IV - V级十二指肠或胰腺损伤的创伤患者行胰十二指肠切除术：一项东部创伤外科学会多中心试验的事后分析
Pancreaticoduodenectomy in trauma patients with grade IV-V duodenal or pancreatic injuries: a post hoc analysis of an EAST multicenter trial.
作者信息
Choron Rachel Leah, Piplani Charoo, Kuzinar Julia, Teichman Amanda L, Bargoud Christopher, Sciarretta Jason D, Smith Randi N, Hanos Dustin, Afif Iman N, Beard Jessica H, Dhillon Navpreet Kaur, Zhang Ashling, Ghneim Mira, Devasahayam Rebekah, Gunter Oliver, Smith Alison A, Sun Brandi, Cao Chloe S, Reynolds Jessica K, Hilt Lauren A, Holena Daniel N, Chang Grace, Jonikas Meghan, Echeverria-Rosario Karla, Fung Nathaniel S, Anderson Aaron, Fitzgerald Caitlin A, Dumas Ryan Peter, Levin Jeremy H, Trankiem Christine T, Yoon JaeHee, Blank Jacqueline, Hazelton Joshua P, McLaughlin Christopher J, Al-Aref Rami, Kirsch Jordan Michael, Howard Daniel S, Scantling Dane R, Dellonte Kate, Vella Michael A, Hopkins Brent, Shell Chloe, Udekwu Pascal, Wong Evan G, Joseph Bellal, Lieberman Howard, Ramsey Walter A, Stewart Collin H, Alvarez Claudia, Berne John D, Nahmias Jeffry, Puente Ivan, Patton Joe, Rakitin Ilya, Perea Lindsey, Pulido Odessa, Ahmed Hashim, Keating Jane, Kodadek Lisa M, Wade Jason, Reynold Henry, Schreiber Martin, Benjamin Andrew, Khan Abid, Mann Laura K, Mentzer Caleb, Mousafeiris Vasileios, Mulita Francesk, Reid-Gruner Shari, Sais Erica, Foote Christopher W, Palacio Carlos H, Argandykov Dias, Kaafarani Haytham, Bover Manderski Michelle T, Moko Lilamarie, Narayan Mayur, Seamon Mark
机构信息
Surgery, Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
出版信息
Trauma Surg Acute Care Open. 2024 Dec 20;9(1):e001438. doi: 10.1136/tsaco-2024-001438. eCollection 2024.
INTRODUCTION
The utility of pancreaticoduodenectomy (PD) for high-grade traumatic injuries remains unclear and data surrounding its use are limited. We hypothesized that PD does not result in improved outcomes when compared with non-PD surgical management of grade IV-V pancreaticoduodenal injuries.
METHODS
This is a retrospective, multicenter analysis from 35 level 1 trauma centers from January 2010 to December 2020. Included patients were ≥15 years of age with the American Association for the Surgery of Trauma grade IV-V duodenal and/or pancreatic injuries. The study compared operative repair strategy: PD versus non-PD.
RESULTS
The sample (n=95) was young (26 years), male (82%), with predominantly penetrating injuries (76%). There was no difference in demographics, hemodynamics, or blood product requirement on presentation between PD (n=32) vs non-PD (n=63). Anatomically, PD patients had more grade V duodenal, grade V pancreatic, ampullary, and pancreatic ductal injuries compared with non-PD patients (all p<0.05). 43% of all grade V duodenal injuries and 40% of all grade V pancreatic injuries were still managed with non-PD. One-third of non-PD duodenal injuries were managed with primary repair alone. PD patients had more gastrointestinal (GI)-related complications, longer intensive care unit length of stay (LOS), and longer hospital LOS compared with non-PD (all p<0.05). There was no difference in mortality or readmission. Multivariable logistic regression analysis determined PD to be associated with a 3.8-fold greater odds of GI complication (p=0.010) compared with non-PD. In a subanalysis of patients without ampullary injuries (n=60), PD patients had more anastomotic leaks compared with the non-PD group (3 (30%) vs 2 (4%), p0.028).
CONCLUSION
While PD patients did not have worse hemodynamics or blood product requirements on admission, they sustained more complex anatomic injuries and had more GI complications and longer LOS than non-PD patients. We suggest that the role of PD should be limited to cases of massive destruction of the pancreatic head and ampullary complex, given the likely procedure-related morbidity and adverse outcomes when compared with non-PD management.
LEVEL OF EVIDENCE
IV, Multicenter retrospective comparative study.
引言
胰十二指肠切除术（PD）用于治疗高级别创伤性损伤的效用仍不明确，且关于其应用的数据有限。我们假设，与非PD手术治疗IV-V级胰十二指肠损伤相比，PD并不能带来更好的治疗效果。
方法
这是一项对2010年1月至2020年12月期间来自35个一级创伤中心的回顾性多中心分析。纳入患者年龄≥15岁，患有美国创伤外科学会IV-V级十二指肠和/或胰腺损伤。该研究比较了手术修复策略：PD与非PD。
结果
样本（n=95）较为年轻（26岁），男性占比82%，主要为穿透伤（76%）。PD组（n=32）与非PD组（n=63）在人口统计学、血流动力学或入院时血液制品需求方面无差异。从解剖学角度来看，与非PD患者相比，PD患者的V级十二指肠、V级胰腺、壶腹和胰管损伤更多（所有p<0.05）。所有V级十二指肠损伤中有43%以及所有V级胰腺损伤中有40%仍采用非PD治疗。三分之一的非PD十二指肠损伤仅采用一期修复。与非PD患者相比，PD患者有更多胃肠道（GI）相关并发症、更长的重症监护病房住院时间（LOS）和更长的住院LOS（所有p<0.05）。死亡率或再入院率无差异。多变量逻辑回归分析确定，与非PD相比，PD发生GI并发症的几率高3.8倍（p=0.010）。在对无壶腹损伤患者（n=60）的亚组分析中，与非PD组相比，PD患者的吻合口漏更多（3例（30%）对2例（4%），p0.028）。
结论
虽然PD患者入院时血流动力学或血液制品需求并不更差，但与非PD患者相比，他们遭受的解剖损伤更复杂，有更多GI并发症且住院时间更长。鉴于与非PD治疗相比，PD可能存在与手术相关的发病率和不良后果，我们建议PD的作用应限于胰头和壶腹复合体严重破坏的病例。
证据水平
IV，多中心回顾性比较研究。
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