An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

INTRODUCTION: Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS: We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS: We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION: CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. LEVEL OF EVIDENCE: Epidemiologic/Diagnostic study, level III.

Retrievable inferior vena cava filters are rarely removed.

There has been an increasing nationwide trend of inferior vena cava (IVC) filter placement over the past 3 years. Most of these have been the newer, removable variety. Although these are marketed as retrievable, few are removed. The purpose of this study was to examine the practice pattern of IVC filter placement at Huntington Hospital. This study is a retrospective chart review of all IVC filter placements and removals between January 1, 2004, and December 31, 2006. The primary data points include indication for placement, major complications (migration, caval thrombosis, pulmonary embolus [PE]), attempted removal, and successful removal. Three hundred ten patients received IVC filters at our institution during this period. Eighty-four were placed in 2004, 95 in 2005, and 131 in 2006. Of those, only 12 (3.9%) were documented permanent filters, whereas the remainder (298) were removable. Of the retrievable filters placed, only 11 (3.7%) underwent successful removal. There were four (1.3%) instances in which the filter could not be removed as a result of thrombus present within the filter and two (0.67%) in which removal was aborted as a result of technical difficulty. Our use of IVC filters has increased steadily over the last 3 years. Despite the rise in use of "removable" filter devices, few are ever retrieved. Although IVC filter insertion appears an effective method of PE prevention, it comes at a cost, both physiological and monetary. It would be wise to devise more stringent criteria to identify those patients in the various populations who truly require filter placement and to be cautious in altering our indications for placement.