Endovisual technologies in the diagnosis and treatment of closed injuries of the pancreas

BACKGROUND: To date, there is no consensus on the optimal treatment and diagnostic algorithm for patients with closed pancreatic injury in cases where emergency surgery is not required. Patients with suspected pancreatic injury require the closest attention and maximum efforts aimed at establishing an accurate diagnosis.

AIM: To optimize the method of diagnosis and surgical intervention for closed abdominal trauma with damage to the pancreas.

MATERIALS AND METHODS: We have analyzed the results of treatment of 125 patients with pancreatic injuries who were treated in the surgical department of the Republican Scientific Center for Emergency Medical Aid and its branches from 2011–2021 among the victims, men predominated — 104 (83.2%) patients, women — 21 (16.8%), age ranged from 20 to 60 years. For the study, two groups of patients with damage to the pancreas with a closed abdominal injury have been formed. Group I included 84 victims in the period from 2011 to 2016 using traditional surgical interventions. Group II included 41 patients in the period from 2016 to 2021 using endovideosurgical technologies for the diagnosis and treatment of patients with a closed injury of the pancreas.

Isolated trauma of the pancreas was diagnosed in 22 (26.1%) patients, combined — in 103 (82.4%). Injuries of the pancreas in case of a closed injury were localized mainly in the tail of the pancreas, less often in the head, body and isthmus.

RESULTS: Resection of the pancreas was performed in the predominant number of cases with III degree of damage, when there was damage to the tail of the gland with a violation of the integrity of the MP. In group I, this volume of operation was performed in 1 out of 4 cases of distal damage to the gland, in group II, resection was also performed in 1 out of 3 cases of damage to the pancreas with ΙΙΙ degree of damage. Suturing was carried out with a hemostatic purpose in case of damage to the integrity of the blood vessel in the projection of the pancreas. It was used in 9 (10.7%) cases in group I and also in 3 (7.3%) cases in group ΙΙ, in both cases II and III degree of damage to the pancreas occurred. Opening of the hematoma of the pancreas was performed in 6 (7.1%) cases in group I, in 4 of which with the I degree of damage to the gland, in the II group it was performed in 3 (7.3%) cases also with I and II degrees of damage. Among our patients in group II there were 12 patients with degree I damage to the pancreas. 6 patients underwent diagnostic videolaparoscopy, bursoscopy (pancreatoscopy), drainage of the omental sac. There were no significant differences in the number of complications in patients undergoing laparotomy and laparoscopy. This indicates that both methods can adequately inspect the abdominal cavity and establish a diagnosis.

Of the 125 victims with dominant damage to the pancreas, 17 (13.6%) died. According to our data on the Pancreatic Injury Mortality Scale, there were no lethal outcomes with mild severity. In the group with moderate severity, 4 (8.6) patients died in group I and in group II, 1 (2.1%) patient, with a severe case, 9 (52.9%) patients died in group I and in group II — 3 (17.6%) patients. The main causes of death in 9 patients were severe destructive post-traumatic pancreatitis, 6 victims had injuries with severe traumatic and hemorrhagic shock, 2 had multiple complications of combined injuries, chest, brain.

CONCLUSIONS: In our opinion, therapeutic laparoscopy can be used for isolated injuries of the pancreas and only for injuries according to American Association for the Surgery of Trauma (AAST) I degree. With II degree of damage, it is better to end the operation with precision hemastosis with drainage of the stuffing bag. At the III degree of damage to the pancreas, it is possible to perform a distal resection. Indications for tamponing rarely arise exclusively within the framework of the treatment tactics “Damage control” and when it is impossible to stop bleeding from the pancreas.