Introduction
Technological advances have led to a trauma pandemic caused by urbanization and the growth of the automobile fleet. According to WHO, the death rate from mechanical trauma ranks third among all fatal outcomes and ranks first among those who die under the age of 40 years, reaching 80% among adolescents and young adults [1, 2]. The consequences of trauma are one of the main causes of disability.
In our country, special attention is paid to improving the health care system, in particular, to improving the quality of diagnosis, treatment and prevention of surgical diseases. The strategy of action on five priority directions of development of the Republic of Uzbekistan for 2017—2021 defines the tasks for raising the level of medical care to the population «...increasing the availability and quality of specialized medical services, further reforming the emergency and urgent medical care, prevention of disability...». Proceeding from this, it is reasonable to carry out researches aimed at improving the tactics of diagnostics and treatment of closed abdominal trauma with pancreatic injury.
Anatomically well-protected pancreas is injured relatively rarely. According to different authors the frequency of pancreas involvement is from 4.3% to 10.7% [3, 4]. Postoperative complications occur in 32—75% of the patients. The lethality rate is also extremely high and varies from 22 to 80% [5, 6].
The issues of early diagnosis, therapeutic tactics in pancreas trauma patients are still the subject of discussions [7, 8]. All this prompted us to analyze the results of pancreatic trauma treatment in RRCEM and its branches from 2011 to 2021.
Aim of study — to determine the method of diagnostics and surgical intervention in traumatic injuries of the pancreas
Material and methods
We analyzed 125 cases of abdominal trauma with pancreatic injuries in the period from 2011 to 2021. Men predominated among the victims — 104 patients (83.2%), while women were — 21 (16.8%), age ranged from 20 to 60 years. Two groups of patients with pancreatic injury in closed abdominal trauma were formed for the study.
Group I included 84 patients based on retrospective clinical and statistical analysis of the provision of specialized medical care in a surgical hospital between 2011 and 2016 using traditional surgical interventions for closed abdominal trauma with pancreatic injury.
Group II included 41 patients based on retrospective and prospective clinical and statistical analysis of specialized medical care in the conditions of a surgical hospital from 2016 to 2021 using endovideo surgical techniques for diagnosis and treatment of patients with pancreatic injuries. in closed abdominal trauma. The circumstances of pancreatic trauma are presented in table 1.
Table 1. Circumstances of the pancreas injury
| Trauma circumstance | Number of patients | Total | ||
| I group | II group | Number | % | |
| Car accident | 42 | 27 | 69 | 55.2 |
| Falling injury | 22 | 10 | 32 | 25.6 |
| Domestic injury | 8 | 1 | 9 | 7.2 |
| Criminal accident | 11 | 2 | 13 | 10.4 |
| Sports injury | 1 | — | 1 | 0.8 |
| Work injury | — | 1 | 1 | 0.8 |
| Total number | 84 | 41 | 125 | 100 |
The largest number of patients in both groups was 69 (55.2%) patients after a traffic accident and 32 (25.6%) patients after a fall from height; the smallest number of patients was observed in sports and work injuries, 1 (0.8%) respectively.
The majority of patients were transported by passing transport or by themselves 67 (54.9%), and 53 (43.4%) victims were delivered by the ambulance team.
Isolated pancreatic trauma was diagnosed in 22 (26.1%) victims, combined trauma in 103 (82.4%). The structure of associated abdominal injuries is presented in table 2.
Table 2. The structure of associated abdominal injuries
| Localisation of associated injury | n=125 | I group (n=84) | II group (n=41) |
| Spleen | 53 | 34 (40.4%) | 19 (46.3%) |
| Liver | 35 | 25 (29.7%) | 10 (24.3%) |
| Duodenum | 4 | 3 (3.5%) | 1 (2.4%) |
| Small intestine | 9 | 5 (5.9%) | 4 (9.7%) |
| Large bowel | 14 | 7 (8.3%) | 7 (17%) |
| Kidney | 7 | 6 (7.1%) | 1 (2.4%) |
| Stomach | 3 | 1 (1.1%) | 2 (4.8%) |
| Gallbladder | 4 | 3 (3.5%) | 1 (2.4%) |
| Diaphragm | 1 | 1 (1.1%) | — |
| Total | 130* | 85* | 45* |
Note. * — the total number of associated abdominal injuries exceeded the total number of observations due to the fact that some of the victims had injuries of several abdominal cavity organs.
As seen in the table in both groups, patients with spleen 53 (42.4%) and liver injuries 35 (28%) prevailed, with the least number with damage to the stomach 5 (4%), duodenum 5 (4%) and gallbladder 5 (4%).
The AAST classification of traumatologists and surgeons was used to divide patients according to the severity of pancreatic injuries [9]. Distribution of patients with closed abdominal trauma with pancreatic injury is presented in table 3.
Table 3. Distribution of patients with closed abdominal trauma with pancreatic injury according to the degree of its damage according to AAST
| Grade | Group | |||
| I | II | |||
| total | % | total | % | |
| I | 26 | 30.9 | 12 | 29.2 |
| II | 42 | 50 | 18 | 43 |
| III | 11 | 13 | 16 | 39 |
| IV | 5 | 5.9 | 7 | 17 |
| V | 0 | 0 | 2 | 4.8 |
| Total | 84 | 100.0 | 41 | 100.0 |
As can be seen from the table, the largest number of patients in both groups were patients with AAST grade I and II lesions. There were no grade V lesions in group I, and there were 2 (4.8%) grade V lesions in group II.
Pancreatic injuries in closed trauma were localized mainly in the tail of the gland, less frequently in the head, body, and isthmus.
To these days, there is no consensus on the optimal therapeutic and diagnostic algorithm for patients with closed pancreatic trauma when emergency surgery is not required. From our point of view, patients with suspected pancreatic trauma require the closest attention and maximum effort to establish an accurate diagnosis.
Diagnostics should be based on anamnestic, clinical, laboratory data, and also the results of X-ray, ultrasound investigation, computer or magnetic resonance imaging. Although enumerated methods do not have 100% sensitivity for pancreatic trauma, but their timely application permits timely diagnosis of trauma complications, in particular, posttraumatic pancreatitis, and justificate therapeutic tactics.
Separate attention should be paid to the victims who are admitted in a severe state with signs of traumatic and hemorrhagic shock, which requires immediate therapeutic and diagnostic measures in the conditions of the shock operating room. A total of 30 (24%) patients were admitted in traumatic shock and 15 (12%) in hemorrhagic shock, which amounted to (36%) patients.
Multispiral computed tomography (MSCT) was performed only in 18 patients from group II. CT was not used in the I group. This examination method was performed in patients in a stable condition with no pathological changes of the abdominal cavity organs revealed by ultrasound examination. Only in 6 cases we detected changes on the side of pancreas — in 4 victims there were heterogeneity of pancreas body and tail, thus transverse linear rupture in the distal part of pancreas body was not excluded. 5 victims had diffuse reduced pancreatic body density, contusion of the head and isthmus with secondary signs of traumatic pancreatitis, fluid in the pouch of omentum and hemoperitoneum. One patient had a large high-density hematoma in the proximal part of the pancreatic body. Taking into account the pancreas location peculiarities, in some clinical situations in case of discrepancy between clinical picture and ultrasound or CT data it is necessary to apply videolaparoscopy in a timely manner.
Results and discussion
There were 12 patients in the II group with the 1st degree of pancreatic injury. Open operations were performed in 6 patients: laparotomy, sanation, drainage of the omentum pouch and abdominal cavity. Diagnostic videolaparoscopy, bursoscopy (pancreatoscopy), drainage of the omentum pouch were performed in another 6 patients.
There were no significant differences in the number of complications in the patients who underwent laparotomy and laparoscopy. This testifies to the fact that both methods allow to revise adequately the abdominal cavity and to establish the diagnosis. The use of video laparoscopic techniques allows to avoid unnecessary laparotomies, which worsen the prognosis as an additional traumatic factor.
Videolaparoscopy in patients with suspected pancreatic trauma should be performed when there is an indication of a specific mechanism of injury, there are questionable peritoneal symptoms, the patient is inadequate, and the results of noninvasive investigations do not allow to exclude pancreatic injury with complete certainty.
Elevated amylase levels in blood and urine on admission were noted in 39 (31%) cases, increased amylase in blood and urine after 3 more hours was observed in 77 (61.4%) patients.
The issues of optimal surgical tactics for different degrees of pancreatic injury remain debatable.
Depending on the nature and localization of the injury, the following types of surgical treatment of pancreatic injuries were used, based on adequate drainage of the injury area; removal of nonviable glandular tissues; restoration or rational diversion of pancreatic juice passage. Types of surgical interventions are presented in (table 4).
Table 4. Types of surgery performed
| № | Name of surgical method | Number of patients | % |
| 1 | Laparoscopic revision, pancreatoscopy. Omentum pouch and abdominal cavity drainage | 6 | 4.8 |
| 2 | Bleeding pancreatic vessel ligation (precisional hemostasis), lesion area drainage | 12 | 9.6 |
| 3 | Pancreatic body and tail resection | 4 | 3.2 |
| 4 | Retroperitoneal hematomas removal | 7 | 5.6 |
| 5 | Omentum pouch and abdominal cavity drainage (as a single stage intervention) | 60 | 48 |
| 6 | Omentum pouch tamponization | 24 | 19.2 |
| 7 | Laparotomy, primary Wirsung duct reconstruction, suturing of pancreatic lesion | 2 | 1.6 |
| 8 | Omentobursostomy forming | 3 | 2.4 |
In two patients with Wirsung duct injury we performed tamponade of the gland wound, in 2 patients — primary reconstruction of the Wirsung duct, in 4 patients — distal resection of the pancreas.
Splenectomy was the most frequent surgical intervention on the abdominal cavity organs in multiple abdominal trauma — 28% (35) cases in the structure of multiple trauma. Less frequently suturing or argon-plasma coagulation of the liver was performed in 25% (32) cases, suturing of wounds of the small intestine — 7.2% (9), suturing of wounds of the large intestine — 11.2% (14). Nephrectomy was performed for kidney ruptures in 4 (3.2%) cases (2 in each group), and in another 3 cases the kidney rupture was sutured.
Among the complications it is worth mentioning those directly related to the pancreatic trauma. According to the literature data, posttraumatic pancreatitis develops at any, even insignificant, pancreatic injury. Therefore, we considered post traumatic pancreatitis as a complication that had significant clinical and laboratory changes. Posttraumatic pancreatitis occurred in the II group in significantly fewer cases than in the I group — 51 (60.7%) of cases versus 18 (43.9%). The incidence of pancreatic necrosis 4 (9.7%) in group II in comparison with 11 (13%) in group I, abscesses of abdominal cavity and omental sac 4.8% in group II and 7.1% in group I also have been noted. It was connected with early start of antienzymatic and antisecretory therapy and in some cases with refusal of tamponization of the damaged area. Pancreatic cysts developed in 3 patients in group I and 1 patient in group II, which were eliminated operatively and routinely. Pancreatic fistula in both groups was formed 1 time each, in group I it closed on its own, in group II it was eliminated operatively after 2 months. Summing up all complications directly related to pancreatic injury, we can indicate a significant decrease in their number in group II in comparison with group I.
J.E. Krige et al. [9] in 2017 proposed the Pancreatic Injury Mortality Score (PIMS) as a composite outcome measure based on 5 variables and found an overall good prognosis (AUC 0.84) in a series of 473 patients with pancreatic injuries (table 5).
Table 5. Pancreatic Injury Mortality Score (PIMS)
| № | Criteria | Points | |
| 1. | Age of patient >55years | 5 | |
| 2. | Shocked | 5 | |
| 3. | Major vascular injury of pancreas | 2 | |
| 4. | Number of associated abdominal injuries: | ||
| none | 0 | ||
| 1 | 1 | ||
| 2 | 2 | ||
| 3 or more | 3 | ||
| 5. | AAST pancreatic injury scale | 1 | |
| 2 | |||
| 3 | |||
| 4 | |||
| 5 | |||
| Mortality rate | |||
| № | Severity level | PIMS score | Mortality, % |
| 1. | Minor | 0—4 | Low risk 1% |
| 2. | Moderate | 5—9 | Medium risk, 15—17% |
| 3. | Severe | 10—20 | High risk, 50% |
According to our data on the Pancreatic Injury Mortality Score (PIMS), patients were distributed as follows (table 6).
Table 6. Distribution of patients according to the PIMS
| Severity | PIMS score | Mortality,% | Number of patients | Mortality, n | % | |
| I gr. | II gr. | |||||
| Minor | 0—4 | Low risk 1% | 35 | 24 | — | |
| Moderate | 5—9 | Medium risk, 15—17% | 36 | 10 | 5 | 10.8 |
| Severe | 10—20 | High risk, 50% | 10 | 7 | 12 | 70.5 |
| Total number of patients | 13 | 4 | 17 | 13.6 | ||
Out of 125 patients with dominant pancreatic injury, 17 (13.6%) died. According to our data on the PIMS scale, there were no fatal outcomes in the minor degree of severity. In the group with a moderate degree of severity 4 patients died in the I group (8.6%), and 1 (2.1%) patient in the II group. In the severe patients of I group 9 patients died, which was (52.9%), and in the II group 4 patients (23.5%). The main causes of lethal outcomes in 9 patients were severe destructive post-traumatic pancreatitis, in 6 patients there were traumas with severe traumatic and hemorrhagic shock, in 2 patients — multiple complications of associated injuries of thorax, and brain.
This study has some limitations. First, this study was a small series from a single center. Thus, nationwide or international studies are necessary.
Conclusion
1. The tactics of surgical treatment in pancreatic injuries depends on the degree of its traumatization.
2. In doubtful diagnostic situations video laparoscopy should be more widely used, which allows avoiding unnecessary laparotomies and is accompanied by low complication and mortality rates.
3. The only indication to perform manipulations on the gland parenchyma in patients with 1st and 2nd degree injuries is ongoing bleeding.
4. Use of pancreatic tamponade for the purpose of hemostasis is undesirable. The best results are achieved by stitching the bleeding vessel and electrocoagulation combined with drainage of the omental pouch.
5. In case of 3rd degree pancreatic injury, associated trauma, hypotension we should limit ourselves to minimal amount of gland surgery, if the patient’s condition is stable, distal pancreatic resection is the operation of choice.
6. The most frequent complication of pancreatic trauma is acute posttraumatic pancreatitis, therefore pancreatitis prevention should be performed in all patients with pancreatic trauma regardless of the severity of injuries.