性膵損傷症例でも救命できる可能性があると考えられた。NOMの成功例の積み上げが続けば，今後手術適応が再検討されるべきであろう。

A case of end‐to‐end anastomotic repair for the proximal main pancreatic duct injury in a child

The therapeutic strategies for the proximal transection of pancreas in children, consequently accompanying main pancreatic duct (MPD) damages, remain controversial for its rare incidence. We experienced one case of proximal MPD injury in a child and performed end‐to‐end anastomotic repair easily without major postoperative complications using intraoperative ultrasonography. Such patients could be discharged from hospital after a short period; however, the long‐term result must be clarified.

Surgical experience on Roux-en-Y pancreaticojejunostomy after local pancreatic head resection for benign tumors of the pancreatic head

To explore the value of Roux-en-Y pancreaticojejunostomy after local pancreatic head resection in treating benign tumors of pancreatic head (BTPH). The clinical data of 12 patients diagnosed as BTPH and treated by Roux-en-Y pancreaticojejunostomy after local pancreatic head resection in Department of General Surgery, Peking University Third Hospital from November 2006 to October 2013 were retrospectively analyzed.Of the 12 cases, 5 patients were male, 7 patients were female, the age of patients ranged from 21 to 64 years(average 42.3 years). Diameter of tumors was 3.0-4.8 cm.Diameter of pancreatic wound after resection was 5.1-7.9 cm, and main pancreatic duct injury happened in 1 case. Two cases of mucinous cystadenoma, 2 insulinoma, 3 solid pseudopapillary tumor and 4 nonfunctional pancreatic neuroendocrine tumors were confirmed histopathologically.No mortality and pancreatic leakage occurred during the perioperative period.All the 12 patients had no sign of recurrence.Experienced good life quality without occurrence of diabetes during the follow-up period of 24-108 months(more than 60 months in 4 cases). Roux-en-Y pancreaticojejunostomy after local pancreatic head resection is a reasonable choice for benign tumors of the pancreatic head as long as the patient is properly selected.

A Case of Blunt Pancreatic Trauma With Main Pancreatic Duct Injury in a Child

A Case of Blunt Pancreatic Trauma With Main Pancreatic Duct Injury in a Child

Endoscopic and operative treatment of delayed complications after pancreatic trauma: An analysis of 27 civilians treated in an academic Level 1 Trauma Centre.

This study evaluated the efficacy of endoscopic treatment of delayed local complications including pseudocysts and persistent pancreatic fistulae in a cohort of civilian patients who had previously sustained a pancreatic injury. A large institutional database was interrogated to identify patients who developed a delayed pancreatic complication among those with pancreatic injuries treated between January 1990 and December 2013. The degree of the pancreatic duct injury was graded using a new duct injury grading system and endoscopic therapeutic outcome assessed according to the grade of injury. During the period under review, 432 consecutive patients were treated for pancreatic injuries of whom 27 (20 men, 7 women, median age 31, range 15-68 years) presented with delayed complications related to the initial pancreatic injury. Sixteen patients had non-resolving symptomatic pancreatic pseudocysts, 10 had persistent pancreatic fistulae and 1 had a symptomatic duct stricture. Fourteen patients with grade 2a, 3a, 3b or 4c main pancreatic duct injuries were successfully treated endoscopically with either pancreatic duct stenting or pseudocyst drainage while 13 patients with grade 4a or 4b duct injuries who had complete duct division with a disconnected duct syndrome failed endoscopic management and required surgical intervention. The 27 patients underwent a total of 49 endoscopic procedures (47 elective, 2 emergency) of whom 4 developed complications related to the endoscopic treatment. All 4 resolved, 2 after urgent endoscopic re-intervention. In this preliminary analysis the Cape Town pancreatic ductal injury grading classification showed a close correlation with outcome after endoscopic and operative intervention.

The prevalence and treatment outcome of main pancreatic duct injury in patients with necrotizing pancreatitis

The prevalence and treatment outcome of main pancreatic duct injury in patients with necrotizing pancreatitis

Pancreatic trauma.

Pancreatic trauma occurs in approximately 4% of all patients sustaining abdominal injuries. The pancreas has an intimate relationship with the major upper abdominal vessels, and there is significant morbidity and mortality associated with severe pancreatic injury. Immediate resuscitation and investigations are essential to delineate the nature of the injury, and to plan further management. If main pancreatic duct injuries are identified, specialised input from a tertiary hepatopancreaticobiliary (HPB) team is advised. A comprehensive online literature search was performed using PubMed. Relevant articles from international journals were selected. The search terms used were: 'pancreatic trauma', 'pancreatic duct injury', 'radiology AND pancreas injury', 'diagnosis of pancreatic trauma', and 'management AND surgery'. Articles that were not published in English were excluded. All articles used were selected on relevance to this review and read by both authors. Pancreatic trauma is rare and associated with injury to other upper abdominal viscera. Patients present with non-specific abdominal findings and serum amylase is of little use in diagnosis. Computed tomography is effective in diagnosing pancreatic injury but not duct disruption, which is most easily seen on endoscopic retrograde cholangiopancreaticography or operative pancreatography. If pancreatic injury is suspected, inspection of the entire pancreas and duodenum is required to ensure full evaluation at laparotomy. The operative management of pancreatic injury depends on the grade of injury found at laparotomy. The most important prognostic factor is main duct disruption and, if found, reconstructive options should be determined by an experienced HPB surgeon. The diagnosis of pancreatic trauma requires a high index of suspicion and detailed imaging studies. Grading pancreatic injury is important to guide operative management. The most important prognostic factor is pancreatic duct disruption and in these cases, experienced HPB surgeons should be involved. Complications following pancreatic trauma are common and the majority can be managed without further surgery.

Blunt pancreatic trauma: evaluation with MDCT technology

The purpose of this paper is to determine the relative frequency of multi-detector CT (MDCT) findings of pancreatic injury in blunt trauma and to determine their diagnostic accuracy in predicting main pancreatic duct injury. Fifty-three patients (31 male, 22 female; mean 44.1 years) with blunt trauma and admission MDCT findings suspicious for pancreatic injury or who underwent MDCT and had a discharge diagnosis of pancreatic trauma were included in this study. Two radiologists reviewed all images and recorded findings suspicious for pancreatic injury, which were subsequently compared to surgical findings to generate diagnostic accuracy. MDCT imaging findings suggestive of pancreatic injury included low attenuation peripancreatic fluid (n = 51), hyperattenuating peripancreatic fluid (n = 13), pancreatic contusion (n = 7), active hemorrhage (n = 2), and pancreatic laceration (n = 16). Diagnostic accuracy of the various imaging findings varied for diagnosing main duct injury; there were highly sensitive, nonspecific imaging findings such as the presence of low attenuation peripancreatic fluid (sensitivity, 100 %; specificity 4.9 %) as well as insensitive, specific findings such as visualizing a pancreatic laceration involving >50 % of the parenchymal width (sensitivity, 50 %; specificity, 95.1 %). In the setting of blunt abdominal trauma, MDCT imaging findings can be grouped into two categories for determining integrity of the main pancreatic duct: indirect, highly sensitive but nonspecific findings and direct, specific but insensitive findings. Awareness of the clinical implications of the various MDCT imaging findings of pancreatic trauma is useful in interpreting their significance.

Medical Treatment in Postoperative Main Pancreatic Duct Injury : A Case Report

Medical Treatment in Postoperative Main Pancreatic Duct Injury : A Case Report