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 A.
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
N1 - Publisher Copyright:
© 2018 Wolters Kluwer Health, Inc.
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 (r 2 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 (r 2 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 - Pancreas
KW - drainage
KW - leak
KW - resection
KW - sew
KW - staple
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U2 - 10.1097/TA.0000000000001987
DO - 10.1097/TA.0000000000001987
M3 - Article
C2 - 29787527
AN - SCOPUS:85052738933
SN - 2163-0755
VL - 85
SP - 435
EP - 443
JO - Journal of Trauma and Acute Care Surgery
JF - Journal of Trauma and Acute Care Surgery
IS - 3
ER -