review of literature on clinical pancreatology - The Pancreapedia

the 28 had pancreatic duct injury <strong>of</strong> which 15 were missed on initial evaluation and referredafter conservative management (n=9) or laparotomy (n=6). Twenty-one patients developedcomplications including abdominal collections (n=10), pancreatic fistulae (n=9), andpseudocysts (n=2). There were 2 deaths (7 %), both <strong>of</strong> which were associated with multipleintra-abdominal injuries. At a median follow-up <strong>of</strong> 8 months (range, 3-44 months), 19 <strong>of</strong> 23patients were asymptomatic and had been discharged from follow-up. It was concluded thatpancreatic trauma in the United Kingdom is mainly the result <strong>of</strong> blunt trauma and mostcommonly affects young males. The presence <strong>of</strong> pancreatic duct disruption accounts formost <strong>of</strong> the complications, but in the absence <strong>of</strong> associated injuries, mortality is rare [658].In another study the diagnosis and treatment <strong>of</strong> blunt abdominal injury to the solid organswere examined, and the differences between children and adults were highlighted.Identification <strong>of</strong> injury to the solid organs in children depends on a high index <strong>of</strong> suspicion,abnormal physical examination findings, and the judicious use <strong>of</strong> laboratory and imagingstudies. Although abdominal and pelvic computed tomography with intravenous contrastremains the gold standard for imaging, it does expose children to a significant dose <strong>of</strong>radiation. Currently, more than 90 percent <strong>of</strong> solid organ injuries in children are treatednonoperatively. Abnormal hemodynamics, however, suggests active bleeding and requiresoperative intervention. Accurate diagnosis <strong>of</strong> the organ injured and degree <strong>of</strong> injury areimportant considerations for "return to play" decisions. The management <strong>of</strong> pancreatic ductalinjuries is somewhat controversial, although the distal spleen preserving pancreatectomy isfrequently the technique <strong>of</strong> choice. It was concluded that pediatric intra-abdominal solidorgan injury is relatively uncommon, but a potential source <strong>of</strong> significant morbidity. Nonoperativemanagement is the standard <strong>of</strong> care for the majority <strong>of</strong> these injuries, althoughcontinued hemodynamic instability mandates operative intervention [659].To evaluate the safety <strong>of</strong> nonoperative management (NOM), to examine the diagnosticsensitivity <strong>of</strong> computed tomography (CT), and to identify missed diagnoses and relatedoutcomes in patients with blunt pancreatoduodenal injury (BPDI). Eleven New Englandtrauma centers (7 academic and 4 nonacademic) with 230 patients (>15 years old) with BPDIadmitted to the hospital during 11 years were studied. Each BPDI was graded from 1(lowest) to 5 (highest) according to the American Association for the Surgery <strong>of</strong> Traumagrading system. Ninety-seven patients (42 %) with mostly grades 1 and 2 BPDI wereselected for nonoperative management: NOM failed in 10 (10 %), 10 (10 %) developedBPDI-related complications (3 in patients in whom nonoperative management failed), and 7(7 %) died (none related to failure <strong>of</strong> NOM). The remaining 133 patients were operated onurgently: 34 (26 %) developed BPDI-related complications and 20 (15 %) died. The initial CTmissed BPDI in 30 patients (13 %); 4 <strong>of</strong> them (13 %) died but not because <strong>of</strong> the BPDI. Themortality rate in patients without a missed diagnosis was 9 percent. There was no correlationbetween time to diagnosis and length <strong>of</strong> hospital stay. The sensitivity <strong>of</strong> CT for BPDI was 76percent (76 % for pancreatic and 70 % for duodenal injuries). It was concluded that thenonoperative management <strong>of</strong> low-grade BPDI is safe despite occasional failures. Misseddiagnosis <strong>of</strong> BPDI continues to occur despite advances in CT but does not seem to causeadverse outcomes in most patients [660].Trauma laparotomy is the most commonly performed procedure in the acute care setting. Ascurrent practice, removed specimens are sent for histological examination. A retrospective<strong>review</strong> <strong>of</strong> all trauma laparotomies with specimens removed and sent to pathology during a12-month period was performed in a Level I trauma center. One hundred five procedures <strong>of</strong>244 trauma laparotomies yielded specimens sent for examination. Eighty-six patients weremale and 19 patients were female with an average age <strong>of</strong> 34 + 14 years. Fifty-six percent <strong>of</strong>the injuries resulted from penetrating trauma and 44 percent were from blunt trauma.Gunshot wound and motor vehicle crash were the most common penetrating and bluntinjuries, respectively. One hundred thirteen specimens were sent to pathology. Forty-threeper cent <strong>of</strong> the specimens were spleen, 24 percent small bowel, 16 percent large bowel, 4