多中心研究当前高级别胰腺损伤的诊断和治疗趋势。
A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.
机构信息
From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO.
出版信息
J Trauma Acute Care Surg. 2021 May 1;90(5):776-786. doi: 10.1097/TA.0000000000003080.
BACKGROUND
Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time.
METHODS
Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate.
RESULTS
Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs.
CONCLUSION
Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice.
LEVEL OF EVIDENCE
Retrospective diagnostic/therapeutic study, level III.
背景
在过去的二十年中，胰腺外伤的治疗效果并没有显著改善。2013 年，西方创伤协会的一项算法强调了一些新的数据，这些数据可能会改善对高等级胰腺损伤（HGPIs；III-V 级）的诊断和治疗。我们假设，磁共振胰胆管成像、胰管支架置入、手术引流与切除以及 HGPIs 的非手术治疗的应用随着时间的推移而增加。
方法
对 2010 年至 2018 年期间来自 32 个中心的成人胰腺损伤的诊断、治疗和结局进行了多中心回顾性分析。通过等级和时间段（PRE，2010-2013 年；POST，2014-2018 年）进行分析，在适当的情况下使用了各种统计检验。
结果
32 个中心报告了 515 例 HGPIs 患者的数据。共有 270 例（53%）为穿透性创伤，58%的患者在没有影像学检查的情况下直接进入手术室。89 例（17%）在 24 小时内死亡。评估了 426 例 24 小时幸存者的治疗和结局。CT 与手术分级之间的一致性为 38%。磁共振胰胆管成像在 IV/V 级损伤中的应用在过去的两年中增加了一倍，但仍然较低。总体上，HGPIs 的治疗和结局没有随时间变化。III 级损伤中进行了 78%的切除术，且随着时间的推移保持稳定，而 IV/V 级损伤的切除术呈下降趋势（56%降至 39%，p=0.11）。在接受引流治疗的 IV/V 级损伤中，胰腺相关并发症（PRCs）的发生率高于接受切除术的患者（61%比 32%，p=0.0051），但 III 级损伤的 PRCs 在切除术和引流术之间无差异。胰腺切除术闭合对 PRCs 无影响。在 IV/V 级损伤中，胰管支架置入的应用随着时间的推移而增加，其中 76%用于治疗 PRCs。
结论
在大多数 HGPIs 病例中，术中分级和 CT 分级是不同的。III 级损伤的患者仍大多接受切除术，但引流术可能是一种非劣效的替代方法。IV/V 级损伤的引流术呈上升趋势，但较高的 PRC 发生率需要对此做法保持谨慎。
证据水平
回顾性诊断/治疗研究，III 级。
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