review of literature on clinical pancreatology - The Pancreapedia

PANCREATIC TRAUMAEfforts to determine the suitability <strong>of</strong> low-grade pancreatic injuries for nonoperativemanagement have been hindered by the inaccuracy <strong>of</strong> older computed tomography (CT)technology for detecting pancreatic injury (PI). A retrospective, multicenter AmericanAssociation for the Surgery <strong>of</strong> Trauma-sponsored trial examined the sensitivity <strong>of</strong> newer 16-and 64-multidetector CT (MDCT) for detecting pancreatic injury, and sensitivity/specificity forthe identification <strong>of</strong> pancreatic ductal injury (PDI). Patients who received a preoperative 16-or 64-MDCT followed by laparotomy with a documented pancreatic injury were enrolled.Preoperative MDCT scans were classified as indicating the presence (+) or absence (-) <strong>of</strong>pancreatic injury and pancreatic ductal injury. Operative notes were <strong>review</strong>ed and all patientswere confirmed as PI (+), and then classified as PDI (+) or (-). As all patients had pancreaticinjury, an analysis <strong>of</strong> pancreatic injury specificity was not possible. PI patients formed thepool for further pancreatic ductal injury analysis. As sensitivity and specificity data wereavailable for pancreatic ductal injury, multivariate logistic regression was performed forpancreatic ductal injury patients using the presence or absence <strong>of</strong> agreement between CTand operative note findings as an independent variable. Twenty centers enrolled 206pancreatic injury patients, including 71 PDI (+) patients. Intravenous contrast was used in203 studies; 69 studies used presence <strong>of</strong> oral contrast. Eight-nine percent were bluntmechanisms, and 96 percent were able to have their duct status operatively classified as PDI(+) or (-). The sensitivity <strong>of</strong> 16-MDCT for all pancreatic injury was 60 percent, whereas 64-MDCT was 47 percent. For pancreatic ductal injury, the sensitivities <strong>of</strong> 16- and 64-MDCTwere 54 percent and 52 percent, respectively, with specificities <strong>of</strong> 95 percent for 16-MDCTscanners and 90 percent for 64-MDCT scanners. Logistic regression showed that nocovariates were associated with an increased likelihood <strong>of</strong> detecting pancreatic ductal injuryfor either 16- or 64-MDCT scanners. The area under the curve was 0.66 for the 16-MDCTpancreatic ductal injury analysis and 0.77 for the 64-MDCT pancreatic ductal injury analysis.This means that both 16- and 64-MDCT have low sensitivity for detecting pancreatic injuryand pancreatic ductal injury, while exhibiting a high specificity for pancreatic ductal injury.Their use as decision-making tools for the nonoperative management <strong>of</strong> pancreatic injuryare, therefore, limited [656].The authors reported a case <strong>of</strong> a grade III pancreatic injury resulting from a blunt abdominaltrauma, referred to our department for observation and treated with distalsplenopancreatectomy. Pancreatic traumas account for approximately 3-5 percent <strong>of</strong> bluntabdominal injuries. In cases <strong>of</strong> isolated pancreatic injuries failure to recognise injury to theWirsung duct is the main cause <strong>of</strong> morbidity and mortality. Spiral CT with contrast medium isthe standard investigation in haemodynamically stable traumatised patients, with a sensitivity<strong>of</strong> approximately 90 percent in the most recent series. However, at least initially, the extent <strong>of</strong>the pancreatic damage is not proportional to the severity <strong>of</strong> the clinical and instrumentalpicture. The patients need to be continuously and carefully monitored and, in the case <strong>of</strong>suspected pancreatic injury, the imaging study should be repeated 12-24 hours after thetrauma. In case <strong>of</strong> doubt, ERCP provides detailed information on the condition <strong>of</strong> theWirsung duct and, in selected cases, may play a therapeutic role through the positioning <strong>of</strong>an intraductal prosthesis. The surgical management <strong>of</strong> blunt pancreatic trauma should beindividualised depending on the site and severity <strong>of</strong> the injury, the interval elapsing after thetrauma and the presence <strong>of</strong> associated injuries [657].Pancreatic trauma is rare and <strong>of</strong>ten missed during initial assessment <strong>of</strong> patients withabdominal trauma. One study <strong>review</strong>ed the experience <strong>of</strong> managing pancreatic trauma at atertiary referral center and discusses the diagnostic and therapeutic challenges. Aretrospective study <strong>of</strong> a prospectively maintained hepato-pancreatico-biliary database for 12years preceding 2007 revealed 28 patients (23 males, 10 children) with a median age <strong>of</strong> 12years (range, 6-16 years) in children and 28 years (range, 17-54 years) in adults. Nineteen <strong>of</strong>