An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

Nickolas Byrge, Marta Heilbrun, Nicole Winkler, Daniel Sommers, Heather Evans, Lindsay M. Cattin, Tom Scalea, Deborah M. Stein, Todd Neideen, Pamela Walsh, Carrie A. Sims, Tejal S. Brahmbhatt, Joseph M. Galante, Ho H. Phan, Ajai Malhotra, Robert T. Stovall, Gregory J. Jurkovich, Raul Coimbra, Allison E. Berndtson, Thomas A. O'CallaghanScott F. Gaspard, Martin Schreiber, Mackenzie R. Cook, Demetrios Demetriades, Omar Rivera, George C. Velmahos, Ting Zhao, Pauline K. Park, David Machado-Aranda, Salman Ahmad, Julie Lewis, William S. Hoff, Ghada Suleiman, Jason Sperry, Samuel Zolin, Matthew M. Carrick, Gina R. Mallory, Jade Nunez, Alexander Colonna, Toby Enniss, Ram Nirula

    Research output: Contribution to journalArticle

    3 Citations (Scopus)

    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 (r2 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.

    Original languageEnglish (US)
    Pages (from-to)435-443
    Number of pages9
    JournalJournal of Trauma and Acute Care Surgery
    Volume85
    Issue number3
    DOIs
    StatePublished - Sep 1 2018

    Fingerprint

    Wounds and Injuries
    Pancreatic Fistula
    Pancreatic Pseudocyst
    Injury Severity Score
    Mortality
    Pancreatic Ducts
    Adult Respiratory Distress Syndrome
    Drainage
    Pancreas
    Morbidity
    Sensitivity and Specificity
    Glasgow Coma Scale
    Trauma Centers
    Registries
    Lactic Acid
    Multivariate Analysis
    Erythrocytes
    Regression Analysis

    Keywords

    • drainage
    • leak
    • Pancreas
    • resection
    • sew
    • staple

    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

    Cite this

    Byrge, N., Heilbrun, M., Winkler, N., Sommers, D., Evans, H., Cattin, L. M., ... Nirula, R. (2018). An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain? Journal of Trauma and Acute Care Surgery, 85(3), 435-443. https://doi.org/10.1097/TA.0000000000001987

    An AAST-MITC analysis of pancreatic trauma : Staple or sew? Resect or drain? / Byrge, Nickolas; Heilbrun, Marta; Winkler, Nicole; Sommers, Daniel; Evans, Heather; Cattin, Lindsay M.; Scalea, Tom; Stein, Deborah M.; Neideen, Todd; Walsh, Pamela; Sims, Carrie A.; Brahmbhatt, Tejal S.; Galante, Joseph M.; Phan, Ho H.; Malhotra, Ajai; Stovall, Robert T.; Jurkovich, Gregory J.; Coimbra, Raul; Berndtson, Allison E.; O'Callaghan, Thomas A.; Gaspard, Scott F.; Schreiber, Martin; Cook, Mackenzie R.; Demetriades, Demetrios; Rivera, Omar; Velmahos, George C.; Zhao, Ting; Park, Pauline K.; Machado-Aranda, David; Ahmad, Salman; Lewis, Julie; Hoff, William S.; Suleiman, Ghada; Sperry, Jason; Zolin, Samuel; Carrick, Matthew M.; Mallory, Gina R.; Nunez, Jade; Colonna, Alexander; Enniss, Toby; Nirula, Ram.

    In: Journal of Trauma and Acute Care Surgery, Vol. 85, No. 3, 01.09.2018, p. 435-443.

    Research output: Contribution to journalArticle

    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, M, 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 2018, 'An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?', Journal of Trauma and Acute Care Surgery, vol. 85, no. 3, pp. 435-443. https://doi.org/10.1097/TA.0000000000001987
    Byrge, Nickolas ; Heilbrun, Marta ; Winkler, Nicole ; Sommers, Daniel ; Evans, Heather ; Cattin, Lindsay M. ; Scalea, Tom ; Stein, Deborah M. ; Neideen, Todd ; Walsh, Pamela ; Sims, Carrie A. ; Brahmbhatt, Tejal S. ; Galante, Joseph M. ; Phan, Ho H. ; Malhotra, Ajai ; Stovall, Robert T. ; Jurkovich, Gregory J. ; Coimbra, Raul ; Berndtson, Allison E. ; O'Callaghan, Thomas A. ; Gaspard, Scott F. ; Schreiber, Martin ; Cook, Mackenzie R. ; Demetriades, Demetrios ; Rivera, Omar ; Velmahos, George C. ; Zhao, Ting ; Park, Pauline K. ; Machado-Aranda, David ; Ahmad, Salman ; Lewis, Julie ; Hoff, William S. ; Suleiman, Ghada ; Sperry, Jason ; Zolin, Samuel ; Carrick, Matthew M. ; Mallory, Gina R. ; Nunez, Jade ; Colonna, Alexander ; Enniss, Toby ; Nirula, Ram. / An AAST-MITC analysis of pancreatic trauma : Staple or sew? Resect or drain?. In: Journal of Trauma and Acute Care Surgery. 2018 ; Vol. 85, No. 3. pp. 435-443.
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    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 (r2 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.",
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    author = "Nickolas Byrge and Marta Heilbrun and Nicole Winkler and Daniel Sommers and Heather Evans and Cattin, {Lindsay M.} and Tom Scalea and Stein, {Deborah M.} and Todd Neideen and Pamela Walsh and Sims, {Carrie A.} and Brahmbhatt, {Tejal S.} and Galante, {Joseph M.} and Phan, {Ho H.} and Ajai Malhotra and Stovall, {Robert T.} and Jurkovich, {Gregory J.} and Raul Coimbra and Berndtson, {Allison E.} and O'Callaghan, {Thomas A.} and Gaspard, {Scott F.} and Martin Schreiber and Cook, {Mackenzie R.} and Demetrios Demetriades and Omar Rivera and Velmahos, {George C.} and Ting Zhao and Park, {Pauline K.} and David Machado-Aranda and Salman Ahmad and Julie Lewis and Hoff, {William S.} and Ghada Suleiman and Jason Sperry and Samuel Zolin and Carrick, {Matthew M.} and Mallory, {Gina R.} and Jade Nunez and Alexander Colonna and Toby Enniss and Ram Nirula",
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    TY - JOUR

    T1 - An AAST-MITC analysis of pancreatic trauma

    T2 - Staple or sew? Resect or drain?

    AU - Byrge, Nickolas

    AU - Heilbrun, Marta

    AU - Winkler, Nicole

    AU - Sommers, Daniel

    AU - Evans, Heather

    AU - Cattin, Lindsay M.

    AU - Scalea, Tom

    AU - Stein, Deborah M.

    AU - Neideen, Todd

    AU - Walsh, Pamela

    AU - Sims, Carrie A.

    AU - Brahmbhatt, Tejal S.

    AU - Galante, Joseph M.

    AU - Phan, Ho H.

    AU - Malhotra, Ajai

    AU - Stovall, Robert T.

    AU - Jurkovich, Gregory J.

    AU - Coimbra, Raul

    AU - Berndtson, Allison E.

    AU - O'Callaghan, Thomas A.

    AU - Gaspard, Scott F.

    AU - Schreiber, Martin

    AU - Cook, Mackenzie R.

    AU - Demetriades, Demetrios

    AU - Rivera, Omar

    AU - Velmahos, George C.

    AU - Zhao, Ting

    AU - Park, Pauline K.

    AU - Machado-Aranda, David

    AU - Ahmad, Salman

    AU - Lewis, Julie

    AU - Hoff, William S.

    AU - Suleiman, Ghada

    AU - Sperry, Jason

    AU - Zolin, Samuel

    AU - Carrick, Matthew M.

    AU - Mallory, Gina R.

    AU - Nunez, Jade

    AU - Colonna, Alexander

    AU - Enniss, Toby

    AU - Nirula, Ram

    PY - 2018/9/1

    Y1 - 2018/9/1

    N2 - 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 (r2 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.

    AB - 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 (r2 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.

    KW - drainage

    KW - leak

    KW - Pancreas

    KW - resection

    KW - sew

    KW - staple

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