Clinical values of percutaneous peri-pancreatic drainage for management of blunt traumatic pancreatic neck transection in adult patients

doi:10.21203/rs.3.rs-3981968/v1

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Clinical values of percutaneous peri-pancreatic drainage for management of blunt traumatic pancreatic neck transection in adult patients

https://doi.org/10.21203/rs.3.rs-3981968/v1

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Purpose

Surgical resection or surgical peri-pancreatic drainage was recommended for patients with blunt traumatic pancreatic neck transection. Peri-pancreatic drainage could be also achieved percutaneously, termed as percutaneous peri-pancreatic drainage (PPPD) in this study. The clinical values of PPPD for patients with blunt traumatic pancreatic neck transection were evaluated in this study.

Methods

Patients with blunt traumatic pancreatic neck transection treated by either surgical resection (n = 5) or PPPD (n = 13) were enrolled in this study, pancreas-related events and prognosis were compared between the surgical resection group and the PPPD group.

Results

The patients of surgical resection and PPPD groups were comparable in background characteristics except for the concomitant abdominal injuries (60% in the surgical resection group and 7.7% in the PPPD group, P = 0.044). The rates of post-operative pancreatic fistula (POPF) and mortality of the surgical resection group are both 20%. All the 13 patients in PPPD group discharged with the external drainage tube which were removed successfully in 12 (92.3%) patients in whom the drainage tube maintenance was 3.0 (2.8, 4.0) months. PPPD was failed in 1 (7.7%) patient who received Roux-en-Y anastomosis between the jejunum and the thickened fistula wall successfully. Three (3/12, 25%) patients developed main pancreatic duct stricture as a long-term complication of PPPD management.

Conclusions

PPPD could be performed safely and effectively for blunt traumatic pancreatic neck transection patients. Delayed internal drainage can be used as a salvage treatment in the case of failed PPPD. Main pancreatic duct stricture is the long-term complication of PPPD management.

pancreatic trauma

peri-pancreatic drainage

percutaneous drainage

non-operative management

Pancreatic trauma is a rare condition with an incidence of around 5% in abdominal trauma patients [1-6]. The reported mortality of pancreatic trauma ranges from 5% to 26.5% for penetrating trauma, and from 8% to 17.8% for blunt trauma [1, 4, 5, 7]. In most countries except the United States and South Africa, about 70%–80% of patients were blunt pancreatic trauma [1, 5, 7].

Due to the anatomic location, sudden compression of the pancreas against the lumbar vertebra always causes pancreatic neck injuries, such as contusion, superficial laceration, or even transection. Pancreatic neck transection is graded as III or IV according to the American Association for the Surgery of Trauma (AAST) [8]. There is no consensus on the management of blunt pancreatic neck transection. Based on very low-quality evidence, the Eastern Association for the Surgery of Trauma (EAST) recommended surgical resection for AAST III and IV injuries [9]. According to the Western Trauma Association (WTA) guideline, distal pancreatectomy was recommended for AAST III injuries and surgical drainage was regarded as a noninferior option, and surgical resection was recommended for AAST IV injuries if adequate surgical expertise is available, otherwise, surgical drainage was preferred [10]. Recent studies demonstrated contrasting results in terms of surgical resection or surgical peri-pancreatic drainage in AAST III and IV pancreatic trauma patients [11, 12].

In clinical practice, peri-pancreatic drainage can be achieved via a percutaneous maneuver using an ultrasound-guided or CT-guided technique. In our center, percutaneous peri-pancreatic drainage (PPPD) was widely used, not only in acute pancreatitis but also in pancreatic trauma patients with stable hemodynamics and without other abdominal injuries requiring surgery. Based on a nationwide analysis, a trend toward non-operative management for pancreatic trauma patients was demonstrated [13]. The World Society of Emergency Surgery (WSES) guidelines also suggested that endoscopic and percutaneous interventions could be considered for AAST IV and AAST III with very proximal pancreatic body injury [14]. Herein, this retrospective study was designed in order to evaluate the clinical values of PPPD management for adult patients with blunt traumatic pancreatic neck transection.

Patients

From August 2010 to August 2022, a total of 21 adult patients were diagnosed with blunt traumatic pancreatic neck transection. Eighteen patients treated by either surgical resection (n=5) or PPPD (n=13) were enrolled in this study after the exclusion of 3 patients who received endoscopic pancreatic duct stenting.

Ethical approval was obtained from the Committee of Ethics in Biomedical Research of Zhejiang University and conformed to the ethical guidelines of the Declaration of Helsinki. Written informed consent was obtained from all participants.

Study design

According to the management initially performed in our hospital, the patients were divided into two groups, namely surgical resection and PPPD, respectively.

Surgical resection included distal pancreatectomy, central pancreatectomy with Roux-en-Y anastomosis and pancreaticoduodenectomy.

PPPD was performed using ultrasound-guided technique in our center and the pigtail catheter was placed into the fluid collection around the pancreatic neck. In the early days after placement of the pigtail catheter, turbid and enzyme-rich peri-pancreatic fluid consisting of blood and inflammatory exudation was drained. If the drainage was sufficient, the drainage fluid turned clear and the area of peri-pancreatic fluid collection gradually shrank. After confirming sufficient drainage, the patients were discharged with the pigtail catheter in place. After discharge, the daily volume of drained fluid was monitored and the abdominal ultrasound examination was performed regularly. If no fluid was drained and no new peri-pancreatic fluid collection was found by abdominal CT examination, the pigtail catheter could be removed.

Definitions

The pancreatic trauma was graded using the AAST grading system according to the enhanced abdominal CT examination [8]. The pancreatic neck transection was defined as AAST IV and AAST III with very proximal (less than 2cm distal to the left edge of superior mesenteric vein) pancreatic body injury. The diagnosis and grading of post-operative pancreatic fistula (POPF) was based on the International Study Group on Pancreatic Surgery definition [15]. Pancreatic duct stricture was diagnosed when the diameter of the distal pancreatic duct was more than 2 times that of the proximal duct.

Statistical analysis

Continuous data were presented as median (interquartile range [IQR]) values and the categorical variables were presented as frequencies and percentages. The Mann-Whitney U test was used for the comparison of continuous variables and the Fisher’s exact test or Pearson’s chi-squared test was used for categorical variables. Data were analyzed using SPSS 22.0 software. A P value <0.05 (two sided) was considered statistically significant.

Background characteristics of the study population

A total of 18 adult patients with blunt traumatic pancreatic neck transection were enrolled in this study. Five patients underwent surgical resection, including distal pancreatectomy (n = 2), pancreatoduodenectomy (n = 1) and central pancreatectomy with Roux-en-Y anastomosis (n = 2). The remaining 13 patients underwent PPPD management.

As indicated in Table 1, the background characteristics between the two groups were comparable except for the concomitant abdominal injuries. Also, 60% of patients in the surgical resection group had combined abdominal injuries, which was significantly higher than the level of 7.7% in the PPPD group.

Table 1

Background characteristics of patients in the surgical resection group and the PPPD group.
Characteristics		Surgical resection	PPPD	P value
No. of patients		5	13
Age (years), Median (Q1, Q3)		47.0 (30.0,60.0)	43.0 (29.5, 73.0)	0.805
Male gender, n (%)		3 (60.0%)	12 (92.3%)	0.172
Time interval from injury to admission (days)		2.0 (1.1–2.5)	2.0 (0.5, 7.0)	0.691
Mechanism of injuries, n (%)				1.000
	Traffic accident	2 (40.0%)	5 (38.5%)
	Crushing	3 (60.0%)	8 (61.5%)
Hemodynamically unstable, n (%)		1 (20.0%)	1 (7.7%)	0.490
AAST grade, n (%)				0.583
	III	2(40.0%)	3(23.1%)
	IV	3(60.0%)	10 (76.9%)
Concomitant abdominal injuries, n (%)		3 (60.0%)	1 (7.7%)	0.044*
Injury Severity Score, Median (Q1, Q3)		25.0 (25.0,31.0)	25.0 (25.0, 34.0)	0.744
PPPD: percutaneous peri-pancreatic drainage.

Management and outcome

In the surgical resection group, one (20%) patient who received central pancreatectomy with Roux-en-Y anastomosis developed grade C POPF which caused massive intra-abdominal hemorrhage and was treated with laparotomy. Unfortunately, this patient developed systematic infection and multi-organ failure after laparotomy and eventually died.

As indicated in Table 2, all 13 patients in the PPPD group were discharged with the pigtail catheter as an external drainage tube. The external drainage tubes were removed successfully in 12 patients (92.3%), in whom the daily volume of drained fluid reduced gradually and the drainage tube maintenance was 3.0 (2.8, 4.0) months.

Table 2

Demographic characteristics and pancreas-related events of patients in the PPPD group.
Patient	Age	Sex	AAST grade	Time interval from injury to admission (days)	Drainage removed successfully	Drainage maintenance (month)	Salvage internal drainage	MPD stricture	Hospital stay (days)	Outcome
1	68	Male	IV	10	Yes	3	No	No	28	alive
2	43	Male	III	3	Yes	12	No	No	31	alive
3	17	Male	IV	0.5	Yes	3	No	No	32	alive
4	51	Male	IV	3	Yes	4	No	Yes	7	alive
5	78	Male	III	7	Yes	2	No	No	12	alive
6	72	Male	IV	21	Yes	4	No	No	21	alive
7	74	Male	IV	2	Yes	2.5	No	Yes	10	alive
8	31	Male	III	1	Yes	2.5	No	No	12	alive
9	28	Female	IV	0.3	Yes	3	No	Yes	24	alive
10	37	Male	IV	7	Yes	3	No	No	11	alive
11	20	Male	IV	1	Yes	3	No	No	10	alive
12	43	Male	IV	0.5	No	4	Yes	/	95	alive
13	75	Male	IV	0.2	Yes	3	No	No	13	alive
PPPD: percutaneous peri-pancreatic drainage; AAST: the American Association for the Surgery of Trauma; MPD: main pancreatic duct.

Only one patient (7.7%) in the PPPD group displayed a constant daily volume of drained fluid of about 500ml/d and the drainage tube could not be removed. This patient received Roux-en-Y anastomosis between the jejunum and the thickened fistula wall 4 months later after pigtail catheter placement. After the operation, this patient recovered uneventfully and remained asymptomatic.

During the follow-up period of PPPD patients, 3 of 12 (25%) patients developed main pancreatic duct (MPD) stricture, with distal duct dilatation and pancreatic atrophy but with no symptoms (Fig. 1A, B). Endoscopic pancreatic duct stenting was attempted in one patient, but failed because the guidewire could not pass through the MPD stricture site (Fig. 1C).

Comparison between surgical resection and PPPD groups

As shown in Table 3, the mortality rate in the surgical resection group was 20% and there were no patient deaths in the PPPD group. The hospital stay was longer in the PPPD group compared with the surgical resection group but without significant difference (24.0 vs 13.0, P = 0.199).

Table 3

Comparison between the surgical resection group and the PPPD group.
Characteristics		Surgical resection	PPPD	P value
No. of patients		5	13
Pancreas-related events, n (%)
	POPF	1 (20.0%)	/
	Discharge with drainage tube	/	13 (100%)
	Drainage tube maintenance (month)	/	3.0 (2.8, 4.0)
	Drainage removed successfully	/	12 (92.3%)
	Salvage operation after failed PPPD	/	1 (7.7%)
	Pancreatic duct stricture after PPPD	/	3 (25.0%)
Hospital stay (days), Median (Q1, Q3)		24.0 (19.0, 30.0)	13.0 (10.5, 29.5)	0.199
Mortality, n (%)		1 (20.0%)	0	0.278
PPPD: percutaneous peri-pancreatic drainage; POPF: post-operative pancreatic fistula.

It remains controversial that either surgical resection or surgical drainage should be preferred for the management of AAST III and IV injuries. The EAST and WTA guidelines gave different answers on this question [9, 16]. A recent study compared surgical resection and surgical peri-pancreatic drainage in patients with AAST IV injuries and concluded that pancreatic resection is warranted in early, conclusive MPD injury and peri-pancreatic drainage is an alternative method if surgery is delayed or MPD injury has not been clearly assessed [12]. Another study indicated that surgical resection is the preferred option and the majority of drainage patients would require additional and delayed pancreas-targeted operations [11]. Due to the fact that peri-pancreatic drainage can be achieved via a percutaneous maneuver, which is termed PPPD in this paper, this retrospective study was performed to compare the clinical values of PPPD and surgical resection in patients with blunt pancreatic neck transection.

In the surgical resection group, 1 (20%) patient developed grade C POPF which resulted in massive intra-abdominal hemorrhage and re-operation; this patient died from sepsis and multi-organ failure. Previous studies reported the clinically relevant POPF rates of surgical resection to be 8–50% in patients with AAST III and IV injuries [9, 11, 12]. The mortality rate in our study was 20%, which is higher than the 8% reported by previous studies [9, 12]. It is noteworthy that the POPF and mortality rates of this cohort were not representative, however, due to the small number of patients enrolled in the surgical resection group of this study.

The patients in the PPPD group showed different clinical outcomes compared with the surgical resection group. Firstly, the external drainage tube was removed successfully in 12/13 (92.3%) patients after a median drainage tube maintenance of 3.0 months and we regarded these patients to have been successfully treated by PPPD. Judged on this criterion, the PPPD management failed in only one patient (7.7%). For this unsuccessful case, the second-line treatment principle was turning the external drainage into internal drainage. In this case, Roux-en-Y anastomosis between the jejunum and the thickened fistula wall was performed 4 months later after pigtail catheter placement. Endoscopic transmural drainage into the stomach or jejunum is an alternative option for internal drainage in patients with fluid collection from the distal gland.

MPD stricture is the long-term complication of PPPD management, and happened in 25% of patients who were successfully treated with PPPD. As another interventional method which was widely used and reported in pancreatic trauma management, endoscopic pancreatic duct stenting was also associated with MPD stricture rates of 26.7–66.7% according to previous studies [17, 18]. MPD stricture will cause distal duct dilatation and distal pancreatic tissue atrophy. In our opinion, this condition can be regarded as “spontaneous distal pancreatectomy”, but it still remains uncertain about its further treatment. In this study, all three patients who developed MPD stricture were followed-up regularly.

We hypothesize that the types of MPD injury predict the outcome of PPPD management. (1) For those patients with complete rupture and disrupted continuity of MPD, the pancreatic fluid secreted by the distal pancreas has nowhere to go after healing and closure of the proximal MPD stump. PPPD management is unlikely to be successful and internal drainage of the distal pancreas will be required. (2) For patients with partial rupture of MPD and where the healing site of MPD is pinpoint-like, MPD stricture with distal duct dilatation and pancreatic atrophy will develop. (3) The ideal consequence of PPPD is that the injured MPD is healed with mild or even no stricture and no harmful impact happens on the distal duct and pancreas. This situation happened in most patients of the PPPD group in this study and was also seen in a previous case report [19].

To our knowledge, this study enrolled largest number of pancreatic trauma patients who were treated by PPPD, and was the first study evaluating the clinical values of PPPD on management blunt traumatic pancreatic neck transection systematically. There are two limitations in this study. Firstly, the MPD injury types were not investigated using endoscopic retrograde pancreatography. As a result, we could not identify the hypothesis that the outcome of PPPD management was decided by MPD injury types. Secondly, evaluation of the quality of life was absent from this study, especially in patients requiring long-term drainage tube maintenance.

As a non-operative management option, PPPD could be performed safely and effectively for blunt traumatic pancreatic neck transection patients with stable vital signs. In the case of failed PPPD management, delayed internal drainage can be used as a salvage treatment. Main pancreatic duct stricture is the long-term complication of PPPD management.

Statements and declarations

Declaration of interest

The authors have no relevant financial or non-financial interests to disclose.

Funding

This study was supported by the National Natural Science Foundation of China (No. 81970552).

Authors’ contributions:

W.X.: study design, data acquisition and manuscript drafting; C.S.: analysis and interpretation of data; Y.S.: critical revision of manuscript. All authors reviewed the manuscript.

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No competing interests reported.

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Clinical values of percutaneous peri-pancreatic drainage for management of blunt traumatic pancreatic neck transection in adult patients

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Version 1

Abstract

Purpose

Methods

Results

Conclusions

Figures

Introduction

Patients And Methods

Results

Background characteristics of the study population

Management and outcome

Comparison between surgical resection and PPPD groups

Discussion

Conclusions

Declarations

References

Additional Declarations

Status:

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