1418 Non-Operative Versus Operative Management for Blunt Pancreatic Trauma in Adults: A Systematic Review of The Literature

Aim Pancreatic injury, a rare consequence of blunt abdominal trauma, is associated with significant morbidity and mortality when the appropriate management is delayed. Due to the rarity of the injury, there is currently a lack of evidence to establish a treatment pathway for adults. The aim of this review was to compare outcomes following non-operative and operative management of adults who suffered blunt pancreatic trauma injuries. Method An electronic literature search was performed from 2008 to 2020. Studies pertaining to adults sustaining blunt pancreatic injuries, of all grades (I-V) of severity, according to the American Association for the Surgery of Trauma, were included. The primary outcome was mortality, whilst secondary outcomes were components of pancreas specific morbidity. 1501 studies were initially identified and screened, and 11 studies were included in the review. Results Qualitative analysis showed an increase risk of mortality with increased severity of injury, and in the operative group compared to non-operative group. All patients who were haemodynamically unstable underwent immediate operative management, whereas the management strategy for patients with haemodynamic stability differed between the studies and depended on either the grade of injury, presence of other organ injury, or failure of initial management strategy. Conclusions This systematic review largely reaffirmed accepted practice in determining operative versus non-operative treatment for blunt pancreatic injury. Larger institutional analyses are required to add strength to the evidence supporting non-operative management for grade III or IV injuries with appropriate monitoring and subsequent intervention if required.

Trombose de veia mesentérica superior: relato de caso

A trombose venosa mesentérica é uma causa rara de isquémia mesentérica, potencialmente letal. A sua apresentação é insidiosa, o que dificulta o seu diagnóstico em fase inicial. Sexo masculino, recebido em unidade de urgência com dor em região periumbilical há 15 dias evoluindo para dor intensa há 4 dias. Procedeu-se ao exame do abdome que se apresentou globoso, flácido e doloroso a palpação em lado direito com ruídos hidroaéreos presentes. Já a tomografia de abdômen total, apresentou derrame pleural, borramento da gordura com formação de coleção em região de hipocôndrio direito, presença de trombo em veia porta, placas de calcificações em parede de aorta, artérias ilíacas e femorais, cisto cortical em rim esquerdo. Foi diagnosticado com trombose em veia mesentérica superior. A conduta adotada foi laparotomia exploradora, enterectomia parcial e enterro anastomose, em caráter de urgência. Realizado incisão xifo-púbica, identificada isquemia de alça de delgado 20 cm da válvula íleo cecal, feita enterectomia de 40 cm, com saída de trombos de vasos ressecados, ligadura e verificada hemostasia, confeccionada anastomose entérica término terminal. Após vinte e nove dias, obteve alta hospitalar. Em termos gerais a trombose de veia mesentérica apresenta-se clinicamente sob as formas: aguda, subaguda ou crónica. Na forma aguda a sintomatologia é exuberante, desproporcional e com rápida evolução. Na subaguda a dor abdominal persiste ao longo de dias ou semanas. Na forma crónica não ocorrem sintomas durante a instalação de trombose. Destaca-se a importância dos exames de imagem para o diagnósticoDescritores: Oclusão Vascular Mesentérica; Dor Abdominal; Serviços Médicos de Emergência.ReferênciasOliveira PH, Oliveira AH, Costa M, Silva A. Trombose Venosa Mesentérica: uma causa rara de oclusão intestinal. Rev Port Cir. 2012;22:61-6.Felga GEG, Forn CG, Pinto JRF, Chebli JMF, Gaburri PD, Souza AFM et al. Trombose venosa mesentérica subaguda. HU Revista. 2003;29(3):488-89.Bassani E, Iglesias GA, Souza MAR, Funes H, Funes F. Trombose Venosa Mesentérica em paciente com apendicite aguda. 2014. Disponível em: <https://faceres.com.br/wp-content/ uploads/ 2014/01/trombose-venosa-mesenterica-em-pacientes-com-apendicite-aguda.pdf>. Acesso em: 09 fev. 2019.Simão JL, De Nadai LC, Giacon PP, Lopes MAM. Uso de contraceptivos orais induzindo trombose mesentérica. Rev Bras Hematol Hemoter. 2008;30(1):75-7. Artifon ELA, Couto-Júnior DS, Fraga GP, Sakai O, Rasslan S. Endoscopic ultrasound (EUS) diagnosis of blunt pancreatic trauma associated to the superior mesenteric vein thrombosis. ABCD, arq. bras. cir. dig. 2010;23(1):64-6.Muñoz S, Cubo P, González-Castillo J, Nuevo JA, Garcia-Lamberechts EJ, Sanz A. Superior mesenteric venous thrombosis: a retrospective study of thirteen cases. Rev. esp. enferm. dig. 2004;96(6):385-94.Caldeira A, Martin F, Pereira E, Sousa R, Gonçalves R, Tristan J et al . Contribuição de Ultrasonografia Abdominal no diagnóstico da Trombose Mesentérica. J Port Gastrenterol. 2009; 16(4):154-58.Tiago J, Ministro A, Nunes JS, Fernandes JF. Isquémia Mesentérica Aguda: cinco anos de experiência institucional (2007-12). Angiol Cir Vasc. 2013;9(1):11-6.Flis V, Mrdža B, Štirn B, Milotic F, Kobilica N, Bergauer A. Revascularização da artéria mesentérica superior isolada para tratamento de isquemia mesentérica crônica. Wiener Klinische Wochenschrift, 2015. 128(3-4):109-13.

Imaging of Blunt Pancreatic Trauma: A Systematic Review

Purpose: Despite several published reports on the value of imaging in acute blunt pancreatic trauma, there remains a large variability in the reported performance of ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). The purpose of this study is to present a systematic review on the utility of these imaging modalities in the acute assessment of blunt pancreatic trauma. In addition, a brief overview of the various signs of pancreatic trauma will be presented. Methods: Keyword search was performed in MEDLINE, EMBASE, and Web of Science databases for relevant studies in the last 20 years (1999 onward). Titles and abstracts were screened, followed by full-text screening. Inclusion criteria were defined as studies reporting on the effectiveness of imaging modality (US, CT, or MRI) in detecting blunt pancreatic trauma. Results: After initial search of 743 studies, a total of 37 studies were included in the final summary. Thirty-six studies were retrospective in nature. Pancreatic injury was the primary study objective in 21 studies. Relevant study population varied from 5 to 299. Seventeen studies compared the imaging findings against intraoperative findings. Seven studies performed separate analysis for pancreatic ductal injuries and 9 studies only investigated ductal injuries. The reported sensitivities for the detection of pancreatic injuries at CT ranged from 33% to 100% and specificity ranged from 62% to 100%. Sensitivity at US ranged from 27% to 96%. The sensitivity at MRI was only reported in 1 study and was 92%. Conclusion: There remains a large heterogeneity among reported studies in the accuracy of initial imaging modalities for blunt pancreatic injury. Although technological advances in imaging equipment would be expected to improve accuracy, the current body of literature remains largely divided. There is a need for future studies utilizing the most advanced imaging equipment with appropriately defined gold standards and outcome measures.

Operative versus non-operative management of blunt pancreatic trauma: A systematic review

Introduction Motor vehicle crashes are common causes of blunt abdominal trauma in the 21st century. While splenic trauma occurs very frequently and thus there is a well-established treatment paradigm, traumatic pancreatic injuries are relatively infrequent, occurring in only 3–5% of traumas. This low incidence means physicians have reduced experience with this condition and there is still ongoing debate with regards to the best practice in managing pancreatic trauma. During severe trauma, the pancreas can be injured as a consequence of blunt and penetrating injury. This has an estimated mortality rate ranging from 9 to 34%. Methods A systematic review was performed using three scientific databases: Embase, Medline and Cochrane and in-line with the PRISMA statement. We included only articles published in English, available as full text and describing only adults. Keywords included: pancrea*, trauma, blunt, operative management and non-operative management. Results Three studies were found that directly compared operative versus non-operative management in blunt pancreatic trauma. Length of stay, mortality and rate of re-intervention were lower in the non-operative group compared to the operative group. However, the average grade of pancreatic injury was lower in the non-operative group compared to the operative group. Discussion Our results revealed that patients who undergo non-operative management tend to have lower grade of injuries and patients with higher grade of injury tend to be managed in an operative fashion. This could be likely due to the fact that higher grade of pancreatic injuries is often accompanied by other injuries such as hollow viscus injury and therefore require operative intervention. Conclusion Non-operative management is a safe approach for low-grade blunt pancreatic trauma without ductal injuries. However, more evidence is required to improve our understanding and treatment plans. We suggest a large international multicentre study combining data from multiple international trauma centres to collect adequate data.