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HPB, 2006; 8: 4Á/9

REVIEW ARTICLE

Classification of and pancreatic trauma

GABRIEL C. ONISCU, ROWAN W. PARKS & O. JAMES GARDEN

Department of Surgery, University of Edinburgh, Edinburgh, UK

Abstract The liver is the most frequently injured intra-abdominal and associated to other organs increases the risk of complications and death. This has highlighted the critical need for an accurate classification system as a basis for the clinical decision-making process. Several classification systems have been proposed in an attempt to incorporate the aetiology, anatomy and extent of injury and correlate it with subsequent clinical management and outcome. The widely accepted Organ Injury Scale is based on anatomical criteria that quantify the disruption of the liver parenchyma and defines six groups which may influence management strategies and relate to outcome. The less common pancreatic injury remains a major source of morbidity and mortality due to the likelihood of associated solid or hollow-organ . The implication of a delay in diagnosis and management emphasizes the need for an accurate classification system. The Organ Injury Scale is widely used for trauma and recognizes the importance of progressive parenchymal injury and in particular ductal injury. Advances in imaging techniques have led to the development of newer radiological classification systems; however, validation of their accuracy remains to be proven. An accurate classification of liver and pancreatic trauma is fundamental for the development of treatment protocols in which clinical decisions are based on the severity of injury.

Key Words: , pancreatic injury, classification system, Organ Injury Scale

Introduction The management of trauma patients has evolved significantly over the last three decades and is based Hepatobiliary and pancreatic trauma represent a on well defined protocols. Therefore, a classification significant management challenge for the emergency system that can define the mechanism and extent of surgeon and specialist alike. These injuries require a injuries and allow appropriate treatment to be for- high index of suspicion, rapid investigation, accurate mulated according to the type of injury is essential to classification and well-defined management protocols ensure a successful outcome in these complex cases. to ensure an optimal outcome with minimal long-term Furthermore, a universally accepted classification consequences. Despite its relatively protected location, the liver is allows for meaningful comparisons of published data. This paper discusses the various classification the most frequently injured intra-abdominal organ schemes proposed for liver and pancreatic trauma [1]. The risk of uncontrolled haemorrhage, develop- and reviews the evidence supporting their use in ment of late complications and associated injury to other organs contribute significantly to the high establishing management protocols and in correlating morbidity and mortality. Furthermore, the myriad of various injuries with outcome. presentations and the combination of different types of injury make liver trauma a complex and challenging Classification of liver trauma management issue. Rationale and principles of liver trauma classification Conversely, pancreatic trauma is rare and its pre- sentation is usually occult, but the association with The number of liver injuries has increased signifi- injury to other organs and the mechanism of trauma is cantly over the last 25 years, mainly as a result of the the key to appropriate investigation, accurate diag- continuing increase in trauma cases. Due to the nosis and useful classification. complexity of hepatic structure, liver trauma can

Correspondence: O. James Garden, Regius Professor of Surgery, Department of Surgery, University of Edinburgh, Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK. Tel: /44 (0) 131 242 3614. Fax: /44 (0) 131 242 3617. E-mail: [email protected]

ISSN 1365-182X print/ISSN 1477-2574 online # 2006 Taylor & Francis DOI: 10.1080/13651820500465881 Classification of liver and pancreatic trauma 5 present with a variety of clinical pictures ranging from injuries, which could be correlated with a certain minor capsular tears to extensive parenchymal dis- management strategy, either conservative or surgical. ruption with associated hepatic or vena cava injury. Thirdly, the different grades of trauma should be Whilst some of the minor injuries can be incidental linked with the likelihood of further complications findings during investigation, patients with major and potential outcome. Last but not least, any hepatic trauma may present with profound clinical classification has to be objective and reproducible, shock and , requiring rapid and must have prospective as well as retrospective resuscitation and immediate operative management. applicability to allow for meaningful comparisons. Clearly, liver trauma has the potential for extensive injuries which must be carefully recognized and Reported schemes for the classification of liver trauma classified to ensure adequate management. Over the last three decades there have been significant devel- The earliest classification of liver trauma was based on opments as well as changes in the management of liver the mechanism of injury and was not refined as trauma [2]. Although it is widely accepted that surgical intervention was the norm. Injuries were penetrating injuries require operative treatment [3], defined as either blunt (crushing or shearing) or there is no absolute agreement regarding the manage- penetrating (stabbing or gunshot). Although this ment of blunt injuries. Prior to 1990 most blunt simple scheme identified the mechanism of injury, it injuries were treated surgically to ensure haemostasis did not satisfy the principles laid out previously. and because of concerns regarding biliary leaks and sepsis. It is now widely accepted that 50Á/80% of liver Classification based on the extent of injury and injuries stop spontaneously and therefore a intraoperative findings conservative approach is effective and relatively safe in With a better understanding of the anatomy of the haemodynamically stable patients who can be closely liver and a growing number of reports documenting a observed [2,4,5]. Severe hepatic injuries in unstable variable outcome depending on the type of liver patients require surgical intervention and several injury, it became apparent that the amount of techniques have been described to control bleeding parenchymal damage and/or vascular involvement and deal with extensive parenchymal damage. It is im- had a significant impact on the management and portant to highlight that often these patients present outcome of liver trauma. Several schemes were to the emergency surgeon without specialist hepatobi- proposed in the 1970Á/1980s [7,8,12Á/15]. liary experience and without the facilities available in These different classification schemes highlighted liver surgical units. In such cases, recognition of the ex- that minimal parenchymal damage was associated tent of the injury according to an accurate and widely with low morbidity and mortality. In a large series of accepted classification system is essential to ensure the 1000 cases, Feliciano and colleagues [7] quoted a 7% optimal management by the appropriate team. overall mortality for simple liver injuries but reported The grading (classification) of liver trauma is also a much higher mortality for injuries requiring ‘com- essential in any discussion regarding outcome, as this plex repair’ procedures. In this later group the is related not only to the nature and extent of the mortality was approximately 34%, a figure compar- injury but also to the severity of any concomitant able to that reported by others [8,12]. However, these injury [6]. It is important to highlight that in the last schemes lacked uniformity in reporting of data and decade, most studies have reported a significant made comparison impossible. correlation between the grade of injury and outcome, with those patients having a higher injury score being Anatomical classification less likely to survive [3,7Á/11]. In view of the complex clinical picture and the In 1990, Buechter et al. [16] acknowledged the variety of treatment options, any modern classification correlation between outcome and the extent of the scheme for liver trauma should be able to fulfil a series parenchymal damage together with the magnitude of of general principles. First of all, it should be able to surgical procedure required to treat the injury. He identify the mechanism of trauma as well as the extent proposed a three grade classification system based on and anatomical details of the injuries. Secondly, it the segmental anatomy of the liver as defined by should be able to recognize distinctive groups of Couinaud (Table I).

Table I. Buechter classification of liver trauma.

Grade* Injury description

I Injuries requiring no operative intervention, or any injury that requires operative intervention limited to a segment or less II Any injury that requires operative intervention involving two or more segments III Any injury with an associated juxta- or retro-hepatic vein injury 6 G. C. Oniscu et al. Buechter suggested that the extent of parenchymal Surgery of Trauma (AAST) defined the most com- damage could be quantified by the number of liver prehensive hepatic injury classification to date segments involved and concluded that trauma invol- [18].This classification system described five grades ving two or more segments was associated with a of injury from I (the least severe) to V (the most significantly worse prognosis. Furthermore, there severe) and was essentially an anatomical one. A VI appeared to be a direct correlation between morbidity grade was added to identify injuries which were and mortality rates and the volume of damaged incompatible with survival. Severity was based on hepatic tissue. This scheme provided a reproducible the potential threat to a patient’s life, but the declared but rather simplistic way of reporting and comparing aim of the scheme was to provide a clear description liver trauma, concentrating on the anatomical and of injuries rather than to generate prognostic values operative aspects of the liver injury with minimal for a particular grade of trauma. This classification attention to the extent of vascular injuries. In addi- system was facilitated by the introduction of CT tion, it was not very clear which injuries might benefit scanning and incorporated both preoperative and from a conservative approach to treatment which intraoperative assessment of the extent of hepatic began to be more widely adopted in the early 1990s. injury. Since its publication, the AAST classification system has been regarded as the standard by which hepatic injuries are described. However, the scheme Vascular injury classification has been criticized for the lack of an anatomical Early classification systems acknowledged that ulti- definition, failing to include the Couinaud segmental mately the extent of vascular injury, rather than the anatomy to quantify the extent of the injury as in the magnitude of the parenchymal damage, was the Buechter classification. Progress in the management principal prognostic factor in patients with liver of severe hepatic trauma also highlighted the need for trauma. In 1994, Namieno et al. [17] proposed a better defined criteria for grade IV and V injuries, in new three grade classification based on vessel injury: order to highlight the technical challenges posed by grade I, subcapsular Glissonian vessel injuries; grade these lesions. Furthermore, with the widespread II, transcapsular Glissonian vessel injuries; and grade availability of CT scanning, there was a sizeable III, in-/out-flow vessel injuries. body of evidence suggesting a more benign clinical However, Namieno’s classification did not have a course than initially thought for haematomas and as a significant impact as it concentrated mainly on the consequence, the classification system was revised in extent of the vascular injuries and failed to acknowl- 1994 [19] (Table II). The specific changes included: edge that extensive parenchymal damage may well an increased threshold for haematomas to /10 cm have a comparable outcome with some of the lesser for grade III; an increased amount of parenchyma vascular lesions. involvement to /75% for grade V; the addition of Couinaud segments for grade IV and V. With the introduction of the AAST classification Organ Injury Scale (AAST) classification and supported by the widespread use of CT scann- In the late 1980s, trauma surgery became better ing, the reporting of various studies had a common defined and standardized management protocols denominator. The experience accumulated with were introduced, such as Advanced Trauma Life this standardized classification allowed for a signi- Support (ATLS). In 1989 the Organ Injury Scaling ficant shift in the management of liver trauma Committee of the American Association for the with a predilection for a non-operative management

Table II. AAST liver injury scale (1994 revision).

Grade* Injury description

I Haematoma Subcapsular, B/10% surface Laceration Capsular tear, B/1 cm parenchymal depth II Haematoma Subcapsular, 10Á/50% surface area; intra-parenchymal, B/10 cm in diameter Laceration 1Á/3 cm parenchymal depth, B/10 cm in length III Haematoma Subcapsular, /50% surface area or expanding; ruptured subcapsular or parenchymal haematoma Intraparenchymal haematoma /10 cm or expanding Laceration / 3 cm parenchymal depth IV Laceration Parenchymal disruption involving 25Á/75% of hepatic lobe or 1Á/3 Couinaud’s segments within a single lobe V Laceration Parenchymal disruption involving /75% of hepatic lobe or /3 Couinaud’s segments within a single lobe Vascular Juxtavenous hepatic injuries; i.e. retrohepatic vena cava/central major hepatic veins VI Vascular Hepatic avulsion

*Advance one grade for multiple injuries, up to grade III. Classification of liver and pancreatic trauma 7 Table III. Lucas classification of pancreatic injuries.

Grade Injury description

I Superficial contusion with minimal damage II Deep laceration or transection of the left portion of the pancreas III Injury of the pancreatic head

going surgery and concluded that even major hepatic trauma, as defined by grade 4 on the CT scheme, could be managed without surgery in haemodynami- cally stable patients. These findings have been sup- ported by recent reports [11,21,23], which have concluded that CT scanning is an essential part of Figure 1. CT scan showing liver trauma with a large haematoma in an accurate classification. segment 7 extending to the capsule and associated perihepatic haematoma. Classification of pancreatic trauma approach even in selected patients with blunt grade IV and V hepatic injuries [4,20]. The additional benefits Although less common than liver trauma, pancreatic of this classification were a correlation between the injuries should be suspected in any patient with degree of injury and outcome [10,11], and the ease of to the trunk or following blunt quantification of associated injuries using similarly compression of the upper [24]. The princi- devised Organ Injury Scales. ples outlined for classification of liver trauma are equally applicable to classification of pancreatic trauma, but the additional critical element that must Radiological classification be acknowledged is the presence of injury to the . Bradley et al. [25] demonstrated that There is no doubt that the introduction and refine- there is a significant association between injury to the ment of CT scanning has had the greatest impact on main pancreatic duct and pancreas-related morbidity. the classification and subsequent management of liver Furthermore, delayed intervention due to late recog- trauma [20]. CT scanning is able to identify sub- nition of these injuries was associated with high capsular or central haematomas, contusions, peri- morbidity. portal tracking of fluid, complex lacerations and In an early report, Lucas [26] suggested that fragmentation or avulsions of the hepatic pedicle appropriate treatment should be formulated accord- [21] (Figure 1). Despite the AAST classification ing to the type of injury and therefore he subdivided incorporating extensive preoperative assessment data pancreatic injuries into three groups (Table III). derived from the CT examination, the perceived Although, this scheme is very succinct, it does not benefit of this investigation, especially in blunt acknowledge the prognostic significance of a pancrea- trauma, has led to the development of additional tic duct injury. CT-based classification schemes. In 1989 Mirvis et al. In 1990, the AAST expanded the Organ Injury [22] proposed a five grade CT-based scheme of Scale to include injuries to the pancreas, hepatic injury, varying from capsular avulsion, super- and bowel [27]. This five grade scheme (Table IV) ficial lacerations, subcapsular haematoma and peri- acknowledges the significance of more complex in- portal tracking to major parenchymal damage and juries to the pancreas, and in particular those injuries vascular injury. This group compared the radiological affecting the pancreatic duct and the head of the findings with the clinical outcome in patients mana- gland. Furthermore, this classification system allowed ged conservatively as well as those patients under- correlation with other organ injury scales, as well as

Table IV. AAST classification of pancreatic trauma.

Grade Injury description

I Haematoma Minor contusion without ductal injury Laceration Superficial laceration without ductal injury II Haematoma Major contusion without ductal injury or tissue loss Laceration Major laceration without ductal injury or tissue loss III Laceration Distal transection or pancreatic parenchymal injury with ductal injury IV Laceration Proximal transection or pancreatic parenchymal injury involving the ampulla V Laceration Massive disruption of the pancreatic head 8 G. C. Oniscu et al.

Table V. Frey and Wardell classification of pancreatic trauma.

Grade and location of injury Injury description

Pancreas Class I (P1) Capsular damage, minor parenchymal damage Class II (P2) Partial/complete duct transection in the body/tail Class III (P3) Major duct injury involving the head of pancreas or the intrapancreatic common bile duct Duodenum Class I (D1) Contusion, haematoma or partial thickness injury Class II (D2) Full thickness duodenal injury Class III (D3) Full thickness injury with / 75% circumference injury or injury to the extrahepatic common bile duct Combined

Type I P1D1,P2D1,D2P1 Type II D2P2 Type III D3P1 Á 2,P3D1 Á 2 Type IV D3P3 integration into more complex scoring systems, such classification of pancreatic ductal injuries: class 1, as Injury Severity Score (ISS) or Trauma Score Á/ radiographically normal duct; class 2a, contrast from Injury Severity Score (TRISS), which determine the branch injuries does not leak outside the pancreatic probability of survival for an individual patient. parenchyma; class 2b Á/ contrast from branch injuries The frequent association between pancreatic and leaks into the retroperitoneal space; class 3: main duodenal trauma and the implications for the defini- duct injuries. tive management of these associated injuries has been Takishima correlated the classification scheme with recognized by Frey and Wardell [28], who proposed a subsequent surgical management and concluded that complex classification system. They defined degrees class 1 and class 2a injuries could be treated non- of pancreatic trauma and duodenal trauma separately operatively with minimal risk of complications, while (Table V) and established four types of combined all other injuries required a and at least a injuries with increasing severity that correlated with drainage procedure. poorer outcome. Although most pancreatic injuries are detected As with liver trauma, CT scanning is the main intraoperatively, it is important to have an accurate diagnostic procedure used to identify pancreatic classification, even if this is established at laparotomy, trauma (Figure 2); however, there is evidence that to ensure adequate treatment of the pancreatic trauma CT is not very accurate in detecting pancreatic duct and any other associated injury. injuries [25,29]. Given the prognostic value of the ductal injury, endoscopic retrograde pancreatography Conclusion (ERP) is currently the gold standard procedure for the characterization of the pancreatic duct. Takishima An accurate classification of hepatic and pancreatic et al. [30] have used this to describe a three class injuries is an essential step in the management of trauma patients. A precise grading system must be guided by the mechanism, anatomy and extent of the injuries and should correlate with a treatment strategy and subsequent outcome. The Organ Injury Scale proposed by the AAST fulfils most of these criteria and at present is the universally accepted classification scheme, which allows meaningful comparisons of the literature and guides further development of manage- ment protocols.

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