The Western Trauma Association (WTA) has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations, or scarcity of experience and cases. Blunt pancreatic trauma falls under one of these clinically complex and rare scenarios. This algorithm is the result of an extensive literature review and input from the WTA membership and WTA Algorithm Committee members.

Postoperative hemorrhage (POH) is a severe adverse event following pancreatic injury. The present study aimed to investigate the risk factors and outcomes of POH after pancreatic injury.

Our study compares the delayed outcomes of operative versus nonoperative management of pancreatic injuries.We analyzed the 2017 Nationwide Readmissions Database on adult (≥18 years) trauma patients with pancreatic injuries. Patients who died on index admission were excluded. Patients were stratified into operative (OP) and non-operative (NOP) groups and compared for outcomes within 90 days of discharge. Multivariable regression analyses were performed.We identified 1553 patients (NOP ​= ​1092; OP ​= ​461). The Mean (SD) age was 39 (17.0) years, 31% of patients were female, and 77% had blunt injuries. Median ISS was 17 [9-25] and 74% had concomitant non-pancreatic intraabdominal injuries. On multivariable analysis, operative management was independently associated with increased odds of 90-day readmissions (aOR ​= ​1.47; p ​= ​0.03), intraabdominal abscesses (aOR ​= ​2.7; p ​< ​0.01), pancreatic pseudocyst (aOR ​= ​2.4; p ​= ​0.04), and need for percutaneous or endoscopic management (aOR ​= ​5.8; p ​< ​0.001).Operative management of pancreatic injuries is associated with higher rates of delayed complications compared to non-operative management. Surgically treated pancreatic trauma patients may need close surveillance even after discharge.Copyright © 2023 Elsevier Inc. All rights reserved.

Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date.A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations.33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n=28, 85%) vs. normal (n=5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3h.Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.Copyright © 2014 Elsevier Ltd. All rights reserved.

The management of high-grade pancreatic trauma is controversial.To review our single-institution experience on the surgical management of blunt and penetrating pancreatic injuries.A retrospective review of records was performed on all patients undergoing surgical intervention for high-grade pancreatic injuries [American Association for the Surgery of Trauma (AAST) Grade III or greater] at the Royal North Shore Hospital in Sydney between January 2001 and December 2022. Morbidity and mortality outcomes were reviewed, and major diagnostic and operative challenges were identified.Over a twenty-year period, 14 patients underwent pancreatic resection for high-grade injuries. Seven patients sustained AAST Grade III injuries and 7 were classified as Grades IV or V. Nine underwent distal pancreatectomy and 5 underwent pancreaticoduodenectomy (PD). Overall, there was a predominance of blunt aetiologies (11/14). Concomitant intra-abdominal injuries were observed in 11 patients and traumatic haemorrhage in 6 patients. Three patients developed clinically relevant pancreatic fistulas and there was one in-hospital mortality secondary to multi-organ failure. Among stable presentations, pancreatic ductal injuries were missed in two-thirds of cases (7/12) on initial computed tomography imaging and subsequently diagnosed on repeat imaging or endoscopic retrograde cholangiopancreatography. All patients who sustained complex pancreaticoduodenal trauma underwent PD without mortality. The management of pancreatic trauma is evolving. Our experience provides valuable and locally relevant insights into future management strategies.We advocate that high-grade pancreatic trauma should be managed in high-volume hepato-pancreato-biliary specialty surgical units. Pancreatic resections including PD may be indicated and safely performed with appropriate specialist surgical, gastroenterology, and interventional radiology support in tertiary centres.©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.

Tumour rupture of gastrointestinal stromal tumours (GISTs) has been considered to be a remarkable risk factor because of its unfavourable impact on the oncological outcome. Although tumour rupture has not yet been included in the current tumor-node-metastasis classification of GISTs as a prognostic factor, it may change the natural history of a low-risk GIST to a high-risk GIST. Originally, tumour rupture was defined as the spillage or fracture of a tumour into a body cavity, but recently, new definitions have been proposed. These definitions distinguished from the prognostic point of view between the major defects of tumour integrity, which are considered tumour rupture, and the minor defects of tumour integrity, which are not considered tumour rupture. Moreover, it has been demonstrated that the risk of disease recurrence in R1 patients is largely modulated by the presence of tumour rupture. Therefore, after excluding tumour rupture, R1 may not be an unfavourable prognostic factor for GISTs. Additionally, after the standard adjuvant treatment of imatinib for GIST with rupture, a high recurrence rate persists. This review highlights the prognostic value of tumour rupture in GISTs and emphasizes the need to carefully take into account and minimize the risk of tumour rupture when choosing surgical strategies for GISTs.

Pancreatic trauma (PT) involving the main pancreatic duct is rare, but represents a challenging clinical problem with relevant morbidity and mortality. It is generally classified according to the American Association for the Surgery of Trauma (AAST) and often presents as concomitant injury in blunt or penetrating abdominal trauma. Diagnosis may be delayed because of a lack of clinical or radiological manifestation. Treatment options for main pancreatic duct injuries comprise highly complex surgical procedures.We retrospectively analyzed clinical data from 12 patients who underwent surgery in two tertiary centers in Germany during 2003-2016 for grade III-V PT with affection of the main pancreatic duct, according to the AAST classification.The median age was 23 (range: 7-44) years. In nine patients blunt abdominal trauma was the reason for PT, whereas penetrating trauma only occurred in three patients. MRI outperformed classical trauma CT imaging with regard to detection of duct involvement. Complex procedures as i.e. an emergency pancreatic head resection, distal pancreatectomy or parenchyma sparing pancreatogastrostomy were performed. Compared to elective pancreatic surgery the complication rate in the emergency setting was higher. Yet, parenchyma-sparing procedures demonstrated safety.Often extension of diagnostics including MRI and/or ERP at an early stage is necessary to guide clinical decision-making. If, due to main duct injuries, surgical therapy for PT is required, we suggest consideration of an organ preservative pancreatogastrostomy in grade III/IV trauma of the pancreatic body or tail.Copyright © 2020. Published by Elsevier Ltd.

Pancreatic injury is rare, but it has a high mortality rate and its optimal treatment remains controversial. This study aimed to evaluate the clinical characteristics, management strategies, and outcomes of patients with blunt pancreatic injury.This retrospective cohort study was performed on patients with a confirmed blunt pancreatic injury who were admitted to our hospital from March 2008 to December 2020. The clinical characteristics and outcomes of patients receiving different management strategies were compared. The risk factors for in-hospital mortality were evaluated by performing a multivariate regression analysis.A total of 98 patients diagnosed with blunt pancreatic injury were identified, with 40 patients having undergone nonoperative treatment (NOT) and 58 patients having undergone surgical treatment (ST). The overall in-hospital deaths were 6 (6.1%), including 2 (5.0%) and 4 (6.9%) in the NOT and ST groups, respectively. Pancreatic pseudocysts occurred in 15 (37.5%) and 3 (5.2%) of the NOT and ST groups, respectively, showing a significant difference between the two groups (P < 0.001). In the multivariate regression analysis, concomitant duodenal injury (OR = 14.42, 95% CI 1.27-163.52; P = 0.031) and sepsis (OR = 43.47, 95% CI, 4.15-455.75; P = 0.002) were independently associated with in-hospital mortality.Except for the higher incidence of pancreatic pseudocysts in the NOT group than in the ST group, there were no significant differences in the other clinical outcomes between the two groups. Concomitant duodenal injury and sepsis were the risk factors for in-hospital mortality.© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.

Pancreatic trauma (PT) is rare among traumatic injuries and has a low incidence, but it can still lead to severe infectious complications, resulting in a high mortality rate. Acute pancreatitis (AP) is a common complication after PT, and when combined with organ dysfunction and sepsis, it will result in a poorer prognosis.We report a 25-year-old patient with multiple organ injuries, including the pancreas, due to abdominal trauma, who developed necrotising pancreatitis secondary to emergency caesarean section, combined with intra-abdominal infection (IAI). The patient underwent performed percutaneous drainage, pancreatic necrotic tissue debridement, and abdominal infection foci debridement on the patient.We report a case of severe AP and IAI secondary to trauma. This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery, and a better outcome was obtained.©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.

Malnutrition is a well-recognized risk factor for major surgery-related complications, but the impact of preoperative nutritional therapy is still debated due to a lack of high-level evidence. The study aims to evaluate the role of preoperative malnutrition in the postoperative course of patients who underwent pancreatic resection.This is a retrospective study involving 488 patients who underwent pancreatic resection. An entropy balance was applied to 134 patients at risk for moderate or severe malnutrition (M/S-MAL) to obtain a cohort equal to 354 patients, with the null or low risk of malnutrition (N/L-MAL). The reweighting scheme was made in two steps. In the 1st reweighting, the two cohorts were homogenized for confounding factors not modifiable. In the 2nd reweighting, the two cohorts were matched for modifiable factors by preoperative dietary support. The entropy balance was evaluated with the d-value. The postoperative results were reported as mean differences (MD) or odds ratio (OR) with a confidence interval at 95% (95 CI).The M/S-MAL included patients with lower values of BMI (d < 0.750), hemoglobin (d = 0.671), serum albumin (d = 0.554), total protein (d = 0.381). The M/S-MAL patients were more frequent ECOG 1-2 (d = 0.418), with jaundice (d = 0.445) or back pain (d = 0.366). The pancreaticoduodenectomy (d = 0.440) and vascular resection (d = 0.620) in the M/S-MAL group were performed more frequently. The pancreatic remnant was more often hard (d = 0.527), and the Wirsung duct dilated (d = 0.459) in the N/L-MAL group. The rate of pancreatic ductal adenocarcinoma was higher in M/S-MAL (d = 0.399). After 1st weighting, M/S-MAL patients have a high comprehensive complication index (CCI) (MD = 5.5; 0.3 to 10.7), were more frequently discharged not at home (OR 2.3; 1.1 to 5.4) with a prolonged mean hospital stay (MD 6.1.1; 0.1 to 12.1, days), After 2nd weighting, the two groups have similar postoperative results.The correction of malnutrition could play an independent role in reducing the severity of complication, length of stay, and type of discharge in patients who underwent pancreatic resection.Copyright © 2022 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers.This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity.Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury.Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system.Therapeutic/care management, level V; Prognostic and epidemiological, level IV.Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Enhanced recovery after surgery (ERAS) protocols reduce length of stay, complications, and costs for elective surgical procedures. It remains challenging to implement ERAS concepts in the acute trauma patient due to deranged physiological reserve from the penetrating or blunt trauma producing altered physiology. However, systems of care improve access to early intervention and potentially reduce mortality. These consensus guidelines examine optimal pre‐hospital, resuscitation‐room, intra‐, and post‐operative treatment, systems of ethical management, and overall care for trauma patients in the post‐resuscitation phase of care. The guideline is presented in three parts, this being part 1.

The pancreas is an entirely retroperitoneal structure, and hence, the initial step of recognizing a pancreatic injury is at times difficult. This is particularly critical since delays in recognition and appropriate management dramatically increase morbidity. This review article discusses the important anatomical features of the pancreas, the large variety of diagnostic maneuvers and their pitfalls, and a management strategy for pancreatic injury that is largely based on the organ injury scale. Nuances in the operative management are highlighted, as they are the most challenging of management dilemmas, making this a review of "What you need to know" about pancreatic trauma.Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.

This study by Chui adds further important evidence in the treatment of high-grade pancreatic injuries and endorses the concept of the model of pancreatic trauma care designed to optimize treatment, minimize morbidity and enhance survival in patients with complex pancreatic injuries. Although the authors have demonstrated favorable outcomes based on their limited experience of 5 patients who underwent a pancreaticoduodenectomy (PD), including 2 patients who were "unstable" and did not have damage control surgery (DCS), we would caution against the general recommendations promoting index PD without DCS in "unstable" grade 5 pancreatic head injuries.©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.

The “obesity paradox” suggests that higher BMI values might be protective in certain conditions. However, it is controversial in polytrauma patients, with different studies presenting varying results.

This study examined the variability in the length of stay (LOS) and daily medical expenses (DME) for hypertension and pneumonia inpatient care. Using 10 years of National Health Insurance Service data (2010-2019), a multilevel analysis assessed variability at the patient and institutional levels. During the study period, the mean LOS decreased, whereas the DME increased for both hypertension and pneumonia. Institutional level variability in the LOS increased during the study period, demonstrating greater variability than that for pneumonia. For both conditions, institutional-level variability was more marked in smaller institutions (hospitals and clinics) than in larger institutions (general and tertiary hospitals). These findings indicate a need for standardized healthcare service protocols to promote consistent and efficient patient care.© 2025 The Korean Academy of Medical Sciences.

Surgical patients can be discharged to a variety of facilities which vary widely in intensity of care. Postoperative readmissions have been found to be more strongly associated with post-discharge events than pre-discharge complications, indicating the importance of discharge destination. We sought to evaluate the association between discharge destination and 30-day outcomes. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were dichotomized based on discharge destination: home versus non-home. The main outcome of interest was 30-day unplanned readmission. The secondary outcomes included post-discharge pulmonary, infectious, thromboembolic, and bleeding complications, as well as death. In this cohort study of over 1.5 million patients undergoing common surgical procedures across eight surgical specialties, we found non-home discharge to be associated with adverse 30-day post-operative outcomes, namely, unplanned readmissions, post-discharge pulmonary, infectious, thromboembolic, and bleeding complications, as well as death. Non-home discharge is associated with worse 30-day outcomes among patients undergoing common surgical procedures. Patients and caregivers should be counseled regarding discharge destination, as non-home discharge is associated with adverse post-operative outcomes.