Introduction
Pancreatic trauma (PT) is infrequent as the pancreas is within the retroperitoneal structure, protected by the paraspinal muscles and spine posteriorly, as well as intraabdominal organs anteriorly. Pancreatic trauma occurs in 1% to 5% of blunt abdominal trauma cases[1–6] and 12% of penetrating abdominal trauma cases.[7] Isolated PT is rare as associated intra-abdominal injuries occur in more than 90% of cases.[8] The most commonly associated abdominal injuries are those of the duodenum, liver, spleen, stomach, small bowel, major abdominal vessels, and diaphragm.[9] Pancreatic trauma constitutes less than 1% of all trauma admissions.[10] Occasionally, PT may be missed during the primary survey and only become obvious if complications develop. Management is determined by the status of the main pancreatic duct (MPD) and associated injuries. Morbidity associated with PT is 30% to 62% due to the retroperitoneal location of pancreas, obscured clinical presentation, and associated multiple organ involvement. Mortality rate is 10% to 30%.[11–14] We analyzed the data of 113 patients with PT managed at our trauma center from January 2015 to December 2020. Our main aims were to describe the clinical characteristics and to analyze the management and outcome of patients with PT at our trauma center.
Materials and methods
Study design
This was an ambispective analysis of prospectively maintained records of patients with PT at the Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, from January 2015 to December 2017 (retrospective) and from January 2019 to December 2020 (prospective). Patients 15 years or older who were diagnosed with PT were included in the study. Patients whose data were incomplete or unavailable and those who refused to provide consent were excluded from the study. This study was approved by the institutional ethics committee.
Methodology
The files of all patients with PT were reviewed, and the following data were collected: patient demographics, mechanism of injury, admission hemodynamic status, PT grade, associated injuries, indications for operative interventions, complications, length of intensive care unit (ICU) stay, length of hospital stay, and outcome. All patients with blunt abdominal trauma were initially evaluated in the emergency department by emergency physicians and trauma surgeons and resuscitated according to advanced trauma life support protocols. Patients who were hemodynamically stable and had no additional indications for early surgery underwent contrast-enhanced computed tomography (CECT) and, if required, magnetic resonance cholangiopancreatography (MRCP). Magnetic resonance cholangiopancreatography was performed in patients with suspected PT, in whom the abdomen CECT was inconclusive regarding MPD status. Pancreatic trauma was graded as per the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (Table 1).[15] Patients were divided into 2 groups based on the type of treatment they received: operative management (OM) and non-OM (NOM). Pancreas-specific complications and pancreas-specific mortality were defined as complications and deaths attributable solely to PT. Pancreatic fistulas were defined as surgical drainage of amylase-rich fluid (amylase >3 times the normal range).
Table 1 -
American Association for the Surgery of Trauma Pancreas Organ Injury Scale
| Grade* |
Injury |
Description |
| I |
Hematoma |
Minor contusion without ductal injury |
| Laceration |
Superficial laceration without ductal injury |
| II |
Hematoma |
Major contusion without ductal injury or tissue loss |
| Laceration |
Major laceration without ductal injury or tissue loss |
| III |
Laceration |
Distal transaction 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 |
*Advance one grade for multiple injuries to the same organ.
Statistical method
Quantitative variables are described as mean ± standard deviation, and qualitative variables are expressed as percentages. A P value less than 0.05 was considered statistically significant. Microsoft Excel 365 was used to collect the data, and statistical analyses was done using Statistical Package for Social Sciences (SPSS), version 16, from SPSS Inc., Chicago, IL, USA.
Results
During the study period, 3611 patients with abdominal trauma were admitted to the Division of Trauma Surgery and Critical Care. Of these, 113 patients (3.1%) had PT and were included in this study. There were 102 male patients (90.3%) and 11 female patients (9.7%) in the study. The mean age of the patients was 27.2 years (range, 15–65 years). The age distribution of the patients is shown in Table 2. Of the 113 patients, 38 (33.7%) were primary cases and 75 (66.3%) were referred from other hospitals. At the time of presentation, 101 patients (89.4%) were hemodynamically stable while 12 (10.6%) were hemodynamically unstable. The mechanism of PT was blunt in 101 patients (89.4%) and penetrating in 12 patients (10.6%). Pancreatic trauma was successfully diagnosed on the torso CECT in 94 patients (93.1%), whereas 19 patients (16.8%) required MRCP to rule out MPD injury. Of these 19 patients, 8 were successfully diagnosed with MPD injury while 11 had no MPD injury.
Table 2 -
Patient Characteristics, AAST grades of PT, Pancreatic and Extrapancreatic Injuries
|
No. Patients |
% |
| Sex |
| Male |
102 |
90.3 |
| Female |
11 |
9.7 |
| Age, y |
| 15–24 |
58 |
51.3 |
| 25–34 |
27 |
23.9 |
| 35–44 |
23 |
20.4 |
| 45–54 |
2 |
1.8 |
| 55–65 |
3 |
2.7 |
| Total |
113
|
100
|
| AAST grade of PT |
| Grade I |
17 |
15.0 |
| Grade II |
21 |
18.6 |
| Grade III |
58 |
51.3 |
| Grade IV |
13 |
11.5 |
| Grade V |
4 |
3.5 |
| Total |
113
|
100
|
| Part of pancreas involved |
| Head |
32 |
28.3 |
| Neck |
16 |
14.15 |
| Body |
35 |
30.9 |
| Tail |
16 |
14.15 |
| Uncinate process |
3 |
2.6 |
| >1 part |
21 |
18.6 |
| Associated extrapancreatic injuries |
| Common bile duct |
4 |
3.57 |
| Pelvic organ injury |
6 |
5.35 |
| Stomach |
7 |
6.2 |
| Duodenum |
7 |
6.2 |
| Large bowel |
7 |
6.25 |
| Mesentery |
8 |
7.14 |
| Small bowel |
9 |
8.03 |
| Diaphragm |
10 |
8.8 |
| Abdominal vascular injury |
13 |
11.6 |
| Kidney |
32 |
28.57 |
| Liver |
34 |
30.35 |
| Spleen |
41 |
36.6 |
| Total |
178
|
—
|
| Associated other organ injuries |
| Thoracic injuries |
43 |
42.57 |
| Injuries to extremities |
29 |
28.71 |
| Injury to head and neck |
18 |
17.82 |
| Soft tissue injuries |
35 |
34.65 |
| Injuries to spine |
19 |
18.81 |
| Pelvic fracture |
9 |
8.91 |
| Total |
153
|
151.5
|
AAST, American Association for the Surgery of Trauma; PT, pancreatic trauma.
The AAST grading of PT is shown in Table 2. Half of the patients (51.3%) had AAST grade III PT, followed by 18.6% with grade II PT. The body of the pancreas was the most common part involved (35, 30.5%), followed by the head of pancreas (32, 28.3%; Table 2). There were 178 other associated abdominal injuries, and 153 extra-abdominal injuries (Table 2). The most common associated abdominal organ injury was splenic (41, 36.6%), followed by liver trauma (34, 30.4%). The AAST grade management of patients is shown in Table 3. Of the 113 patients with PT, 68 patients (60.2%) were managed with OM and 45 patients (39.8%) with NOM. The indications for surgery in patients with OM are shown in Table 4. In the operative group, PT was the primary indication for surgery in 30 patients (44.1%), followed by bowel injury in 23 patients (33.7%; Table 4). Damage control surgery was performed in 12 patients (10.6%) who were hemodynamically unstable and transferred immediately to the operating room without any additional radiological investigations. In the OM group, 28 patients (41.2%) underwent spleen preserving distal pancreatectomy, the most common procedure performed in our study. The procedures performed in this study are illustrated in Fig. 1. The complications associated with the different AAST grades of PT are shown in Table 5.
Table 3 -
Management of PT
| AAST PT Classification |
Type of Management |
Total |
P
|
| OM |
NOM |
| Grade I |
1 |
16 |
17 |
<0.001 |
| Grade II |
3 |
18 |
21 |
<0.001 |
| Grade III |
49 |
9 |
58 |
<0.001 |
| Grade IV |
11 |
2 |
13 |
<0.001 |
| Grade V |
4 |
0 |
4 |
<0.001 |
| Total |
68
|
45
|
113
|
|
AAST, American Association for the Surgery of Trauma; OM, operative management; NOM, nonoperative management; PT, pancreatic trauma.
Table 4 -
Indication for Surgery in the Patients with PT
| Indication for Surgery |
No. Patients |
% |
| PT |
30 |
44.11 |
| Splenic trauma |
3 |
4.41 |
| Liver trauma |
4 |
5.8 |
| Pelvic fracture |
4 |
5.8 |
| Bowel and mesenteric injury |
23 |
33.7 |
| Others |
8 |
11.6 |
| Total |
68
|
100
|
Others, retroperitoneal hematoma, omental, and abdominal wall trauma.
;)
Figure 1: Different operative procedures performed during the study period.
Table 5 -
Complication in the Patients with PT
| Complications |
AAST Classification |
| Grade I |
Grade II |
Grade III |
Grade IV |
Grade V |
| Bleeding |
0 |
0 |
9 |
3 |
0 |
| Pancreatic fistula |
0 |
0 |
12 |
4 |
0 |
| Pancreatic abscess |
0 |
0 |
2 |
0 |
0 |
| Obstruction |
0 |
0 |
7 |
0 |
0 |
| Intra-abdominal sepsis |
0 |
0 |
11 |
5 |
0 |
| Burst abdomen |
0 |
0 |
9 |
1 |
0 |
| Extrapancreatic complications (isolated organ/system complication) |
1 |
3 |
20 |
6 |
2 |
| Systemic complications (AKI, VAP, sepsis) |
1 |
4 |
21 |
5 |
1 |
AAST, American Association for the Surgery of Trauma; AKI, acute kidney injury; PT, pancreatic trauma; VAP, ventilator-associated pneumonia.
The mean ± SD length of hospital stay was 17.9 ± 20.5 days for patients who were managed by NOM and 32.3 ± 35.7 days for those managed by OM (P = 0.002). Intensive care unit stay was 8.75 ± 14.9 days for patients managed with NOM and 14.6 ± 17.9 days for those managed with OM (P = 0.012). The mean length of hospital and ICU stay was lower in the NOM group than in the OM group. Overall, 86 patients (76%) were successfully discharged, while 27 patients (23.8%) died during the study period. Among the 68 patients managed by OM, 49 (72.05%) were discharged successfully, and 19 (27.9%) died during hospital stay (Table 6). Among these 19 patients, 14 died because of sepsis (6 PT-related and 8 extrapancreatic injuries), and 5 died because of class IV hemorrhagic shock related to extrapancreatic injuries. Of the 45 patients managed by NOM, 37 (82.2%) were discharged, while 8 (17.8%) died during treatment. Among these 8 patients, only 1 patient died directly from PT, 5 died because of sepsis associated with extrapancreatic injuries, and 2 died from severe traumatic brain injury (Table 6).
Table 6 -
Cause of Death in the Patients with PT
| Cause of Mortality |
NOM Group |
OM Group |
Total |
| Hemorrhagic shock |
0 |
5 |
5
|
| Sepsis (PT related) |
1 |
6 |
7
|
| Head injury |
2 |
0 |
2
|
| Sepsis (other injuries related) |
5 |
8 |
13
|
| Total |
8
|
19
|
27
|
NOM, nonoperative management; OM, operative management; PT, pancreatic trauma.
Discussion
Pancreatic trauma is uncommon and accounts for less than 1% of all trauma-related hospitalizations. The typical retroperitoneal position, absence of specific clinical signs, and inaccuracy of routine investigations make pancreatic injuries difficult to diagnose. In the present study, PT constituted 3.1% of the total trauma admissions and 4.6% of abdominal trauma. The common mechanism of PT varies among studies from different geographical regions.[10,16–18] The incidence of the blunt mechanism of PT ranges from 8% to 80%.[10,16–19] In the present study, the blunt mechanism accounted for 89.4% of PT cases. A similar trend has been reported in Australia and Scotland.[16,17] However, reports from Africa and America have shown penetrating trauma to be the most common mechanism of injury.[10,18] Blunt PT is caused by acceleration-deceleration injuries and direct compression force to the epigastrium. Motor vehicle crashes with steering wheel impact to the epigastrium are a common mechanism of PT. Handlebar injuries, particularly in the pediatric population, are another key mechanism of PT. Sutherland et al.[20] reported that bicycle handlebar injury is the most prevalent cause of high-grade PT. In this study, the most common mechanism of PT was road traffic accidents, particularly motorcycle accidents. Similar results were observed in other studies.[20–22] Sutherland et al.[20] reported that motor vehicle crashes were the most common cause of PT in adults, whereas bicycle handlebar injury was the most common cause of PT in children. In the present study, PT was more common in males (90.3%) than in females. This is because in India, most PT is caused by road traffic accidents, and most motor vehicles are driven by males. Similar results were observed in other studies.[20–24]
In the present study, of the 113 patients, only 38 (33.7%) were brought to the trauma center directly; the remaining 75 (66.3%) were referred from other hospitals. The reason behind this high referral rate is that our center is the only level I trauma center in the area. Patients were either brought to the trauma center directly or referred from other hospitals. The referred patients are transferred either immediately after receiving primary treatment or later because of missed injuries or resultant complications. This indicates the lack of standardized, protocol-based decisions to transfer patients to other hospitals when they require a higher standard of care or when expertise is unavailable. Patients can present either in stable condition or can be hemodynamically unstable because of injury. In our study, 101 patients (89.4%) were hemodynamically stable at the time of presentation. Similar findings were reported by Gupta et al.[22]; however, in a study conducted by Menahem et al.,[25] 50% of patients were hemodynamically unstable at the time of presentation.
The pancreas is a retroperitoneal organ, and screening using ultrasonography or other routine radiological techniques is difficult. The effective noninvasive technique for identifying PT is a CECT scan; however, the sensitivity of CECT ranges from 43% to 95%.[26–28] Cook et al.[29] reported that CECT scans showed normal results in 40% of patients with surgically confirmed PT; however, in the present study, CECT was able to detect pancreatic injury in 94 patients (93%). Contrast-enhanced computed tomography was inconclusive for determining the status of the MPD in 7% of patients who then underwent MRCP. Although endoscopic retrograde cholangiopancreatography allows for the visualization of ductal structures and aids in ductal integrity,[5,30] it is frequently unavailable during emergencies and at night. It may also be inappropriate for patients with associated serious injuries. In patients with PT, MRCP may be performed at any time, making it more accessible than endoscopic retrograde cholangiopancreatography. Increased serum amylase level can aid in the diagnosis of PT. However, the association between elevated serum amylase levels and PT is weak because in trauma patients, serum amylase levels may be increased because of injuries to other organs, such as the salivary gland, duodenum, esophagus, liver, head, and face.[29,31,32] Serum amylase levels after blunt trauma are time dependent, and persistently elevated or rising levels are a better indicator of PT; however, they do not reflect the severity of PT.[27] Serum lipase levels are also nonspecific in PT.[33]
Because the spine is immobile and the pancreatic tail is the most mobile part of the pancreas, a shearing force between the two can cause PT at the pancreatic body and neck levels. In most published series, AAST grades I to III PT were predominant.[22,23,34] Petrone et al.[34] analyzed 18 series of 1631 patients and found that grade III PT was the most common, followed by grade II PT. Gupta et al.[22] obtained similar results. In the present study, half of the patients (51.3%) sustained AAST grade III PT, followed by grade II PT (Table 2). The body of the pancreas was the most common part involved, exhibiting damage in 35 patients (30.9%). Krige et al.[23] and others[22,34] also observed that the body of the pancreas was the most commonly injured part. In another study conducted by Lee et al.,[35] the body and neck were the parts most commonly (57%) injured. Because of the retroperitoneal location of the pancreas, PT is frequently associated with other abdominal and extra-abdominal injuries.[22] According to literature, the incidence of isolated PT varies widely. Akhrass et al.[10] reported isolated PT in 2% of patients, whereas Bradley et al.[36] reported isolated PT in 41.5% of patients. In the present study, isolated PT was observed in 35 patients (16.4%). The spleen was the most common associated extrapancreatic abdominal organ injured in 41 patients (36.6%), followed by the liver in 34 patients (30.3%; Table 2). Duodenal injury was present in 7 patients (6.2%). In a study by Feliciano et al.,[37] hollow viscus injuries were the most common associated abdominal injuries. The reason for more injuries associated with PT in our study could be the blunt mechanisms of injury due to road traffic crashes or falls from a significant height.
The management of a pancreatic injury is determined by the patient’s hemodynamic condition at the time of presentation, degree of PT, status of the MPD, and other associated injuries. Bradley et al.[36] demonstrated an association between AAST PT grade and outcome. They observed that the status of the MPD is an important predictor of outcome in PT and assists in treatment decision making. Although multiple studies have advised drainage procedures in low-grade PT, recent studies have shown better outcomes with NOM. Distal pancreatectomy has been recommended as the treatment of choice for AAST grade III PT. However, preservation of the spleen is controversial. Recent studies have advocated spleen preservation whenever possible. Other procedures include Roux-en-Y pancreaticojejunostomy, distal pancreaticogastrostomy, and stenting with repair of the duct and pancreas. However, there has recently been a tendency for initial NOM, followed by management of its complications, particularly in pediatric patients. Grade IV and V pancreatic injuries occur on the right side of the superior mesenteric vessels, and their management is controversial because of the limited literature available. Distal pancreatectomy may not be indicated in these cases because the amount of residual pancreatic tissue is very small. Several procedures, including drainage alone, pancreaticogastrostomy, and midsegment pancreatectomy, have been proposed. External drainage is considered the safest procedure if there is no pancreatic head or duodenal devitalization and the ampulla is intact.[38] In the present study, 45 patients (39.8%) were managed with NOM, whereas 68 (60.2%) were managed with OM. All except 2 patients with AAST grade I or II PT were successfully managed nonoperatively. Managed by OM were 49 of the 58 patients with AAST grade III PT, 11 of 13 with grade IV AAST PT, and all 4 patients with grade V PT. Among the patients with PT who underwent OM, 30 (44.2%) had PT as the primary indication for surgery; the other 38 patients (66.6%) were taken for surgery because of other intra-abdominal injuries. Bowel perforation was the most common indication for surgery in the patients with PT. In a review by Petrone et al.,[37] AAST grade I and II pancreatic injuries were successfully managed nonoperatively, whereas those with grade III or higher underwent OM. In another study by Menahem et al.,[25] 50% of patients had higher grade AAST (grade III, IV, V) PT and underwent OM. Patients with PT of AAST grades I and II can be managed by NOM, whereas those with AAST grade III or higher PT require OM.[1,39] Moheseni et al.[40] evaluated 274 patients with grade IV PT, 104 of whom underwent resection procedures, while 170 were managed with nonresection procedures. Although there was no statistically significant difference between the 2 groups, resection procedures were associated with a longer hospital stay.
Complications of PT range from 26% to 86%.[10,39,41,42] The most common complication in the present study was abdominal sepsis, affecting 25 patients (22%), followed by pancreatic fistula in 12 patients (10.6%). Approximately 30% of deaths after PT are caused by sepsis and multiorgan failure. Several studies have found mortality of 30% and morbidity of 66%.[36,43,44] According to Phillips et al.,[43] when head injuries and early mortalities were eliminated, the mortality rate decreased from 16.9% to 6.8%. Petrone et al.[34] observed mortality of 18% and showed that factors such as hemodynamic instability, advanced age, blunt trauma, and associated injuries increased mortality. They also observed that the mortality rate directly related to PT is very low. In the present series, overall morbidity and mortality were 38.9% and 23.8%, respectively. Of the 27 patients who died during the study period, 8 (7%) died directly because of complications related to PT and 19 (16.8%) died because of complications related to the other organ injuries. Twenty patients died because of sepsis, 5 because of hemorrhagic shock and 2 because of severe traumatic brain injuries (Table 6).
Conclusion
Pancreatic trauma is rare but still challenging for trauma surgeons, with persistent management controversies. Early diagnosis is crucial for a patient’s favorable outcome, while a delay in diagnosis is associated with much higher morbidity and mortality. Grade I-II PT can be successfully managed non-operatively, whereas grade IV-V pancreatic injury necessitates surgical intervention. Operative management is the treatment of choice for grade III PT; however, selected cases can be managed by NOM. Whenever possible, spleen-preserving distal pancreatectomy should be performed for distal pancreatic transections.
Conflict of interest statement
The authors declare no conflict of interest.
Author contributions
All authors contributed to the conception and design of the study. Material preparation, data collection, and analysis were performed by Anand A, Dar PMUD, Kaur S, and Mishra B. The first draft of the manuscript was written by Anand A and Dar PMUD. All authors commented on the previous versions of the manuscript. All authors have read and approved the final manuscript.
Funding
The authors did not receive support from any organization for the submitted work.
Ethical approval of studies and informed consent
This study was approved by the Institute Ethical Ethics Committee of the All India Institute of Medical Sciences (registration number IECPG-585/24-10-2019), and written informed consent was obtained from the patients in the prospective part of the study and was waived by the ethical committee for the retrospective part of the analysis. This manuscript has the consent of the patient for the use of his/her data and for the publication of the data that appear in the article.
Acknowledgments
None.
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