An AAST-MITC analysis of pancreatic trauma

Staple or sew? Resect or drain?

Nickolas Byrge, Marta Heilbrun, Nicole Winkler, Daniel Sommers, Heather Evans, Lindsay M. Cattin, Tom Scalea, Deborah M. Stein, Todd Neideen, Pamela Walsh, Carrie A. Sims, Tejal S. Brahmbhatt, Joseph M Galante, Ho H Phan, Ajai Malhotra, Robert T. Stovall, Gregory Jurkovich, Raul Coimbra, Allison E. Berndtson, Thomas A. O'Callaghan & 21 others Scott F. Gaspard, Martin A. Schreiber, Mackenzie R. Cook, Demetrios Demetriades, Omar Rivera, George C. Velmahos, Ting Zhao, Pauline K. Park, David Machado-Aranda, Salman Ahmad, Julie Lewis, William S. Hoff, Ghada Suleiman, Jason Sperry, Samuel Zolin, Matthew M. Carrick, Gina R. Mallory, Jade Nunez, Alexander Colonna, Toby Enniss, Ram Nirula

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

INTRODUCTION Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r2 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries.

Original languageEnglish (US)
Pages (from-to)435-443
Number of pages9
JournalJournal of Trauma and Acute Care Surgery
Volume85
Issue number3
DOIs
StatePublished - Sep 1 2018

Fingerprint

Wounds and Injuries
Pancreatic Fistula
Pancreatic Pseudocyst
Injury Severity Score
Mortality
Pancreatic Ducts
Adult Respiratory Distress Syndrome
Drainage
Pancreas
Morbidity
Sensitivity and Specificity
Glasgow Coma Scale
Trauma Centers
Registries
Lactic Acid
Multivariate Analysis
Erythrocytes
Regression Analysis

Keywords

  • drainage
  • leak
  • Pancreas
  • resection
  • sew
  • staple

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Byrge, N., Heilbrun, M., Winkler, N., Sommers, D., Evans, H., Cattin, L. M., ... Nirula, R. (2018). An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain? Journal of Trauma and Acute Care Surgery, 85(3), 435-443. https://doi.org/10.1097/TA.0000000000001987

An AAST-MITC analysis of pancreatic trauma : Staple or sew? Resect or drain? / Byrge, Nickolas; Heilbrun, Marta; Winkler, Nicole; Sommers, Daniel; Evans, Heather; Cattin, Lindsay M.; Scalea, Tom; Stein, Deborah M.; Neideen, Todd; Walsh, Pamela; Sims, Carrie A.; Brahmbhatt, Tejal S.; Galante, Joseph M; Phan, Ho H; Malhotra, Ajai; Stovall, Robert T.; Jurkovich, Gregory; Coimbra, Raul; Berndtson, Allison E.; O'Callaghan, Thomas A.; Gaspard, Scott F.; Schreiber, Martin A.; Cook, Mackenzie R.; Demetriades, Demetrios; Rivera, Omar; Velmahos, George C.; Zhao, Ting; Park, Pauline K.; Machado-Aranda, David; Ahmad, Salman; Lewis, Julie; Hoff, William S.; Suleiman, Ghada; Sperry, Jason; Zolin, Samuel; Carrick, Matthew M.; Mallory, Gina R.; Nunez, Jade; Colonna, Alexander; Enniss, Toby; Nirula, Ram.

In: Journal of Trauma and Acute Care Surgery, Vol. 85, No. 3, 01.09.2018, p. 435-443.

Research output: Contribution to journalArticle

Byrge, N, Heilbrun, M, Winkler, N, Sommers, D, Evans, H, Cattin, LM, Scalea, T, Stein, DM, Neideen, T, Walsh, P, Sims, CA, Brahmbhatt, TS, Galante, JM, Phan, HH, Malhotra, A, Stovall, RT, Jurkovich, G, Coimbra, R, Berndtson, AE, O'Callaghan, TA, Gaspard, SF, Schreiber, MA, Cook, MR, Demetriades, D, Rivera, O, Velmahos, GC, Zhao, T, Park, PK, Machado-Aranda, D, Ahmad, S, Lewis, J, Hoff, WS, Suleiman, G, Sperry, J, Zolin, S, Carrick, MM, Mallory, GR, Nunez, J, Colonna, A, Enniss, T & Nirula, R 2018, 'An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?', Journal of Trauma and Acute Care Surgery, vol. 85, no. 3, pp. 435-443. https://doi.org/10.1097/TA.0000000000001987
Byrge, Nickolas ; Heilbrun, Marta ; Winkler, Nicole ; Sommers, Daniel ; Evans, Heather ; Cattin, Lindsay M. ; Scalea, Tom ; Stein, Deborah M. ; Neideen, Todd ; Walsh, Pamela ; Sims, Carrie A. ; Brahmbhatt, Tejal S. ; Galante, Joseph M ; Phan, Ho H ; Malhotra, Ajai ; Stovall, Robert T. ; Jurkovich, Gregory ; Coimbra, Raul ; Berndtson, Allison E. ; O'Callaghan, Thomas A. ; Gaspard, Scott F. ; Schreiber, Martin A. ; Cook, Mackenzie R. ; Demetriades, Demetrios ; Rivera, Omar ; Velmahos, George C. ; Zhao, Ting ; Park, Pauline K. ; Machado-Aranda, David ; Ahmad, Salman ; Lewis, Julie ; Hoff, William S. ; Suleiman, Ghada ; Sperry, Jason ; Zolin, Samuel ; Carrick, Matthew M. ; Mallory, Gina R. ; Nunez, Jade ; Colonna, Alexander ; Enniss, Toby ; Nirula, Ram. / An AAST-MITC analysis of pancreatic trauma : Staple or sew? Resect or drain?. In: Journal of Trauma and Acute Care Surgery. 2018 ; Vol. 85, No. 3. pp. 435-443.
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abstract = "INTRODUCTION Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS We identified 704 pancreatic injury patients of whom 584 (83{\%}) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r2 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7{\%} sensitivity and 61.6{\%} specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4{\%}), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95{\%} CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95{\%} CI 2.2-32.9). CONCLUSION CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries.",
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TY - JOUR

T1 - An AAST-MITC analysis of pancreatic trauma

T2 - Staple or sew? Resect or drain?

AU - Byrge, Nickolas

AU - Heilbrun, Marta

AU - Winkler, Nicole

AU - Sommers, Daniel

AU - Evans, Heather

AU - Cattin, Lindsay M.

AU - Scalea, Tom

AU - Stein, Deborah M.

AU - Neideen, Todd

AU - Walsh, Pamela

AU - Sims, Carrie A.

AU - Brahmbhatt, Tejal S.

AU - Galante, Joseph M

AU - Phan, Ho H

AU - Malhotra, Ajai

AU - Stovall, Robert T.

AU - Jurkovich, Gregory

AU - Coimbra, Raul

AU - Berndtson, Allison E.

AU - O'Callaghan, Thomas A.

AU - Gaspard, Scott F.

AU - Schreiber, Martin A.

AU - Cook, Mackenzie R.

AU - Demetriades, Demetrios

AU - Rivera, Omar

AU - Velmahos, George C.

AU - Zhao, Ting

AU - Park, Pauline K.

AU - Machado-Aranda, David

AU - Ahmad, Salman

AU - Lewis, Julie

AU - Hoff, William S.

AU - Suleiman, Ghada

AU - Sperry, Jason

AU - Zolin, Samuel

AU - Carrick, Matthew M.

AU - Mallory, Gina R.

AU - Nunez, Jade

AU - Colonna, Alexander

AU - Enniss, Toby

AU - Nirula, Ram

PY - 2018/9/1

Y1 - 2018/9/1

N2 - INTRODUCTION Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r2 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries.

AB - INTRODUCTION Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r2 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries.

KW - drainage

KW - leak

KW - Pancreas

KW - resection

KW - sew

KW - staple

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