Extension of nonoperative management of blunt pancreatic trauma to include grade III injuries: a safety analysis.
BACKGROUND
In hemodynamically stable patients after blunt pancreatic trauma, the main pancreatic duct (MPD) disruption (American Association for the Surgery of Trauma [AAST] grade III-IV-V lesions) is usually treated surgically or by endoscopic stent placement, whereas injuries without duct involvement (grade I-II) are liable to medical treatment. To date, no evidence has been reported regarding nonoperative management (NoM) of grade III injuries. We aimed to evaluate the safety of extending medical management to include cases of distal MPD involvement (grade III).


METHODS
Data were collected on patients admitted after blunt pancreatic trauma between January 1999 and December 2007. Patients exhibiting hemodynamic instability or hollow organ perforations were excluded from this study, as they were surgically managed. In all remaining cases NoM was attempted. Antibiotic prophylaxis and early total enteral nutrition were routinely adopted. Grade III patients received octreotide during hospitalization and for 6 months after discharge.


RESULTS
Eleven patients (2 with grade I injury, 3 with grade II injury, and 6 with grade III injury, all diagnosed by contrast-enhanced helical CT) were included. Nonsurgical management was carried out in all of these patients. Among grade III patients, one developed a peripancreatic abscess; another, a pancreatic fistula. Both were successfully treated nonoperatively. The average length of hospital stay was similar in grade I-II and grade III patients. After a median follow-up of 57 months no mortality or pancreatic sequelae had occurred.


CONCLUSIONS
Under the aforementioned conditions, an attempt to extend NoM to include patients with AAST-grade III lesions can be justified. However, such a strategy demands continuous patient monitoring, because should the case worsen, surgery might become necessary.
Pata
Giacomo
G
Department of Medical and Surgical Sciences, 1st Division of General Surgery, University of Brescia, Viale Europa, 11, 25123, Brescia, Italy. giacomopata@alice.it
Casella
Claudio
C
Di Betta
Ernesto
E
Grazioli
Luigi
L
Salerni
Bruno
B
D000328:Adult; D019072:Antibiotic Prophylaxis; D003287:Contrast Media; D004750:Enteral Nutrition; D005260:Female; D005500:Follow-Up Studies; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D015282:Octreotide / Q000627:therapeutic use; D010179:Pancreas / Q000293:injuries*; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging / Q000628:therapy*
D003287:Contrast Media; D005765:Gastrointestinal Agents; D015282:Octreotide