Open Access

Outcomes following operative vs. non-operative management of blunt traumatic pancreatic injuries: a retrospective multi-institutional study

  • Poppy Addison1, 2,
  • Toni Iurcotta1, 2,
  • Leo I. Amodu1, 2,
  • Geoffrey Crandall1,
  • Meredith Akerman3,
  • Daniel Galvin1,
  • Annemarie Glazer1,
  • Nathan Christopherson1,
  • Jose Prince1,
  • Matthew Bank1,
  • Christopher Sorrentino1,
  • Joaquin Cagliani2,
  • Jeffrey Nicastro1, 2,
  • Gene Coppa1, 2,
  • Ernesto P. Molmenti1, 2 and
  • Horacio L. Rodriguez Rilo1, 2, 4Email author
Contributed equally
Burns & Trauma20164:39

https://doi.org/10.1186/s41038-016-0065-5

Received: 21 June 2016

Accepted: 26 November 2016

Published: 9 December 2016

Abstract

Background

Traumatic pancreatic injuries are rare, and guidelines specifying management are controversial and difficult to apply in the acute clinical setting. Due to sparse data on these injuries, we carried out a retrospective review to determine outcomes following surgical or non-surgical management of traumatic pancreatic injuries. We hypothesize a higher morbidity and mortality rate in patients treated surgically when compared to patients treated non-surgically.

Methods

We performed a retrospective review of data from four trauma centers in New York from 1990–2014, comparing patients who had blunt traumatic pancreatic injuries who were managed operatively to those managed non-operatively. We compared continuous variables using the Mann-Whitney U test and categorical variables using the chi-square and Fisher’s exact tests. Univariate analysis was performed to determine the possible confounding factors associated with mortality in both treatment groups.

Results

Twenty nine patients were managed operatively and 32 non-operatively. There was a significant difference between the operative and non-operative groups in median age (37.0 vs. 16.2 years, P = 0.016), grade of pancreatic injury (grade I; 30.8 vs. 85.2%, P value for all comparisons <0.0001), median injury severity score (ISS) (16.0 vs. 4.0, P = 0.002), blood transfusion (55.2 vs. 15.6%, P = 0.0012), other abdominal injuries (79.3 vs. 38.7%, P = 0.0014), pelvic fractures (17.2 vs. 0.00%, P = 0.020), intensive care unit (ICU) admission (86.2 vs. 50.0%, P = 0.003), median length of stay (LOS) (16.0 vs. 4.0 days, P <0.0001), and mortality (27.6 vs. 3.1%, P = 0.010).

Conclusions

Patients with traumatic pancreatic injuries treated operatively were more severely injured and suffered greater complications than those treated non-operatively. The greater morbidity and mortality associated with these patients warrants further study to determine optimal triage strategies and which subset of patients is likely to benefit from surgery.

Keywords

Injury Management Non-operative Operative Pancreas Trauma

Background

Opinions have differed on modalities of diagnosis and treatment of traumatic pancreatic injuries, since the first documented case nearly 200 years ago [1]. The rarity of the injury, 1–2% of blunt trauma and 5–7% of penetrating [2], makes it difficult for surgeons to develop significant clinical experience in this area. Adding to the complexity, physical exam findings can be absent, laboratory findings non-specific, and imaging unreliable [3]. Once pancreatic injury has been diagnosed, management can be controversial and outcomes difficult to predict.

In order to make the diagnosis, risk factors for injury and confounding factors must be known: demographics, mechanism of injury, presence of other abdominal injuries, time to presentation and utility of imaging modalities. A series from the UK found that the patients suffering pancreatic trauma had a median age of 27 years, the majority were male (M/F = 2.5 to 1), and injured via a blunt mechanism [4]. Pancreatic trauma was first described following a motor vehicle collision [1] and still commonly occurs this way in adults. Sudden blunt force, such as from a steering wheel or bicycle handlebars, compresses the pancreas against the vertebral column; however, any blunt trauma to the abdomen should raise suspicion for pancreatic injury. As the pancreas is situated centrally and retroperitoneally at the level of the L1 and L2 vertebrae, in close proximity to the aorta, inferior vena cava, and portal vein among other viscera [5]; the vast majority of injuries with sufficient energy to injure the pancreas also injure surrounding organs [3]. The classical presentation of upper abdominal pain, leukocytosis, and hyperamylasemia can be absent for the first 24 h following injury [6]. The diagnostic utility of computed tomography (CT) varies significantly with the experience of the radiographic technician and interpreter, with delayed or missed diagnoses occurring between 1.3 and 47% [7]. Considering the lack of clinical experience and pathognomonic findings, diagnosing pancreatic trauma quickly and correctly can be extremely difficult.

Recently, there has been a paradigm shift toward non-operative management of pancreatic injuries in stable patients after blunt trauma [8], particularly in pediatric patients [9], and a growing body of literature comparing outcomes between operative and non-operative management. In a study of pediatric patients, the authors found that both groups of patients had similar lengths of stay (LOS) and readmission rates [9]. There was also a trend toward increased non-pancreatic complications in patients who had pancreatic resections and increased pancreatic complications in the non-operative cohort. In a similar study carried out by Mattix and colleagues regarding outcomes of pediatric patients [10], those treated operatively had higher injury severity scores (ISS). The LOS was longer, and the incidence of pseudocysts, drainage procedures, and pancreatitis was higher in the non-operative group; however, these were not statistically significant [10]. Variables found to be predictive of mortality after pancreatic trauma were increasing age, ISS, hemodynamic compromise, and non-operative management [4].

In a review of 101 patients with blunt pancreatic trauma in 1998, Bradley et al. concluded that without hyperamylasemia, or other reasons for exploratory surgery, the sole deciding factor for management is pancreatic duct involvement [11]. Consistent with his and the findings of others, the Eastern Association for the Surgery of Trauma (EAST) released a level III recommendation regarding the management of pancreatic trauma in 2009 [12]. On the basis of the American Association for the Surgery of Trauma (AAST) grading scheme, injuries that do not involve the duct (grades I and II) warrant drainage, injuries that involve the duct (grade III) warrant resection followed by drainage, and more significant injuries (grades IV and V) had no treatment recommendations made. The common co-existence of traumatic pancreatic injuries with other intra-abdominal injuries makes these guidelines more difficult to follow in actual clinical practice.

We sought to compare outcomes in patients with traumatic pancreatic injuries who were treated operatively to patients who were treated non-operatively. To do this, we performed a retrospective review of patient records from four trauma centers in a large multi-institutional healthcare system in the state of New York. We hypothesize a higher morbidity and mortality rate in patients treated operatively compared to the non-operative group.

Methods

Patients included in this study were seen at four trauma centers that are part of the Northwell Health System in New York (Cohen Children’s Medical Center (CCMC), Huntington Hospital (HH), Staten Island University Hospital (SIUH), North Shore University Hospital (NSUH)). CCMC and NSUH are designated level I trauma centers, with CCMC specifically being a pediatric level I trauma center. HH is a designated area trauma center, while SIUH is a regional trauma center. All pancreatic injuries were graded using the AAST classification, and were based predominantly on CT imaging. Pancreatic injury grades were changed if intra-operative findings were inconsistent with imaging. Regulatory approval was obtained from the Northwell Health Institutional Review Board (IRB). For the purpose of this study, operative cases were defined as patients requiring any operative intervention. The overwhelming majority of patients had abdominal procedures, and only procedures related to the index traumatic incident and admission were considered. Charts were retrospectively reviewed and the data entered into a Research Electronic Data Capture (REDCap) database. Charts reviewed were paper charts for more recent cases, and some charts had been archived in the form of microfilm.

Descriptive statistics were calculated by group: operative or non-operative subjects (mean ± standard deviation, median, 25th and 75th percentiles for continuous data, and frequencies and percentages for categorical data). The Mann-Whitney U test was used to compare operative and non-operative subjects for continuous variables such as age, number of comorbidities, laboratory values, ISS, Glasgow Coma Score (GCS). The chi-square test or Fisher’s exact test as deemed appropriate was used to compare the two groups for categorical variables such as gender, race, and ethnicity.

Time to presentation from injury was analyzed by applying standard methods of survival analysis, i.e., computing the Kaplan-Meier product-limit curves, in which the data was stratified by group. No data were considered censored, and groups were compared using the log-rank test. The median rates for each group were obtained from the Kaplan-Meier/product-limit estimates, and their corresponding 95% confidence intervals were computed using the Greenwood’s formula to calculate the standard error.

Intensive care unit (ICU) LOS and hospital LOS were both analyzed using the above described survival methods; however, the patient was discharged alive from ICU (or hospital), and those subjects who died while in the ICU (or hospital) were considered censored at their date of death. Based on our chart review, no patients were transferred to other institutions. To determine possible confounding factors associated with mortality in the cohort of 61 patients, we performed a univariate analysis comparing the deceased patients to those that were alive, irrespective of whether the patient was treated operatively or non-operatively.

A result was considered statistically significant at the P < 0.05 level of significance. All analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).

Results

A total of 61 patients were identified, of which 29 were managed operatively and 32 non-operatively. All patients who had penetrating injuries (n = 8) were excluded from these analyses.

There was a significant difference between the operative and non-operative groups in median age (37.0 vs. 16.2 years, P = 0.016), grade of pancreatic injury (grade I; 30.8 vs. 85.2%, P value for all comparisons <0.0001), median ISS (16.0 vs. 4.0, P = 0.002), blood transfusion (55.2 vs. 15.6%, P = 0.0012), other abdominal injuries (79.3 vs. 38.7%, P = 0.0014), pelvic fractures (17.2 vs. 0.00%, P = 0.020), ICU admission (86.2 vs. 50.0%, P = 0.003), median LOS (16.0 vs. 4.0 days, P < 0.0001), and mortality (27.6 vs. 3.1%, P = 0.010). The results of our univariate analysis demonstrated that the following factors were associated with mortality irrespective of operative or non-operative treatment; median ISS (25.0 vs. 9.0, P = 0.014), blood transfusion within 24 h of admission (88.9 vs. 25.0%, P = 0.0005), presence of chest injury (66.7 vs. 26.9%, P = 0.05), presence of other abdominal injuries (100 vs. 51.0%, P = 0.008), pelvic fractures (33.3 vs. 3.9%, P = 0.020), ICU admission (100 vs. 61.5%, P = 0.024), post-injury pancreatitis (0.0 vs. 40.0%, P = 0.022), low median amylase (33.0 vs. 123.0, P = 0.039), and low median serum bicarbonate (18.8 vs. 24.0, P = 0.026).

Demographic characteristics are outlined in Table 1, injury and treatment information in Tables 2 and 3, respectively, details of outcomes and complications are found in Table 4, and the results of the univariate analysis to determine factors associated with mortality are found in Table 5.
Table 1

Demographic characteristics

Variable

Operative group

Non-operative group

P value

N

29

32

N/A

Age in years (median)

37.0

16.2

0.016

Number of comorbidities (median)

0.00

0.00

0.190

Male sex (%)

65.5

78.1

0.273

Race (%)

 Caucasian

63.0

64.3

 

 African-American

11.1

7.1

0.940

Ethnicity

 Hispanic

15.8

0.0

 

 Non-Hispanic

84.2

100.0

0.234

N/A not applicable

The italicized values are values that are at or below the statistical level of significance (0.05)

Table 2

Details of injury

Variable

Operative group

Non-operative group

P value

Type of blunt mechanism (%)

 Fall

17.9

15.6

0.108

 MVC

57.1

37.5

 

 Auto-pedestrian collision

7.1

3.1

 

 Bicycle accident

3.6

28.1

 

 Non-accidental trauma

0.0

6.3

 

 Animal-related

3.6

0.0

 

 Sports-related

7.1

6.3

 

 Others

3.6

3.1

 

Pancreatic injury grade (%)

 1

30.8

85.2

<0.0001

 2

34.6

3.7

 

 3

26.9

0.0

 

 4

3.9

7.4

 

 5

3.9

3.7

 

Radiologic diagnosis (%)

31.0

90.6

<0.0001

Site of injury (%)

 Head

33.3

33.3

0.931

 Neck

16.7

9.5

 

 Body

20.8

28.6

 

 Tail

29.2

28.6

 

Time from injury to presentation (median, h)

0.7

6.8

0.678

Laboratory values (median)

 Lipase

166.0

352.0

0.062

 Amylase

89.0

133.5

0.331

 Alkaline phosphatase

73.5

134.0

0.012

 Serum bicarbonate

21.0

25.0

0.030

 AST

70.0

40.0

0.095

 ALT

53.0

35.0

0.101

 Ph

7.30

7.32

0.712

 HCT

38.0

39.6

0.315

 Hb

12.5

13.5

0.734

ISS (median)

16.0

4.0

0.002

GCS (median)

15.0

15.0

0.658

Blood transfusion on admission (%)

55.2

15.6

0.001

Median blood units transfused

5.5

3.0

0.227

Associated chest injury (%)

44.8

21.9

0.057

Other abdominal injuries (%)

79.3

38.7

0.001

Head injury (%)

14.3

9.4

0.700

Spinal fractures (%)

10.7

3.1

0.331

Long bone fractures (%)

21.4

12.5

0.491

Pelvic fractures (%)

17.2

0.0

0.020

ALT alanine aminotransferase, AST aspartate aminotransferase, ISS injury severity score, GCS Glasgow Coma Score, MVC motor vehicle collision

The italicized values are values that are at or below the statistical level of significance (0.05)

Table 3

Treatment and operative information

Variable

Operative group

Non-operative group

P value

Operative approach (%)

 Open

89.7

N/A

 

 Minimally invasive

10.3

N/A

 

Pancreatic resection (%)

 Yes

46.4

N/A

 

 No

53.6

N/A

 

Type of resection (%)

 Distal pancreatectomy

84.6

N/A

 

 Other resections

15.4

N/A

 

Other proceduresa

 Drain placement

  Yes

17.2

N/A

 

  No

82.8

N/A

 

 Repair of injury

  Yes

13.8

N/A

 

  No

86.2

N/A

 

 Evacuation of hematoma

  Yes

13.7

N/A

 

  No

86.2

N/A

 

 Negative laparotomy

  Yes

3.5

N/A

 

  No

96.6

N/A

 

 Other procedures

  Yes

20.7

N/A

 

  No

79.3

N/A

 

 Endoscopic procedure

14.3

9.4

0.695

N/A not applicable

aPerformed in patients who had surgery but did not have pancreatic resections

Table 4

Outcomes and complications

Variable

Operative group

Non-operative group

P value

Mortality status

 Dead (%)

27.6

3.1

0.010

 Alive (%)

72.4

96.9

 

Cause of death (%)

 CVA

14.3

0.0

 

 Shock

42.9

0.0

1.000

 Others

42.9

100.0

 

ICU admission (%)

86.2

50.0

0.003

30-day readmission (%)

0.0

12.5

0.116

Surgery 30 days after discharge (%)

0.0

6.3

0.494

Post-injury complications

 Pancreatitis (%)

20.7

46.9

0.032

 Pancreatic pseudocyst (%)

3.5

6.3

1.000

 Pancreatic hematoma (%)

17.2

6.3

0.241

 Pancreatic necrosis (%)

13.8

0.0

0.050

 Endocrine insufficiency (%)

3.5

0.0

0.475

 Intra-abdominal fluid collection (%)

69.0

21.9

0.0002

 TPN requirement (%)

42.9

22.6

0.096

ICU LOS (median, days)

5.0

4.0

0.065

Hospital LOS (median, days)

16.0

4.0

<0.0001

CVA cerebrovascular accident, ICU intensive care unit, LOS length of stay, TPN total parenteral nutrition

The italicized values are values that are at or below the statistical level of significance (0.05)

Table 5

Univariate analysis for independent predictors of mortality

Variable

Dead

Alive

P value

Median ISS

25.0

9.0

0.014

Blood transfusion (%)

88.9

25.0

0.0005

Chest injury (%)

66.7

26.9

0.050

Other abdominal injuries (%)

100.0

51.0

0.008

Head injury (%)

25.0

9.6

0.232

Spinal fractures (%)

12.5

5.8

0.445

Long bone fractures (%)

25.0

15.4

0.610

Pelvic fractures (%)

33.3

3.9

0.020

ICU admission (%)

100.0

61.5

0.024

30-day readmission rate (%)

0.0

7.8

1.000

30-day operation post-discharge (%)

0.0

3.9

1.000

Post-injury pancreatitis (%)

0.0

40.4

0.022

Post-injury pseudocyst (%)

0.0

5.8

1.000

Post-injury pancreatic hematoma (%)

22.2

9.6

0.273

Post-injury pancreatic necrosis (%)

11.1

5.8

0.481

Endocrine insufficiency (%)

0.0

1.9

1.000

Abdominal fluid collection (%)

77.8

38.5

0.065

TPN requirement (%)

25.8

33.3

1.000

Median laboratory values

 AST

76.0

52.0

0.422

 ALT

70.0

37.5

0.492

 Lipase

70.0

261.3

0.067

 Amylase

33.0

123.0

0.039

 Bicarbonate

18.8

24.0

0.026

 Lactate

2.2

3.2

0.376

ALT alanine aminotransferase, AST aspartate aminotransferase, ICU intensive care unit, ISS injury severity score, TPN total parenteral nutrition

The italicized values are values that are at or below the statistical level of significance (0.05)

Discussion

We conducted a retrospective review of all patients with blunt traumatic pancreatic injuries seen at four large hospitals over a 24-year time period. Our aim was to compare outcomes in patients with blunt traumatic pancreatic injuries who were treated operatively to those treated non-operatively.

Our results indicate that patients who were treated non-operatively were more likely to be younger and had lower pancreatic injury grades and ISS. Patients treated operatively were older, more severely injured as reflected by higher ISS, and had more associated injuries, notably other non-pancreatic abdominal injuries and pelvic fractures. While there were no differences in initial hemoglobin concentration and hematocrit between groups, more patients who were treated operatively received blood transfusions within 24 h of admission compared to patients treated non-operatively. Patients treated with surgery had longer hospital stays and a higher incidence of pancreatic necrosis, were more likely to develop intra-abdominal fluid collections, and had a higher mortality rate. These occurrences are likely due to the greater severity of injury in this group of patients. However, the non-operative cohort had the only incidents of readmission within 30 days from the date of hospital discharge and a higher percentage of patients with post-injury pancreatitis. The results of univariate analysis demonstrated that ISS, the need for blood transfusion, associated chest, abdominal and pelvic injuries, ICU admission, and low median serum bicarbonate (acidosis) were associated with mortality, independent of operative or non-operative treatment.

Our results imply a higher rate of morbidity and mortality in patients with blunt traumatic injuries of the pancreas who received operative intervention compared to those who did not. This finding, in combination with the results of the univariate analysis, suggests that severity of injuries and not the modality of management are predictive of outcomes. These results call into question the utility of operative intervention in patients with traumatic pancreatic injuries in the context of polytrauma, as well as patients without clear-cut indications for surgery. Indeed, involvement of the pancreas may itself be an indicator of severe abdominal traumatic injury. The need to distinctly identify patients with traumatic pancreatic injuries that stand to benefit from surgery is further underscored by the presence of some patients in the study cohort with grades IV and V injuries that were managed without operation.

In our cohort, we found that grades I, IV, and V injuries tended to be treated non-operatively, while grades II and III were more commonly treated with surgery. While clear-cut indications for surgical exploration such as penetrating abdominal injuries cannot be disputed, the high incidence of associated non-pancreatic abdominal injuries suggests that the decision to operate was not based on the severity of the pancreatic injury alone. In consideration of the high occurrence of multi-organ abdominal injuries, future recommendations for management should examine polytrauma rather than isolated pancreatic injuries in order to be more clinically useful.

The utility of amylase in diagnosing injury to the pancreas, elevation of which indicates pancreatic inflammation and suggests ductal injury, has been controversial. Reports on the application of amylase testing range from no observed correlation between pancreatic trauma and elevations in amylase [13], to affirmation that amylase could indeed signify pancreatic injury [14]. Other reports have shown that contrary to predictions, the increasing severity of pancreatic injury on the basis of presence or absence of ductal injury was not associated with increased serum amylase [15, 16]. Takashima and Matsuno independently found that the amount of time elapsed from the inciting pancreatic trauma to the measurement of amylase may have implications for the diagnostic value of the enzyme in the emergent setting. Serum amylase taken less than 3 [17] or 2 [18] h post-trauma was not diagnostic of blunt pancreatic injury, while delayed measurements were positively correlated with injury. In the present study, mean serum amylase was lower for the operative than for the non-operative group although the difference was not significant. The absence of a statistically significant difference in amylase levels when comparing the two groups of patients in this study could be attributable to a combination of factors: (1) the difference in median time from injury to presentation was not statistically significant, which is crucial considering the change in serum amylase with time; (2) most injuries were grade I and grade II, which by definition are injuries that do not involve ductal disruption. These results complement the current EAST recommendations that amylase levels, although indicative, should not be considered diagnostic for pancreatic trauma [12]. Post-injury pancreatitis and elevated amylase appear to be associated with a lower risk of death according to univariate analysis (Table 5). This association may be explained by the fact that patients with milder injuries present later to hospital, and this leads to higher serum amylase measurements at the time of evaluation. High serum amylase levels are part of the diagnostic criteria for acute pancreatitis.

Patients treated operatively were given blood transfusions more frequently than patients in the non-operative group in spite of similar hemoglobin concentrations and hematocrits at presentation. While blood transfusion does have some detrimental effects, it is prudent to suggest that blood transfusion was given for ongoing hemorrhage in the setting of traumatic injury, or as a result of intra-operative blood loss. It is noteworthy that the amount of units of blood transfused between the groups did not differ significantly. Multiple meta-analyses have demonstrated that each transfused unit of packed red cells increases the risk of infection [19, 20] and is likely due to the immunomodulation that occurs when infusing allogeneic leukocytes [21]. Additionally, transfusion is associated with increased risk of thromboembolism [22], potentially due to increased cell aggregability that occurs during storage [23]. Considering these serious risks, a restrictive transfusion strategy should be considered even for patients managed operatively.

Although our study population was inclusive of all age groups, the higher morbidity and mortality we observed among the operative group might have been mitigated or nullified if pediatric and adult patients had been analyzed separately. In a retrospective review of 167 cases of pediatric blunt trauma to the pancreas leading to grades II and III injuries, Iqbal et al. showed that patients managed operatively by distal pancreatectomy had a quicker return to normal diet (7.8 vs. 2.5 days; P = 0.007), fewer complications necessitating further management (including pseudocyst formation) (0 vs. 18%; P = 0.001), and shorter time to resolution compared to patients managed non-operatively (22.6 vs. 38.6 days; P = 0.05) [24]. The results of Iqbal’s study differ from our findings for several possible reasons: (1) Iqbal’s study examined only patients with grades II and III injuries, while the majority of patients in the non-operative group in our study had grade I injuries; (2) there was no difference in ISS and associated injuries between the patients managed operatively and those managed non-operatively in Iqbal’s study. In summary, patients managed operatively in our cohort may have had worse outcomes than the operatively managed group in Iqbal’s study, due to a higher pancreatic injury grade when compared to patients managed non-operatively, higher ISS, and a higher prevalence of associated injuries. This report also calls to question the extension of the current EAST guidelines to the pediatric population.

All patients who presented to the emergency room with penetrating pancreatic injuries were treated operatively and for that reason were excluded completely from our analyses.

Patients treated by operation were older than patients in the non-operative treatment group. This occurrence might explain the more severe injuries, as older patients might be exposed to higher energy mechanisms of injury such as motor vehicle collisions (MVCs), in comparison to younger patients in the non-operative group who had a larger percentage of bicycle-related injuries. Our completed but unpublished research demonstrates no difference in mortality when comparing pediatric to adult patients with traumatic pancreatic injuries, but comparison of similar age groups or controlling for confounding due to age is needed to draw any definitive conclusions.

Our database, compiled from all blunt traumatic pancreatic injury cases seen at four hospitals from 1990 to 2014, is a relatively large dataset for a very rare injury. In absolute terms, this is a small sample size. While we were able to perform a univariate analyses, the sample size and the small number of patients developing specific outcome measures make it impossible to control confounding using multivariate analysis. A larger sample would have also provided the opportunity to carry out several sub-group analyses.

Despite these limitations, we were able to present a relatively large study on traumatic pancreatic injuries, with regard to the number of patients and variables examined.

Recommendations for future study would be larger scale studies to determine predictors of mortality and survival in patients with isolated traumatic pancreatic injuries, or pancreatic injuries in the setting of polytrauma. Findings from these studies would lay the necessary foundation for the development of consensus guidelines on indications for operative management and procedures of choice in patients with traumatic pancreatic injuries.

Conclusions

Operative management of traumatic pancreatic injuries in our cohort appears to have been carried out in more severely injured patients who were already at risk of worse outcomes compared to the patients managed non-operatively. The actual effect of modality of management on patient outcomes is difficult to ascertain with a small sample size. While surgery may have been undertaken on account of injury severity and mechanism, further studies need to be carried out to determine the subset of patients who are likely to benefit from surgery and what group of patients may be given a trial of non-operative management. More investigation needs to be carried out on the subject of optimal management of patients with pancreatic injury in the setting of polytrauma.

Notes

Abbreviations

ALT: 

Alanine aminotransferase

AST: 

Aspartate aminotransferase

GCS: 

Glasgow Coma Score

ICU: 

Intensive care unit

ISS: 

Injury severity score

LOS: 

Length of stay

Declarations

Acknowledgements

We would like to recognize the efforts of Mrs. Renee Cercone in editing this manuscript and making it ready for submission.

Funding

No funding was received for this study.

Availability of data and materials

The data used in the publication of this manuscript is stored on the Northwell Health REDCap server and is available upon request.

Authors’ contributions

HR, PA, TI, LA, MA, EM, DG, JP, JN, GFC, GC, CS, NC, AG, and MB conceived of the study. HR, EM, LA, MA, JC, PA, TI, JN, GFC, and GC carried out the study design. HR, GC, TI, PA, LA, CS, AG, MB, DG, NC, and JP participated in the data acquisition. MA, LA, TI, and PA analyzed the data. PA, TI, LA, HR, and MA interpreted the data. PA, TI, LA, MA, and HR helped in the writing of the manuscript. PA, TI, LA, and HR did the manuscript editing. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable

Ethics approval and consent to participate

This study was approved by the Northwell Health Institutional Review Board (IRB). A waiver of informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization was granted for this study.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Surgery, Hofstra-Northwell School of Medicine
(2)
Pancreas Disease Center, Northwell Health
(3)
Department of Biostatistics, Feinstein Institute for Medical Research
(4)
Northwell Health

References

  1. Travers B. Rupture of the pancreas. Lancet. 1827;12:384.Google Scholar
  2. Sharpe JP, Magnotti LJ, Weinberg JA, Zarzaur BL, Stickley SM, Scott SE, et al. Impact of a defined management algorithm on outcome after traumatic pancreatic injury. J Trauma Acute Care Surg. 2012;72(1):100–5.View ArticlePubMedGoogle Scholar
  3. Debi U, Kaur R, Prasad KK, Sinha SK, Sinha A, Singh K. Pancreatic trauma: a concise review. World J Gastroenterol. 2013;19(47):9003–11.View ArticlePubMedPubMed CentralGoogle Scholar
  4. O’Reilly DA, Bouamra O, Kausar A, Malde DJ, Dickson EJ, Lecky F. The epidemiology of and outcome from pancreatoduodenal trauma in the UK, 1989–2013. Ann R Coll Surg Engl. 2015;97(2):125–30.View ArticlePubMedGoogle Scholar
  5. Patton JH, Fabian TC. Complex pancreatic injuries. Surgical Clinics. 1996;76(4):783–95.View ArticlePubMedGoogle Scholar
  6. Jurkovich GJ, Bulger E. Duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 5th ed. New York: McGraw-Hill; 2004. p. 709–33.Google Scholar
  7. Geyer LL, Körner M, Linsenmaier U, Huber-Wagner S, Kanz KG, Reiser MF, et al. Incidence of delayed and missed diagnoses in whole-body multidetector CT in patients with multiple injuries after trauma. Acta Radiol. 2013;54(5):592–8.View ArticlePubMedGoogle Scholar
  8. Heuer M, Hussmann B, Lefering R, Taeger G, Kaiser GM, Paul A, et al. Pancreatic injury in 284 patients with severe abdominal trauma: outcome, course, and treatment algorithm. Langenbecks Arch Surg. 2011;396:1067–76.View ArticlePubMedGoogle Scholar
  9. Wood JH, Partrick DA, Bruny JL, Sauaia A, Moulton SL. Operative vs nonoperative management of blunt pancreatic trauma in children. J Pediatr Surg. 2010;45(2):401–6.View ArticlePubMedGoogle Scholar
  10. Mattix KD, Tataria M, Holmes J, Kristoffersen K, Brown R, Groner J, et al. Pediatric pancreatic trauma: predictors of nonoperative management failure and associated outcomes. J Pediatr Surg. 2007;42(2):340–4.View ArticlePubMedGoogle Scholar
  11. Bradley EL, Young PR, Chang MC, Allen JE, Baker CC, Meredith W, et al. Diagnosis and initial management of blunt pancreatic trauma: guidelines from a multiinstitutional review. Ann Surg. 1998;227(6):861–9.View ArticlePubMedPubMed CentralGoogle Scholar
  12. Bokhari F, Phelan H, Holevar M, Brautigam R, Collier B, Como JJ, et al. EAST guidelines for the diagnosis and management of pancreatic trauma. Chicago: Eastern Association for the Surgery of Trauma; 2009.Google Scholar
  13. Jones RC. Management of pancreatic trauma. Ann Surg. 1978;187(5):555–64.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Mayer JM, Tomczak R, Rau B, Gebhard F, Beger HG. Pancreatic injury in severe trauma: early diagnosis and therapy improve the outcome. Dig Surg. 2002;19(4):291–7. discussion 7-9.View ArticlePubMedGoogle Scholar
  15. Jobst MA, Canty Sr TG, Lynch FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatr Surg. 1999;34(5):818–23. discussion 23-4.View ArticlePubMedGoogle Scholar
  16. Herman R, Guire KE, Burd RS, Mooney DP, Ehlrich PF. Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma. J Pediatr Surg. 2011;46(5):923–6.View ArticlePubMedGoogle Scholar
  17. Takishima T, Sugimoto K, Hirata M, Asari Y, Ohwada T, Kakita A. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg. 1997;226(1):70–6.View ArticlePubMedPubMed CentralGoogle Scholar
  18. Matsuno WC, Huang CJ, Garcia NM, Roy LC, Davis J. Amylase and lipase measurements in pediatric patients with traumatic pancreatic injuries. Injury. 2009;40(1):66–71.View ArticlePubMedGoogle Scholar
  19. Horvath KA, Acker MA, Chang H, Bagiella E, Smith PK, Iribarne A, et al. Blood transfusion and infection after cardiac surgery. Ann Thorac Surg. 2013;95(6):2194–201.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Rohde JM, Dimcheff DE, Blumberg N, Saint S, Langa KM, Kuhn L, et al. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. Jama. 2014;311(13):1317–26.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Refaai M, Blumberg N. Transfusion immunomodulation from a clinical perspective: an update. Expert Rev Hematol. 2013;6(6):653–63.View ArticlePubMedGoogle Scholar
  22. Gangireddy C, Rectenwald JR, Upchurch GR, Wakefield TW, Khuri S, Henderson WG, et al. Risk factors and clinical impact of postoperative symptomatic venous thromboembolism. J Vasc Surg. 2007;45(2):335–41. discussion 341–2.View ArticlePubMedGoogle Scholar
  23. Hovav T, Yedgar S, Manny N, Barshtein G. Alteration of red cell aggregability and shape during blood storage. Transfusion. 1999;39(March):277–81.View ArticlePubMedGoogle Scholar
  24. Iqbal CW, St Peter SD, Tsao K, Cullinane DC, Gourlay DM, Ponsky TA, et al. Operative vs nonoperative management for blunt pancreatic transection in children: multi-institutional outcomes. J Am Coll Surg. 2014;218(2):157–62.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s) 2016

Advertisement