Kollár Dániel, Molnár F Tamás, Zsoldos Péter, Oláh Attila
Sebészeti és Mellkassebészeti Osztály, Petz Aladár Megyei Oktató Kórház Győr, Vasvári Pál u. 2-4., 9024.
Orv Hetil. 2018 Jan;159(2):43-52. doi: 10.1556/650.2018.30938.
The management of thoracic and abdominal organ injuries has very thorough and extensive literature, including evidence-based protocols. Pancreatic trauma stands as an exception. Blunt or penetrating trauma of the pancreas is rather rare (less than 2% of all trauma cases, approximately 3-12% of all abdominal trauma), leading to the lack of high-level evidences regarding its treatment. Damage of the pancreas parenchyma can cause substantial morbidity and mortality, therefore it is essential to separate cases where conservative treatment suffices from those that need surgical approach. This study aims to review the conclusions of relevant articles of the past decades concerning the management of both adult and childhood pancreatic trauma. Classifications and their reliability are revised. We enlist scaling systems that can help in making decision whether to operate or to treat conservatively, from physical examination to diagnostic measures and complications. To date, the treatment principles of pancreatic trauma are not based either on prospective or on randomised trials. The database search of studies retrieved only retrospective and/or small case cohorts, case reports and expert opinions (levels 4 and 5 of evidence). However, it is a generally accepted conviction that the damage of the main pancreatic duct determines if the pancreatic injury is of low or high grade. Available classifications are based on the same principle. Conservative treatment is feasible given that the patient is hemodinamically stable and the pancreatic duct is unimpaired. If duct lesion is discovered, adult cases are to be treated with minimally invasive (percutaneous or endoscopic) measures or surgically (including reconstruction, resection and drainage). The management of childhood injuries has controversial literature. Many arguments can be enumerated on the operative as also on the non-operative approach, this confusion is to be clarified in the future. The highest morbidity rates are derived from the late diagnosis of the pancreatic duct, while increased mortality is seen in the polytrauma patient groups. Levels 1-2 evidence-based recommendations are needed, but planning of strong trials is critically limited due to the small number of cases and the heterogeneity of the relevant patient groups. Orv Hetil. 2018; 159(2): 43-52.
胸腹部器官损伤的管理有非常全面和广泛的文献，包括循证方案。胰腺创伤是个例外。胰腺钝性或穿透性创伤相当罕见（占所有创伤病例的不到2%，约占所有腹部创伤的3 - 12%），导致缺乏关于其治疗的高级别证据。胰腺实质损伤可导致相当高的发病率和死亡率，因此区分保守治疗足够的病例和需要手术治疗的病例至关重要。本研究旨在回顾过去几十年有关成人和儿童胰腺创伤管理的相关文章的结论。对分类及其可靠性进行了修订。我们列出了从体格检查到诊断措施及并发症的、有助于决定是手术还是保守治疗的评分系统。迄今为止，胰腺创伤的治疗原则并非基于前瞻性或随机试验。对研究的数据库检索仅得到回顾性和/或小病例队列、病例报告及专家意见（证据级别为4级和5级）。然而，一个普遍接受的观点是，主胰管损伤决定了胰腺损伤是低级别还是高级别。现有的分类基于相同原则。如果患者血流动力学稳定且胰管未受损，保守治疗是可行的。如果发现有导管损伤，成人病例应采用微创（经皮或内镜）措施或手术治疗（包括重建、切除和引流）。儿童损伤的管理文献存在争议。关于手术和非手术方法都有很多争议，这种混乱在未来有待澄清。最高的发病率源于胰管的延迟诊断，而多发伤患者组的死亡率增加。需要1 - 2级循证建议，但由于病例数量少且相关患者组的异质性，开展有力试验的计划受到严重限制。《匈牙利医学周报》。2018年；159(2): 43 - 52。
