S. Rabinowitz1,2, J. Wycech2,3, A. Tymchak1,2,3,4, M. Crawford2, M. Gomez3, A. A. Fokin2, I. Puente1,2,3,4 1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA
Introduction:
There are several challenges of detecting pancreatic injury within the first hours post trauma, as clinical presentation is often delayed, imaging may be obscured, and enzyme analysis is unreliable. The aim of this study was to evaluate characteristics of patients with pancreatic injuries who had a negative initial computed tomography (CT) scan to determine indicators that can be used in detecting pancreatic injury.
Methods:
This IRB approved retrospective cohort study included 23 patients, ages 17-94, diagnosed with pancreatic injuries at a Level 1 trauma center between 01/2012 and 06/2018. Studied variables included: injury severity score (ISS), incidence of hemoperitoneum, contrast CT imaging, operative vs. non-operative management (NOM), enzyme levels, organ injury score (OIS), co-injuries, intensive care unit length of stay (ICULOS), hospital LOS (HLOS), complications and mortality.
Results:
Of the 23 patients, 9 (39.1%) had negative initial CT for pancreatic injury within the first 12 hours post trauma and were the subject of analysis. In this cohort, the mean ISS was 29.4. CT scans for all 9 patients were positive for hemoperitoneum. Although initial contrast CT scans were negative for pancreatic injuries, they showed other abdominal organ trauma. As a result, 8 patients underwent urgent laparotomy during which injuries to the pancreas were diagnosed, and in 4 patients (44.4%) pancreas was immediately operated on. Only 1 of the 9 patients had attempted NOM, which failed, and pancreatic injury was discovered during laparotomy. Elevated amylase and lipase levels were seen in only 1 patient. Pancreas injuries categorized by region were: 7 patients had injuries to the pancreatic tail and 2 to the pancreatic head/neck. There were no injuries to the pancreatic duct. The mean pancreas OIS was 1.6. All 9 patients had additional solid organ injuries (SOI) and/or hollow viscus injuries (HVI): 4 patients had other SOI without HVI, 3 had other SOI with HVI, and 2 had pancreas injuries with HVI only. The most common SOI in association with pancreas was spleen (66.7%, n=6). All spleen injuries were categorized as severe (mean spleen OIS 4.3) and resulted in splenectomy. In patients with pancreatic injuries with two other SOI, the most common combination was spleen and left kidney injuries (33.3%, n=3). There was also incidence of lumbar trauma involving L1-L2 fractures in 2 patients: one had spleen and kidney co-injuries, while the other had spleen and left colon trauma. Mean ICULOS was 9.5 days and HLOS was 17.3 days. Complications, such as peritonitis and blood loss anemia developed in 4 patients, however no mortality was recorded.
Conclusion:
Early CT scans can be less sensitive for the detection of pancreatic injuries in patients with multiple abdominal organ injuries. High grade spleen injuries, especially when combined with left kidney, left colon or lumbar vertebrae trauma, should be considered risk factors for possible pancreatic damage.