Journal of Experimental and Clinical SurgeryJournal of Experimental and Clinical SurgeryВестник экспериментальной и клинической хирургии2070-478X2409-143XVoronezh State Medical University named after N.N. Burdenko168710.18499/2070-478X-2023-16-2-186-193Review of literatureОбзор литературыReview ArticlePancreatic TraumaТравма поджелудочной железыhttps://orcid.org/0000-0002-9106-0951555621869003157-8985FirsovaVictoria GlebovnaФирсоваВиктория Глебовна
Russian Federation

MD, PhD, surgeon

д.м.н, врач-хирург

victoria.firsova@mail.ruMunicipal Hospital №35ГБУЗ Нижегородской области «Городская больница №35 Советского района»Nizhny Novgorod, Russian Federation2906202316218619308012023Copyright ©; 2023, Voronezh N.N. Burdenko State Medical UniversityCopyright ©; 2023, ФГБОУ ВО ВГМУ им. Н.Н. Бурденко Минздрава России2023Voronezh N.N. Burdenko State Medical UniversityФГБОУ ВО ВГМУ им. Н.Н. Бурденко Минздрава Россииhttps://vestnik-surgery.com/journal/about/editorialPolicieshttps://vestnik-surgery.com/journal/article/view/1687

Traumatic pancreatic injuries are associated with significant morbidity and mortality. The review analyses recent studies on epidemiology, classification, diagnosis and treatment of patients with pancreatic injury. Pancreatic injury in abdominal trauma is observed from 3% to 12% of cases, the overall mortality ranges from 0% to 31% and is largely determined by damage to other organs. The most widely accepted grading system for defining categories of pancreatic injuries is Organ Injury Scaling developed by the American Association for the Surgery of Trauma. A high index of suspicion is necessary for early diagnosis, since in the first hours after the injury clinical manifestations and laboratory parameters are not specific, and changes in the CT picture do not correlate to the severity of the injury in 20-40% of cases. Contrast-enhanced CT is the first-line diagnostic tool in hemodynamically stable patients. MRI with MRCP and ERCP is used to evaluate the integrity of the pancreatic duct. Nonoperative management is recommended for hemodynamically stable grade I and grade II pancreatic injuries. Patients with pancreatic duct injury require predominantly surgical treatment. The preferred type of surgery for grade III and more severe injuries (distal resection, drainage of the damaged area combined with endoscopic drainage and stenting, or organ-preserving surgery in the form of pancreaticojejunostomy, pancreaticogastrostomy) remains controversial. In case of pancreatic injury proximal to the venous confluence, drainage of the damaged area is the only fairly safe option for the patient, indications for pancreaticoduodenal resection are limited to concomitant injury of the bile duct, duodenum with involvement of the major duodenal papilla, massive bleeding from crushed tissues of the pancreatic head. Larger prospective studies are warranted for better management of patients with pancreatic trauma.

Травма поджелудочной железы относится к редким повреждениям, но характеризуется значительной летальностью и развитием серьезных осложнений. Обзор представляет анализ исследований последних лет, посвященных эпидемиологии, классификации, диагностике и лечению больных с травмой поджелудочной железы. Повреждение поджелудочной железы при травме брюшной полости наблюдается от 3% до 1 % случаев, общая летальность составляет от 0% до 31% и во многом определяется повреждениями других органов. В общемировой практике наиболее широко используется градация травмы поджелудочной железы - по тяжести на основании шкалы повреждения органов американской ассоциации по хирургии травм. Ранняя диагностика возможна при настороженности врача в отношении повреждения поджелудочной железы - в первые часы после травмы клинические проявления, лабораторные показатели не специфичны, а изменения в КТ-картине не соответствуют тяжести травмы в 20-40% случаев. КТ с контрастированием является методом диагностики первой линии у пациентов со стабильной гемодинамикой. МРТ с МРХПГ и ЭРХПГ используются для уточнения состояния панкреатического протока. Пациентам с выявленной при КТ изолированной травмой поджелудочной железы I и II степеней показано консервативное лечение. Больным с травмой панкреатического протока показано преимущественно хирургическое лечение. Предпочтительный вид операции при повреждениях III степени и выше (дистальная резекция, дренирование зоны повреждения в сочетании с эндоскопическим дренированием и стентированием протока или органосохраняющая операция в объеме панкреатикоеюностомии, панкреатикогастростомии) остается спорным. При травме поджелудочной железы правее венозного конфлюенса выполнение только дренирования зоны повреждения представляет достаточно безопасный вариант для пациента, показания к панкреатодуоденальной резекции ограничены сочетанной травмой желчного протока, двенадцатиперстной кишки с вовлечением большого дуоденального сосочка, массивным кровотечением из размозженных тканей головки поджелудочной железы. Необходимо продолжение исследований с включением большого числа пациентов для улучшения результатов лечения при травме поджелудочной железы.

Pancreas injuriespancreatic duct/injuriespancreatic duct/stentТравма поджелудочной железыповреждение панкреатического протокаэндоскопическое стентирование панкреатического протокаRaza M, Abbas Y, Devi V, Prasad KV, Rizk KN, Nair PP. Non operative management of abdominal trauma - a 10 years review. World J Emerg Surg. 2013; 8: 14. doi: 10.1186/1749-7922-8-14.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.Iacono C, Zicari M, Conci S, Valdegamberi A, De Angelis M, Pedrazzani C, Ruzzenente A, Guglielmi A. Management of pancreatic trauma: A pancreatic surgeon's point of view. Pancreatology. 2016; 16(3): 302-8. doi: 10.1016/j.pan.2015.12.004.Ull C, Bensch S, Schildhauer TA, Swol J. Blunt Pancreatic Injury in Major Trauma: Decision-Making between Nonoperative and Operative Treatment. Case Rep Surg. 2018; 2018: 6197261.Kuza CM, Hirji SA, Englum BR, Ganapathi AM, Speicher PJ, Scarborough JE. Pancreatic Injuries in Abdominal Trauma in US Adults: Analysis of the National Trauma Data Bank on Management, Outcomes, and Predictors of Mortality. Scand J Surg. 2020; 109(3): 193-204. doi: 10.1177/1457496919851608.Kang WS, Park YC, Jo YG, Kim JC. Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center. Ann Surg Treat Res. 2018; 95(1): 29-36. doi: 10.4174/astr.2018.95.1.29.Uchida K, Hagawa N, Miyashita M, Maeda T, Kaga S, Noda T, Nishimura T, Yamamoto H, Mizobata Y. How to deploy a uniform and simplified acute-phase management strategy for traumatic pancreatic injury in any situation. Acute Med Surg. 2020; 7(1): e502.Shibahashi K, Sugiyama K, Kuwahara Y, Ishida T, Okura Y, Hamabe Y. Epidemiological state, predictive model for mortality, and optimal management strategy for pancreatic injury: A multicentre nationwide cohort study. Injury. 2020; 51(1): 59-65.Ando Y, Okano K, Yasumatsu H, Okada T, Mizunuma K, Takada M, Kobayashi S, Suzuki K, Kitamura N, Oshima M, Suto H, Nobuyuki M, Suzuki Y. Current status and management of pancreatic trauma with main pancreatic duct injury: A multicenter nationwide survey in Japan. J Hepatobiliary Pancreat Sci. 2021; 28(2): 183-191. doi: 10.1002/jhbp.877.Buitendag JJP, Kong VY, Laing GL, Bruce JL, Manchev V, Clarke DL. A comparison of blunt and penetrating pancreatic trauma. S Afr J Surg. 2020; 58(4): 218.Al-Thani H, Ramzee AF, Al-Hassani A, Strandvik G, El-Menyar A. Traumatic Pancreatic Injury Presentation, Management, and Outcome: An Observational Retrospective Study From a Level 1 Trauma Center. Front Surg. 2022; 8: 771121. doi: 10.3389/fsurg.2021.771121.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.Heuer M, Hussmann B, Lefering R, Taeger G, Kaiser GM, Paul A, Lendemans S. Trauma Registry of the DGU. Pancreatic injury in 284 patients with severe abdominal trauma: outcome, course, and treatment algorithm. Langenbecks Arch Surg. 2011; 396(7): 1067-76.Siboni S, Kwon E, Benjamin E, Inaba K, Demetriades D. Isolated blunt pancreatic trauma: A benign injury? J Trauma Acute Care Surg. 2016; 81(5): 855-859. doi: 10.1097/TA.0000000000001224.Phillips B, Turco L, McDonald D, Mause E, Walters RW. A subgroup analysis of penetrating injuries to the pancreas: 777 patients from the National Trauma Data Bank, 2010-2014. J Surg Res. 2018; 225: 131-141.Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, McAninch JW, Pachter HL, Shackford SR, Trafton PG. Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma. 1990; 30(11): 1427-9.Ayoob AR, Lee JT, Herr K, LeBedis CA, Jain A, Soto JA, Lim J, Joshi G, Graves J, Hoff C, Hanna TN. Pancreatic Trauma: Imaging Review and Management Update. Radiographics. 2021; 41(1): 58-74.Coccolini F, Kobayashi L, Kluger Y, Moore EE, Ansaloni L, Biffl W, Leppaniemi A, Augustin G, Reva V, Wani I, Kirkpatrick A, Abu-Zidan F, Cicuttin E, Fraga GP, Ordonez C, Pikoulis E, Sibilla MG, Maier R, Matsumura Y, Masiakos PT, Khokha V, Mefire AC, Ivatury R, Favi F, Manchev V, Sartelli M, Machado F, Matsumoto J, Chiarugi M, Arvieux C, Catena F, Coimbra R. WSES-AAST Expert Panel. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg. 2019; 14: 56.Kumar A, Panda A, Gamanagatti S. Blunt pancreatic trauma: A persistent diagnostic conundrum? World J Radiol. 2016; 8(2): 159-73.Mitra B, Fitzgerald M, Raoofi M, Tan GA, Spencer JC, Atkin C. Serum lipase for assessment of pancreatic trauma. Eur J Trauma Emerg Surg. 2014; 40(3): 309-13. doi: 10.1007/s00068-013-0341-z.Mahajan A, Kadavigere R, Sripathi S, Rodrigues GS, Rao VR, Koteshwar P. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury. 2014; 45(9): 1384-93. doi: 10.1016/j.injury.2014.02.014.Rau CS, Wu SC, Chien PC, Kuo PJ, Chen YC, Hsieh HY, Hsieh CH, Liu HT. Identification of Pancreatic Injury in Patients with Elevated Amylase or Lipase Level Using a Decision Tree Classifier: A Cross-Sectional Retrospective Analysis in a Level I Trauma Center. Int J Environ Res Public Health. 2018; 15(2): 277.Elbanna KY, Mohammed MF, Huang SC, Mak D, Dawe JP, Joos E, Wong H, Khosa F, Nicolaou S. Delayed manifestations of abdominal trauma: follow-up abdominopelvic CT in posttraumatic patients. Abdom Radiol (NY). 2018; 43(7): 1642-1655.Sharbidre KG, Galgano SJ, Morgan DE. Traumatic pancreatitis. Abdom Radiol (NY). 2020; 45(5): 1265-1276. doi: 10.1007/s00261-019-02241-7.Higashi H, Kanki A, Watanabe S, Yamamoto A, Noda Y, Yasokawa K, Higaki A, Tamada T, Ito K. Traumatic hypovolemic shock revisited: the spectrum of contrast-enhanced abdominal computed tomography findings and clinical implications for its management. Jpn J Radiol. 2014; 32(10): 579-84. doi: 10.1007/s11604-014-0354-5.Biffl WL, Zhao FZ, Morse B, McNutt M, Lees J, Byerly S, Weaver J, Callcut R, Ball CG, Nahmias J, West M, Jurkovich GJ, Todd SR, Bala M, Spalding C, Kornblith L, Castelo M, Schaffer KB, Moore EE. WTA Multicenter Trials Group on Pancreatic Injuries. A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries. J Trauma Acute Care Surg. 2021; 90(5): 776-786.Odedra D, Mellnick VM, Patlas MN. Imaging of Blunt Pancreatic Trauma: A Systematic Review. Can Assoc Radiol J. 2020; 71(3): 344-351. doi: 10.1177/0846537119888383.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 GJ, 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. An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain? J Trauma Acute Care Surg. 2018; 85(3): 435-443.Wortman JR, Uyeda JW, Fulwadhva UP, Sodickson AD. Dual-Energy CT for Abdominal and Pelvic Trauma. Radiographics. 2018; 38(2): 586-602. doi: 10.1148/rg.2018170058.Gupta A, Stuhlfaut JW, Fleming KW, Lucey BC, Soto JA. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics. 2004; 24(5): 1381-95.Boraschi P, Donati F, Cervelli R, Pacciardi F. Secretin-stimulated MR cholangiopancreatography: spectrum of findings in pancreatic diseases. Insights into Imaging. 2016; 7(6): 819-29.Chereau N, Wagner M, Tresallet C, Lucidarme O, Raux M, Menegaux F. CT scan and Diagnostic Peritoneal Lavage: towards a better diagnosis in the area of nonoperative management of blunt abdominal trauma. Injury. 2016; 47(9): 2006-11. doi: 10.1016/j.injury.2016.04.034.Schellenberg M, Inaba K, Bardes JM, Cheng V, Matsushima K, Lam L, Benjamin E, Demetriades D. Detection of traumatic pancreatic duct disruption in the modern era. Am J Surg. 2018; 216(2): 299-303.Ho VP, Patel NJ, Bokhari F, Madbak FG, Hambley JE, Yon JR, Robinson BR, Nagy K, Armen SB, Kingsley S, Gupta S, Starr FL, Moore HR 3rd, Oliphant UJ, Haut ER, Como JJ. Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017; 82(1): 185-199. doi: 10.1097/TA.0000000000001300.Menahem B, Lim C, Lahat E, Salloum C, Osseis M, Lacaze L, Compagnon P, Pascal G, Azoulay D. Conservative and surgical management of pancreatic trauma in adult patients. Hepatobiliary Surg Nutr. 2016; 5(6): 470-477. doi: 10.21037/hbsn.2016.07.01.Barut B, Ciftci F, Kayaalp C. Spleen preserving distal pancreatectomy in isolated pancreatic trauma. Ann Ital Chir. 2017; 6: S2239253X17027426.Aoki Y, Sasanuma H, Kimura Y, Saito A, Morishima K, Kaneda Y, Endo K, Yoshida A, Kihara A, Sakuma Y, Horie H, Hosoya Y, Lefor AK, Sata N. Pancreas-preserving double pancreaticogastrostomy after traumatic injury to the head of the pancreas: a case report. J Int Med Res. 2020; 48(10): 300060520962967. doi: 10.1177/0300060520962967.Mohseni S, Holzmacher J, Sjolin G, Ahl R, Sarani B. Outcomes after resection versus non-resection management of penetrating grade III and IV pancreatic injury: A trauma quality improvement (TQIP) databank analysis. Injury. 2018; 49(1): 27-32.Serra F, Barbato G, Tazzioli G, Gelmini R. Pancreaticogastrostomy as reconstruction choice in pancreatic trauma surgery: Case report and review of the literature. Int J Surg Case Rep. 2019; 65: 102-106.Chikhladze S, Ruess DA, Schoenberger J, Fichtner-Feigl S, Pratschke J, Hopt UT, Bahra M, Wittel UA, Globke B. Clinical course and pancreas parenchyma sparing surgical treatment of severe pancreatic trauma. Injury. 2020; 51(9): 1979-1986. doi: 10.1016/j.injury.2020.03.045.Du B, Wang X, Wang X, Shah S, Ke N. A rare case of central pancreatectomy for isolated complete pancreatic neck transection trauma. BMC Surg. 2019; 19(1): 91. doi: 10.1186/s12893-019-0557-x.Lin BC, Wong YC, Chen RJ, Liu NJ, Wu CH, Hwang TL, Hsu YP. Major pancreatic duct continuity is the crucial determinant in the management of blunt pancreatic injury: a pancreatographic classification. Surg Endosc. 2017; 31(10): 4201-4210.Lin BC, Chen RJ, Hwang TL. Lessons learned from isolated blunt major pancreatic injury: Surgical experience in one trauma centre. Injury. 2019; 50(9): 1522-1528. doi: 10.1016/j.injury.2019.05.027.Shimizu T, Kittaka H, Taniguchi K, Uchiyama K, Akimoto H. Bracy procedure with ductal mucosal pancreaticogastrostomy and an internal stent for pancreatic complex deep injury: how to do it. Surg Today. 2018; 48(9): 894-898. doi: 10.1007/s00595-018-1667-2.Nagashima F, Inoue S, Matsui D, Bansyoutani Y, Tokuda R, Fuzisaki O, Kobayashi M. Efficacy of damage control surgery and staged endoscopic pancreatic ductal double stenting therapy for severe pancreatic head injury: a case report. J Med Case Rep. 2021; 15(1): 404.Lin BC, Hwang TL. Resection versus drainage in the management of patients with AAST-OIS grade IV blunt pancreatic injury: A single trauma centre experience. Injury. 2022; 53(1): 129-136.