Objective The authors' objective was to resolve the current controversies surrounding the diagnosis and management of blunt pancreatic trauma (BPT). Background Data 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. Methods 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. Results 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. Conclusions 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.

Background: Pancreatic leak is a major source of morbidity associated with pancreatic surgery. We sought to identify disease and technique-dependent factors associated with morbidity and mortality after distal pancreatectomy. Methods: Retrospective review of patients who underwent distal pancreatectomy during a 5-year period. Clinical, technical, and pathologic data were correlated with operative morbidity or mortality. Results: Fifty-one patients underwent distal pancreatectomy for primary pancreatic disease, extrapancreatic malignancy, or trauma. Overall perioperative mortality and morbidity rates were 4% and 47%, respectively. Pancreatic leak was the most common complication, occurring in 26% of patients. Overall complications and pancreatic leaks occurred more often after distal pancreatectomy for trauma and in patients with a sutured pancreatic stump closure. Conclusions: Distal pancreatectomy can be performed with a low rate of mortality, though pancreatic leak is a common cause of morbidity. The urgency of the procedure and the method of pancreatic stump closure may influence postoperative morbidity.

Morbidity, mortality, and technical factors of distal pancreatectomy.

Background:Major duct injury is the principal determinant of outcome for patients with pancreatic trauma, and there are a number of therapeutic choices available specific to the location of the insult. We report a series of blunt major pancreatic injury cases, with a review of the different procedur

Management of blunt major pancreatic injury.

Risk factors for mortality and intra-abdominal morbidity after distal pancreatectomy.

Background: Although relatively uncommon, traumatic pancreatic injury is associated with significant morbidity and mortality. The objectives of this review were to validate the American Association for the Surgery of Trauma organ injury grading system for pancreatic injury by defining its relationship to subsequent morbidity and to characterize the independent predictors of postoperative complications. Methods: We undertook a retrospective review of all patients with a pancreatic injury, confirmed by laparotomy, admitted to our Level I trauma center from 1986 and 1999. Pancreatic injury severity was assessed on the basis of the operative report. Outcome parameters included mortality, pancreatic complications (pancreatic fistula, pseudocyst, pancreatitis), intensive care unit (ICU) complications (acute respiratory distress syndrome, pneumonia, renal failure, multiple organ failure syndrome), abdominal complications (abscess, wound infection, ventral hernia, enteric fistula), and length of stay. Results: There were 193 patients identified. Mortality was 12%. Overall morbidity in the series was 50%, with a 22% prevalence of pancreas-related complications. Multivariate analysis revealed that the grade of pancreatic injury was an independent predictor of both pancreatic complications (odds ratio, 4.4; 95% confidence interval, 1.9-10) and mortality (odds ratio, 2.6; 95% confidence interval, 1.2-5.8). Pancreatic and ICU complications were associated with longer ICU and hospital stays. Conclusion: The American Association for the Surgery of Trauma Organ Injury Score predicts the development of complications and mortality after pancreatic injury and identifies patients who will require extensive resources and may benefit from transfer to a Level I trauma center.

Predictors of morbidity after traumatic pancreatic injury.

Ninety-one pancreatic injuries, 47 from blunt trauma, were reviewed with respect to management principles stressed in qi previous reviews. The pancreatic complication rate was 25%. Blunt injury was suspected preoperatively in only 30%. Even short-term observation led to morbidity. Operations done more than 6 hours after admission had a higher complication rate (45%) than those done less than 6 hours after admission (18%). Penrose drainage without a sump was not associated with increased complications. Distal pancreatectomy was done 32 times; splenectomy was done in only 18 patients. Individual duct ligation was rarely done and did not result in a high fistula rate. Pancreatic stump oversew with nonabsorbable suture was associated with a higher rate of pancreatic complications than absorbable suture (58% vs 30%). Only 56% of patients receiving distal pancreatectomy required hyperalimentation. Postoperative serum amylase values were not useful, and amylase values from drainage fluid predicted complications only when they were above 100,000 U/L. Details of pancreatic trauma management are less important than early operation in minimizing morbidity.

Rebekah L. Wold

Papers

Diagnosis and treatment of pancreatic injuries. An analysis of management principles.