Damage control surgery for severe pancreatic trauma

Pancreatic trauma as a challenge before and during explorative laparotomy is associated with multiple visceral injuries or critical conditions. Its optimal management remains controversial.The current concept of damage control surgery (DCS) has been increasingly accepted. DCS

Feasibility and safety of “bridging” pancreaticogastrostomy for pancreatic trauma in Landrace pigs

BACKGROUND In recent years,we created and employed a new anastomosis method,“bridging”pancreaticogastrostomy,to treat patients with extremely severe pancreatic injury.This surgery has advantages such as short length of surgery,low secondary trauma,rapid construction of shunts for pancreatic fluid,preventing second surgeries,and achieving good treatment outcomes in clinical practice.However,due to the limited number of clinical cases,there is a lack of strong evidence to support the feasibility and safety of this surgical procedure.Therefore,we carried out animal experiments to examine this procedure,which is reported here.AIM To examine the feasibility and safety of a new rapid method of pancreaticogastrostomy,“bridging”pancreaticogastrostomy.METHODS Ten Landrace pigs were randomized into the experimental and control groups,with five pigs in each group.“Bridging”pancreaticogastrostomy was performed in the experimental group,while routine mucosa-to-mucosa pancreaticogastrostomy was performed in the control group.After surgery,the general condition,amylase levels in drainage fluid on Days 1,3,5,and 7,fasting and 2-h postprandial blood glucose 6 mo after surgery,fasting,2-h postprandial peripheral blood insulin,and portal vein blood insulin 6 mo after surgery were assessed.Resurgery was carried out at 1 and 6 mo after the former one to examine the condition of the abdominal cavity and firmness and tightness of the pancreaticogastric anastomosis and pancreas.RESULTS After surgery,the general condition of the animals was good.One in the control group did not gain weight 6 mo after surgery,whereas significant weight gain was present in the others.There were significant differences on Days 1 and 3 after surgery between the two groups but no differences on Days 5 and 7.There were no differences in fasting and 2-h postprandial blood glucose and fasting and 2-h insulin values of postprandial peripheral blood and portal vein blood 6 mo after surgery between the two groups.One month after surgery,the sinus tract orifice/anastomosis was patent in the two groups.Six months after surgery,the sinus tract orifice/anastomosis was sealed,and pancreases in both groups presented with chronic pancreatitis.CONCLUSION“Bridging”pancreaticogastrostomy is a feasible and safe a means of damage control surgery during the early stage of pancreatic injury.

Applying refined pancreaticogastrostomy techniques in pancreatic trauma

We comment on a study titled“Feasibility and safety of"bridging"pancreaticogastrostomy for pancreatic trauma in Landrace pigs”in which ten pigs were randomized to either experimental“bridging”pancreaticogastrostomy(PG)or a control group with a routine mucosa-to-mucosa PG.At six months anastomoses had strictured and closed in both groups.The authors concluded that“bridging”PG is feasible and safe in damage control surgery during the early stage of pancreatic injury.In this letter we comment on the study design,specifically leaving a 2 cm gap between the pancreatic stump and the stomach and highlight the complexity of performing pancreatic anastomoses following trauma pancreaticoduodenectomy as to our experience in a high volume trauma centre.Our data emphasize that pancreatic anastomoses in trauma are complex procedures with significant postoperative morbidity and are best managed collaboratively by trauma and hepatopancreaticobiliary surgical teams with the required technical skills.

Initial suction drainage decreases severe postoperative complications after pancreatic trauma:A cohort study

BACKGROUND Few studies have addressed the question of which drain types are more beneficial for patients with pancreatic trauma(PT).AIM To investigate whether sustained low negative pressure irrigation(NPI)suction drainage is superior to closed passive gravity(PG)drainage in PT patients.METHODS PT patients who underwent pancreatic surgery were enrolled consecutively at a referral trauma center from January 2009 to October 2021.The primary outcome was defined as the occurrence of severe complications(Clavien-Dindo grade≥Ⅲb).Multivariable logistic regression was used to model the primary outcome,and propensity score matching(PSM)was included in the regression-based sensitivity analysis.RESULTS In this study,146 patients underwent initial PG drainage,and 50 underwent initial NPI suction drainage.In the entire cohort,a multivariable logistic regression model showed that the adjusted risk for severe complications was decreased with NPI suction drainage[14/50(28.0%)vs 66/146(45.2%);odds ratio(OR),0.437;95%confidence interval(CI):0.203-0.940].After 1:1 PSM,44 matched pairs were identified.The proportion of each operative procedure performed for pancreatic injury-related and other intra-abdominal organ injury-related cases was comparable in the matched cohort.NPI suction drainage still showed a lower risk for severe complications[11/44(25.0%)vs 21/44(47.7%);OR,0.365;95%CI:0.148-0.901].A forest plot revealed that NPI suction drainage was associated with a lower risk of Clavien-Dindo severity in most subgroups.CONCLUSION This study,based on one of the largest PT populations in a single high-volume center,revealed that initial NPI suction drainage could be recommended as a safe and effective alternative for managing complex PT patients.

Severe acute pancreatitis complicated with intra-abdominal infection secondary to trauma:A case report

BACKGROUND Pancreatic trauma(PT)is rare among traumatic injuries and has a low incidence,but it can still lead to severe infectious complications,resulting in a high mortality rate.Acute pancreatitis(AP)is a common complication after PT,and when combined with organ dysfunction and sepsis,it will result in a poorer prognosis.CASE SUMMARY We report a 25-year-old patient with multiple organ injuries,including the pancreas,due to abdominal trauma,who developed necrotising pancreatitis secondary to emergency caesarean section,combined with intra-abdominal infection(IAI).The patient underwent performed percutaneous drainage,pancreatic necrotic tissue debridement,and abdominal infection foci debridement on the patient.CONCLUSION We report a case of severe AP and IAI secondary to trauma.This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery,and a better outcome was obtained.

Pancreaticojejunostomy, hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction for benign pancreatic diseases

Surgery such as digestive tract reconstruction is usually required for pancreatic trauma and severe pancreatitis as well as malignant pancreatic lesions. The most common digestive tract reconstruction techniques (e.g., Child’s type reconstruction) for neoplastic diseases of the pancreatic head often encompass pancreaticojejunostomy, choledochojejunostomy and then gastrojejunostomy with pancreaticoduodenectomy, whereas these techniques may not be applicable in benign pancreatic diseases due to an integrated stomach and duodenum in these patients. In benign pancreatic diseases, the aforementioned reconstruction will not only increase the distance between the pancreaticojejunostomy and choledochojejunostomy, but also the risks of traction, twisting and angularity of the jejunal loop. In addition, postoperative complications such as mixed fistula are refractory and life-threatening after common reconstruction procedures. We here introduce a novel pancreaticojejunostomy, hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction in two cases of benign pancreatic disease, thus decreasing not only the distance between the pancreaticojejunostomy and choledochojejunostomy, but also the possibility of postoperative complications compared to common reconstruction methods. Postoperatively, the recovery of these patients was uneventful and complications such as bile leakage, pancreatic leakage and digestive tract obstruction were not observed during the follow-up period.

Management and outcome of pancreatic trauma:a 6-year experience at a level I trauma center

Background: Pancreatic trauma (PT) accounts for less than 1% of all trauma admissions. Occasionally, PT is undetected during theprimary survey and becomes apparent only when complications arise. It occurs in up to 5% of blunt abdominal trauma cases and 12%of individuals with penetrating abdominal injuries. Management is determined by the status of the main pancreatic duct and associatedinjuries.Methods: This was an ambispective study conducted at the Jai Prakash Narayan Apex Trauma Center, All India Institute ofMedical Sciences,New Delhi, from January 2015 to December 2017 (retrospective), and January 2019 to December 2020 (prospective). In total, 113patients with PT were included in this study.Results:We analyzed the data of 113 patients with PT included in this study, of whichmales predominated (93.7%). Blunt PT was presentin 101 patients (89.4%) and penetrating PT in 12 patients (10.6%). Half of the patients (51.3%) had the American Association for theSurgery of Trauma grade III PT, followed by grade II (18.6%), and grade I (15%). Of the total 113 patients, 68 (60.2%) were treated withoperative management, and 45 (39.8%) with nonoperative management. Distal pancreatectomy, with or without splenectomy, was themost common procedure performed in our study, followed by drainage. There were 27 mortalities (23.8%) during the study period, ofwhich 7 were directly related to PT and 20 were due to other organ-related sepsis and hemorrhagic shock.Conclusion: Pancreatic trauma is rare but challenging for trauma surgeons, with persistent management controversies. Early diagnosisis important for favorable results;however, a delay in diagnosis has been associated with higher morbidity and mortality. Low-grade pancreaticinjuries can be successfully managed nonoperatively, whereas high-grade pancreatic injuries require surgical intervention.

An overview of pancreatic trauma

Pancreatic trauma remains a challenge to a trauma surgeon even with extensive advancement in medicine.The mortality and morbidity associated with this injury remain high.A high index of suspicion,mechanism of injury,and early identification hold key in the final outcome.The management of pancreatic injury should involve a multidisciplinary team comprising of trauma surgeons,radiologists,and gastroenterologists.This review highlights the burden of the pancreatic injury and its management.