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 A. 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

    7 Scopus citations

    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 (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.

    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

    Keywords

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

    ASJC Scopus subject areas

    • Surgery
    • Critical Care and Intensive Care Medicine

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  • Cite this

    Byrge, N., Heilbrun, M., Winkler, N., Sommers, D., Evans, H., Cattin, L. M., Scalea, T., Stein, D. M., Neideen, T., Walsh, P., Sims, C. A., Brahmbhatt, T. S., Galante, J. M., Phan, H. H., Malhotra, A., Stovall, R. T., Jurkovich, G. J., Coimbra, R., Berndtson, A. E., ... 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