JOP. J Pancreas (Online) 2009 Nov 5; 10(6):657-663. ORIGINAL ARTICLE Management of Pancreatic Injuries after Blunt Abdominal Trauma. Experience at a Single Institution Ker-Kan Tan, Diana Xinhui Chan, Appasamy Vijayan, Ming-Terk Chiu TTSH-NNI Trauma Centre, Tan Tock Seng Hospital. Singapore, Singapore ABSTRACT Context Pancreatic injuries after blunt abdominal trauma could result in significant morbidity, and even mortality if missed. Objective Our aim was to review our institution’s experience with blunt pancreatic trauma. Setting Our study included all cases of blunt traumatic pancreatic injuries. Patients Sixteen patients (median age 41 years; range: 18-60 years) were treated for blunt pancreatic trauma from December 2002 to June 2008. Main outcome measure Pancreatic injuries were graded according to the definition of the American Association for the Surgery of Trauma (AAST). Results CT scans were performed on 10 (62.5%) patients, with the remaining 6 (37.5%) sent to the operating theatre immediately due to their injuries. Of the 12 (75.0%) patients who underwent exploratory laparotomy, 2 (12.5%) had a distal pancreatectomy (AAST grade III), 1 (6.3%) underwent a Whipple procedure (AAST grade IV) while another 2 (12.5%) were too hemodynamically unstable for any definitive surgery (AAST grade IV and V); the remaining 7 (43.8%) pancreatic injuries were managed conservatively. Four (25.0%) patients had their injuries managed non-operatively. Some of the associated complications included intra-abdominal collection (n=2, 12.5%) and chest infection (n=2, 12.5%). Conclusion Blunt pancreatic trauma continues to pose significant diagnostic and therapeutic challenges. In view of the numerous associated injuries, priority must be given to stabilizing the patient before any definitive management of the pancreatic injuries is carried out. Mortality in these patients is usually a result of the magnitude of their associated injuries. INTRODUCTION Surgical management of pancreatic trauma remains debatable with options ranging from simple drainage to Injury to the pancreas after blunt abdominal trauma is pancreaticoduodenectomy, each with their benefits and less frequent than that of other solid organs, such as the associated complications. All these issues prompted us liver and spleen. Pancreatic injuries rarely occur alone to review our institution’s experience of pancreatic and are often associated with other intra-abdominal injuries after blunt abdominal trauma and to highlight injuries [1]. Hence, these patients must be managed as the various challenges in its management. all other trauma patients with the aim of ensuring hemodynamic stability first before any specific METHODS treatment of the pancreatic injuries if such treatment is required. Study Population With the increasing adoption of non-operative All patients in this study were treated at Tan Tock Seng management in blunt abdominal trauma [1], an Hospital from December 2002 to June 2008. Tan Tock accurate diagnosis of pancreatic injury is of paramount Seng Hospital is a 1,300 bed hospital in Singapore importance due to its numerous associated which provides medical care to over 1.5 million complications [2]. However, this is often difficult pre- people. It handles the highest number of trauma operatively due to its retroperitoneal location, the lack patients in Singapore and admits an average of 1,000 of early clinical signs and suboptimal standard severe trauma patients yearly, of which 96% are for investigations [2]. blunt injuries, with 40% of trauma admissions having Received June 1st, 2009 - Accepted August 16th, 2009 an injury severity score (ISS) of more than 16 Key words /injuries; Pancreas; Wounds, Nonpenetrating (unpublished personal data). Abbreviations AAST: American Association for the Surgery of All patients with blunt abdominal trauma were initially Trauma; GCS: Glasgow coma scale; ISS: injury severity score; reviewed in the Emergency Department by the OIS: organ injury scale emergency physicians and trauma surgeons. Any Correspondence Ker-Kan Tan patient who was persistently hemodynamically Department of General Surgery, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore unstable from a suspected abdominal injury which was Phone: +65-635.77.807; Fax: +65-635.77.809 refractory to resuscitation or with other definite E-mail: [email protected] indications for exploratory laparotomy warranted Document URL http://www.joplink.net/prev/200911/01.html immediate surgery. Otherwise, computed tomography JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 6 - November 2009. [ISSN 1590-8577] 657 JOP. J Pancreas (Online) 2009 Nov 5; 10(6):657-663. Table 1. Pancreatic organ injury scale (OIS-AAST) [3]. Grading Injury Description Grade I Hematoma Mild contusion without duct injury Laceration Superficial laceration without duct injury Grade II Hematoma Major contusion without duct injury Laceration Major laceration without duct injury or tissue loss Grade III Laceration Distal transection or parenchymal injury with duct injury Grade IV Laceration Proximal transection or parenchymal injury involving the ampulla Grade V Laceration Massive disruption of the pancreatic head (CT) scans were routinely performed for these patients range: 33-45%), median platelet level of 263 x109/L straight from the Emergency Department. (range: 72-360 x109/L; reference range: 170-420 Our study included all cases with pancreatic injuries x109/L), median white blood cells of 12.5 x109/L from blunt abdominal trauma which were diagnosed (range: 6.1-30.0 x109/L; reference range: 4-10 x109/L) either through CT scans and/or during exploratory and median INR of 1.08 (range: 0.98-2.02). Serum laparotomy. Patients were excluded if they suffered amylase estimation was carried out in 12 patients penetrating injuries. The data collected include the (75.0%), for which only 6 (50.0%) had elevated levels patient’s age, gender, mechanism of injury, initial vital which were not related to the grading of the pancreatic signs, ISS, selected investigations, laparotomy injury. Table 2 reports the various characteristics of the observations, severity of pancreatic injuries and the study group. eventual outcome. All trauma patients were managed Six (37.5%) patients were immediately sent to the by one dedicated surgical trauma team in the operating theatre from the Emergency Department due institution. Pancreatic injuries were graded according to refractory hemodynamic instability in the presence to the pancreatic injury severity score (organ injury of suspected hemoperitoneum after focused assessment scale as defined by the American Association for the with sonography for trauma with or without the aid of Surgery of Trauma (OIS-AAST) (Table 1) [3]. diagnostic peritoneal lavage. In these 6 patients, almost all (n=5; 83.3%) had massive associated intra- STATISTICS abdominal injuries which resulted in significant intra- Median, range, and frequencies were reported as abdominal hemorrhage, ranging from major vessel descriptive statistics. laceration to massive lacerations of the liver. The two patients with grades IV and V pancreatic lacerations ETHICS died from circulatory collapse due to the associated Oral consent was obtained from each patient. The patients were treated according to the ethical guidelines of the "World Medical Association Declaration of Table 2. Characteristics of the 16 patients with pancreatic injuries after blunt abdominal trauma (frequencies or median and range). Helsinki - Ethical Principles for Medical Research Variable Results Involving Human Subjects" adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964, as Age (years) 41 (18-60) revised in Tokyo 2004. Gender: - Male 12 (75.0%) RESULTS - Female 4 (25.0%) Mechanism of injuries: From December 2002 to June 2008, 16 patients having - Road traffic accident 9 (56.3%) a median age of 41 years (range: 18-60 years) formed - Assault 5 (31.3%) the study group. All patients arrived at the Emergency - Fall 2 (12.5%) Department within 2 hours from the alleged incident. Heart rate (beats per minute) 86 (53-136) There was a male predominance of 75% (n=12) and Systolic blood pressure (mmHg) 107 (63-174) motor vehicle collisions and blunt assault from Glasgow coma scale (GCS) 15 (9-15) assailants accounted for 56.3% (n=9) and 31.3% (n=5) Hematocrit (%) 37.9 (21.8-43.1) of the injuries, respectively. According to the AAST 9 grading for pancreatic injury, grade I injury was Platelet level (x10 /L) 263 (72-360) 9 present in 4 (25.0%) patients, grade II in 7 (43.8%), White blood cells (x10 /L) 12.5 (6.1-30.0) grade III in 2 (12.5%), grade IV in 2 (12.5%) and grade INR 1.08 (0.98-2.02) V in1 (6.3%). Injury severity score (ISS) 17 (8– 54) The median Glasgow coma scale (GCS) [4] on arrival Length of hospital stay (days) 14 (1-127) was 15 (range: 9-15) while median heart rate and Amylase determined 12 (75.0%); 6 elevated, 6 normal systolic blood pressure were 86 beats per minute (bpm) CT scan performed 10 (62.5%) (range: 53-136 bpm) and 107 mmHg (range: 63-174 mmHg), respectively. Review of the initial MRCP performed 2 (12.5%) hematological investigations showed a median Surgery performed 12 (75.0%) hematocrit of 37.9% (range: 21.8-43.1%; reference Outcome (deaths) 2 (12.5%) JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 6 - November 2009. [ISSN 1590-8577] 658 JOP. J Pancreas (Online) 2009 Nov 5; 10(6):657-663. Table 4. Associated injuries in our series of 16 patients with pancreatic injuries. Associated injury Number of patients Colonic injuries 5 (31.3%) Duodenal injuries 4 (25.0%) Major vessel injuries 4 (25.0%) Mesenteric tears 4 (25.0%) Small bowel injuries 3 (18.7%) Liver injuries 3 (18.7%) Splenic injuries 3 (18.7%) Gastric injuries 3 (18.7%) Figure 1. CT scan showing peripancreatic hematoma. Endoscopic retrograde cholangiopancreatography (ERCP) was not carried out in our series but magnetic injuries within 12 hours post-operatively without any resonance cholangiopancreatography (MRCP) was definitive resection performed.